By: Buddy Gardner, PGY-1
Leo Tolstoy was a prominent Russian author in the 19th century who is commonly regarded as one of the greatest writers of all time. In 1886, he wrote a novella, The Death of Ivan Ilyich, which is a fictional first-person narrated account of a man’s injury and slow spiral of terminal illness toward death. This article serves not to recount the events of the novella, but rather to outline some of its themes and how they relate to working in medicine.
Theme 1: The inability of a person in emotional distress to describe their experience in a manner sufficient to truly convey to the listener what they are feeling. Ivan Ilyich struggled with this difficulty throughout his entire death experience. This theme was most evident to me when Ivan Ilyich recalled his entire life, along with his pleasant upbringing. Ilyich reflects that although he is aware that all men come to an end, he cannot truly grasp that this is his fate as well. He is unable to adequately describe his whole being, formed from various life experiences, but attempts to do so by recalling his lost childhood pleasures. One of the most common and frustrating aspects of a slow death must be the inability to explain the entirety of your life and its experiences—and therefore what you are losing—to the loved ones around you.
Theme 2: The personification of pain and death. As Ivan Ilyich spirals further toward death, his dread over his pain and of death itself takes on the form of an ever-present being. He remarks that no matter where he looks or what he does, IT is there, and IT is watching him. He explains how small pleasures, such as a game of bridge, give him the brief illusion that he is free from IT, but that IT inevitably penetrates these illusions every time. Ivan Ilyich’s pain and dread over dying become such a presence in his life that they engulf him and become all he can think about. They take on the form of an ominous being, always looming over him, waiting for him to sink slowly into this black hole. This must be a very difficult part of pain and dying for the patient, as this entity is only a reality to the patient, and even if the patient explains what he or she feels, nobody can truly understand the omnipresence of suffering until it is experienced firsthand.
Themes 3 and 4: The rejection of loved ones in the face of death, and the inability to admit the need for emotional support. One striking aspect of the story was the severity with which Ivan Ilyich rebelled against his loved ones. He and his family entered a negative feedback cycle in which his suffering led to irritability, which led to their dislike for him, which led to increased loneliness, which ultimately furthered his suffering. Unfortunately for Ivan Ilyich, he does not realize that he wishes to make amends with his family until he is too near death, and it is too late to communicate. This theme is important to remember in health care, as the physician may become the subject of the patient’s blame. In stressful times, one must remember that this is a common reaction and that the person pushing others away is likely more in need of support than ever.
Theme 5: The focus on external factors instead of internal states of affairs. Ivan Ilyich realizes during his death that he spent his entire life worrying about social status, promotions and the way his house looked. He recognizes that while he was improving all of these aspects of his life, his inner being was consequently deteriorating. It seems likely that many dying people realize that much of what they worried over was ultimately insignificant, and Ivan Ilyich is no different. One day, we all will die, and what will matter is not how big our houses were or how high we climbed up the proverbial societal ladder, but how we affected those around us and how we spent our time with those we loved. Thus Maya Angelou’s quotation: “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”