J. Biomedical Science and Engineering, 2013, 6, 1-7 JBiSE
http://dx.doi.org/10.4236/jbise.2013.610A1001 Published Online October 2013 (http://www.scirp.org/journal/jbise/)
For the love and respect of the service: Applied aesthetics
and palliative care
Marcia Brennan
Department of Religious Studies, Rice University, Houston, Texas, USA
Received 14 August 2013; revised 5 September 2013; accepted 12 September 2013
Copyright © 2013 Marcia Brennan. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
In this article, the author discusses her experiences as
an artist in residence in the Department of Palliative
Care and Rehabilitation Medicine a t the Univ ersity o f
Texas M. D. Anderson Cancer Center. Emphasis is
placed on applied aesthetics in palliative care and
their implications for addressing communication, spi ri-
tual, and health care issues for military service mem-
bers. Drawing on six vivid case studies, the author
examines the various ways in which end of life narra-
tives can shed valuable light on key issues concerning
individuals’ life experiences in the Navy, the Army,
and the Air Force. These cherished images strength-
ened people’s spirits at the end of life, and each of the
men told their stories with pride.
Keywords: Palliative Medicine; End of Life;
Psychosocial Oncology; Aesthetics; Communication;
Spirituality
1. INTRODUCTION
Since March of 2009, it has been my great privilege to
serve as an artist in residence in the Department of Pal-
liative Care and Rehabilitation Medicine at the Univer-
sity of Texas M. D. Anderson Cancer Center. In my “day
job”, I am an associate professor of art history and re-
ligious studies at Rice University in Houston, Texas,
where my research areas include modern and contempo-
rary art history and museum studies, comparative mysti-
cism, and the medical humanities. Despite the differ-
ences between my research fields, each of these areas
shares a common set of themes and challenges, namely:
how do we find a languag e to describ e states of being for
which there is no language? How do we represent the
unrepresentable and translate the untranslatable? How do
we formulate metaphors of transience to describe sub-
jects that are simultaneously coming into form and going
out of form, sometimes within the fr amework of a single
image? And how do we represent the fragile zones of
contingency that mark both gradual tran sitions as well as
more dramatic shifts between states of being? Notably,
these issues are as pertinent to theoretical discussions of
abstract painting’s simultaneously dissolving and crys-
tallizing structures as they are in the contemplation of
spiritual experience and mystical ecstasy, as they are in
the very real challenges of people at the end of life. Thus,
throughout all of my work I am fascinated—and pro-
foundly moved—by subjects and situations that repeat-
edly exceed our capacity to represent them, even as we
repeatedly attempt to do so, often through imagery that
conveys transitional states and transformational visions
[1,2]1.
At M. D. Anderson, my work is sponsored by COL-
LAGE: The Art for Cancer Network, a non-profit or-
ganization conceived and founded by Dr. Jennifer
Wheler. Working on both the Acute Palliativ e Care Inpa-
tient Unit and the Palliative Care Outpatient Clinic, I
assist patients and their caregivers in constructing mean-
ingful narratives to express their insigh ts and experien ces.
Thus I primarily serve as a translator, yet much of what I
translate is ineffable. I create a context, and provide
critical skills, so that people facing extraordinarily diffi-
cult life situations have an opportunity for personal and
symbolic expression, which then becomes clothed in
aesthetic form.
As an artist in residence, I constantly confront the
challenge of creating human connections across a formi-
dable gulf of separation. Frequently, when I initially ap-
proach a patient, I am told that the work “sounds inter-
esting, but I have no artistic ability”. This invites me to
1This article represents part of a larger project in which I focus on
creative expressions at the end of life. The texts range from a scholarly
book on aesthetics and psychosocial oncology, entitled Words Beyon
d
Words: Finding Language at the End of Life (forthcoming from Intel-
lect Books, UK), to a personal discussion of the mystical and artistic
dimensions of my end of life work in The Angels In Between:The Boo
k
of Muse (Winchester, UK: Axis Mundi Books, 2013).

M. Brennan / J. Biomedical Science and Engineering 6 (2013) 1-7 2
respond, “Well, let’s just say for a moment that you did
have artistic ability. What images would you want to
write about?” Depending on the circumstances I might
also ask, “Where are you from? What do you love to
do?”, or even more simply (yet never simply), “What do
you love?” Sometimes I’ll just ask people directly, “If
you had an image in your mind of something that holds
special meaning for you—and it can be anything at all—
what would that be?” Very often a flash of illumination
will become visible on the person’s face, and they will
share an image with me. They will describe a subject or a
scene, while I gently encourage them to talk and make
notes to help crystallize their thou ghts. Once the artwork
is complete, I read the person’s words back to them,
while making any additions or corrections that they in-
dicate. The narrative is then inscribed into a handmade
paper journal, which the person is able to keep and share
with their family, either as a medium for further creative
expression or as a legacy gift that performs a memorial
function. The portable microenvironment of the text thus
provides a durable yet tender memory of this transient
moment in their lives.
Beyond this brief initial d escription, there is not an es-
tablished protocol or predetermined procedure for our
interactions [3]2. Instead, I have found that the opposite
approach works best, as this creative practice requires a
significant degree of self-overcoming. People come from
all over the world, as well as from half a mile down the
road, seeking treatment at M. D. Anderson. Not only are
each person and each situation unique, but at the end of
life dramatic physical and emotional changes can occur
almost immediately. Thus it is necessary to exercise sub-
tle discernment and to practice the art of allowance while
stepping lightly, speaking softly, and meeting everyone’s
gaze directly so as to see the person and not the illness.
In this article I present six stories that feature vivid
descriptions of people’s experiences in the military, in-
cluding the Navy, the Army, and the Air Force. At the
end of life, these cherished images promoted communi-
cation and strengthened people’s spirits, and each of the
men told their stories with pride.
2. NAVY
For the Love and Respect of the Service: The
Navy Uniforms
“Would you please go in and work with this man? He
has no family anywhere in the area, and he’s sitting all
alone in his room, writing.”
By the time this visit occurred, I knew very well that
the nurse’s brief description could mean just about any-
thing. As always, I approached the man’s room while
remaining open to the open. I knocked gently on the door,
introduced myself, and asked if I could visit with him for
a few moments. All of which is to say that I walked into
this man’s room with absolutely no expectations. Yet
within a short while, an intricate story was emerging. I
asked the man where he was from, and to our mutual
surprise, we discovered that we had much in common.
This man originally came from New York, although he
had left in the late nineteen fifties (I was born nearby in
Connecticut in the mid-nineteen sixties). We also found
that we shared the same mixed ethnic heritage on both
sides of our families. Now we sat together, so many dec-
ades later and thousands of miles away, in his hospital
room at M. D. Anderson.
This man’s artwork centered on the male relatives of
his family and their strong connection to the Navy, a
tradition that extend ed from his grandfather to his father,
his uncles, himself, and his son. This older man was also
a war veteran who was very tough and grounded in his
perspective. So it was all the more surprising when he
shared a story of supernatural appearances. This man told
me that, when he was a young man, his deceased grand-
father and father came to him at a critical juncture in his
life. Now the memory of their presences was returning to
him at the end of his life, another crucial moment of tran-
sition. His story is entitled:
For The Love And Respect Of The Service:
The Navy Uniforms3
For my image,
I go to my son and my famil y .
I include all of them,
Because we have stayed together
Through all the problems
And not gone our separate ways.
First, I need to tell you that the name James
Is sort of sacred in our family.
My grandfather was James, Senior.
His son, my uncle, was James, Junior.
And I’m Robert James.
The best thing I can say about my family
2Notably, artists in residence are neither therapists nor art therapists.
While the patient interactions often contain important psychodynamic
insights and revelations, these activities represent not a therapy, but a
critical intervention that broadly allows for the expression of personal
uniqueness. Regarding some of the overlapping psychosocial and sup-
p
or
t
functions that artistic activities can provide within an interdisci-
p
linary team, see the section on “Art Therapy” in Max Watson et al.,
Oxford Handbook of Palliative Care, 2nd ed. (Oxford: Oxford Univer-
sity Press, 2009) , pp. 803-804.
Is that there is one night I’ve never forgotten.
Once a week, the whole family showed up
At my grandmother’s house
To have a meal tog ether.
3All names have been changed to preserve the privacy of the individu-
als involved.

M. Brennan / J. Biomedical Science and Engineering 6 (2013) 1-7 3
We ate in the dining room,
And we were a large family.
But the two chairs at the head of the table
That were my grandfather’s chair
And my father’s chair
Were always left empty after they passed away.
That night, I was just getting ready to sit down and eat
When one of my uncles turned to another uncle
And said, in a loud voice,
“What are we going to do about this boy?”
I had just joined the Na vy earlier that week,
But I hadn’t told anyone.
As soon as my uncle sa id those wor ds
I looked up from my chair
And I saw my Granddad in his Navy uniform,
And I saw my Dad in his Navy uniform.
They had both been dead for years,
But they were sitting there at the table
In their Navy uniforms.
And then I saw my two uncles,
Who were in street clothes,
Wearing their Navy uniforms.
I knew I had to join the service
Because of the love and respect I had for these men,
And the love and respect they had for the service.
And I knew that, if I didn’t join the service,
I could never sit down with them at that table again.
After I read these tender and powerful words aloud,
this man and I held hands for a few minutes. He was very
grateful for the visit, and he particularly appreciated the
handmade journal, because he said that he had some
more experiences he wanted to record.
Reflecting these themes, the West Coast visual artist
Lyn Smallwood has created a drawing set in an Italian-
American home in New York during the late nineteen
fifties (Figure 1). Delicately rendered in graphite on
Arches paper, the drawing’s atmosphere is soft and inti-
mate as an extended family sits down together at a long,
formal dining room table. Much like in traditional homes
of this era , two wooden colonn ades flank the outer edg es
of the high-ceilinged dining room, while in the room
beyond, a sideboard holds assorted china. This drawing
is presented from the perspective of someone who has
just entered the dining room through the open doorway
that leads in from the kitchen. The tip of the din ing room
chandelier glows brightly overhead and provides a
source of emphasis and contrast that opens and illumi-
nates the scene. The chandelier also centers the composi-
tion visually as it establishes a direct linear pathway ex-
tending through the middle of the long dining room table.
Figure 1. Lyn Smallwood, The Navy Uniforms, 2013, graphite
on Arches paper.
This primary sight line ultimately leads to the dark
wooden door that frames the grandfather’s luminous
presence at the head of the table [4]4.
In this multi-figure composition, the dining room table
appears symbolically like an extended family tree. It’s as
though one of the man’s uncles has just loudly asked,
“What are we going to do about this boy?” and gestured
down the table toward his nephew, while the family
looks up and over at him. In turn, th e young man himself
has also just looked up from his seat at the foot of the
table to see his grandfather and father in their Navy uni-
forms. His grandmother is seated in her customary place
at her husband’s side. Next to her are the man’s two un-
cles, followed by family members of all ages, ranging
from elderly people to very young children. Everyone is
dressed formally for Sunday dinner. The two younger
uncles wear sailor’s white middy sh irts, while the grand-
father and father are senior presences dressed in the suits
of Navy officers, with decorations on their chests. The
scene culminates in the bright glow of their Navy uni-
forms, an etheric vision that stayed with this man for the
rest of his life [5]5.
Notably, The Navy Uniforms contains highly concrete
and detailed imagery that combines an intensity of visu-
4For an extended discussion of the historical imagery associated with
death and dying, see Philippe Ariès, Images of Man and Death, Trans.
Janet Lloyd (Cambridge: Harvard University Press, 1985).
5Regarding the phenomena of supernatural appearances at the end o
f
life, see especially Peter and Elizabeth Fenwick, The Art of Dying: A
J
ourney to Elsewhere (London: Continuum, 2008).

M. Brennan / J. Biomedical Science and Engineering 6 (2013) 1-7 4
alization with emotional poignancy and spiritual insight.
Taken together, these elements create a sense of sus-
pended temporality—a lucid state where time seems to
stand still—and this quality i s as compelling as it is heart
opening. In turn, this man’s narrative engages many dif-
ferent states of being. The story begins with the immedi-
ate physical context of an older man sitting alone in his
hospital room at the end of life. Our visit together opens
up a youthful memory of the time when he first joined
the Navy, and his grandfather and father appeared to him
in spirit form. Often during the production of an artwork,
a person will begin in one state of mind and body, and
they will experience additional states of being as the visit
unfolds. When the artwork is complete, the person re-
turns to their physical surroundings in a slightly altered
form, one that is more uplifted. These transitions can
help to renew the spirit and perspective of the person at
the end of life. As we work together, I have often wit-
nessed people enter into a profound state of peace, to
unclench their hands, to uncurl their bodies from a fetal
position, and to stop trembling. It’s as though the per-
son’s subtle bodily memories and experiences help to
strengthen and transform their curren t physical condition
and bring them to a more elevated place inside of them-
selves.
At the same time, these uplifted states are often asso-
ciated with narratives that are extremely concrete and
sensual. Much like this man’s story of his grandmother’s
dining room table, end of life narratives are frequently
extremely visual, aural, and tactile, just as they can en-
gage a strong sense of taste and smell. Deep bodily mem-
ory seems to be both sensitive and etheric, and it appears
to inhabit a state of consciousness that is parallel to the
time and place in which the person is actually living.
Along these lines, I have also frequently observed that, at
the end of life, a person’s surroundings can become ex-
tremely constrained as the world appears to shrink before
their eyes. Yet in these very limited circumstances, seem-
ingly little things can become monumental. As a differ-
ent perspective emerges, so too does an altered sense of
scale and proportion, and in this state bodily memories
and experiences are not constrained by the familiar pa-
rameters of time and space. Thus paradoxically, at the
end of life there can be an expansiveness of vision that
recognizes the large within the small, the numinous
within the ordinary, and the past and the future contained
within the fullness of the present.
3. ARMY
3.1. The Edge Blade
One day I visited with a middle-aged man whose metas-
tatic renal cell cancer had spread throughout his abdo-
men. He was enrolled in a Phase One clinical trial, and
he was on the palliative ward receiving supportive care
for pain control. This man had spent several years in the
Army, where he worked as a mechanical engineer. As he
told me, “I enjoy designing things and seeing them come
off of the paper and into life. That’s pretty gratifying.”
After chatting briefly about his professional work, I
asked the man about his imagery. At first he was a bit
reticent, but after a moment he shared a powerful, meta-
phorically resonant story about his father and his career
in the Army. These images visibly brought this man
strength at this difficult moment in his life:
The Edge Blade
My image is of this little pocket knife
That my dad used to keep out in the back shed.
He always stuck it in a piece of wood
That he whittled.
If I ever needed an edge blade,
I knew I could find one there.
When I think o f home,
I think of that.
My dad was a big, burly guy,
And he’s the reason I joined the military.
I always looked up to my d ad .
3.2. The Emblem of a Career Army Soldier
Another day I met with an older man who was at the
very end of his life. While he was now retired, the bulk
of his multi-decade career was spent in the Army, and he
had served in Viet Nam. Although it was difficult for
him to talk, we were able to visit briefly. When I asked
him about his cherished images, he briefly replied, “A
soldier. One who comes and goes.” He then told me that
he was in the military for several years, and “I was on the
outside as well, but then I went back into the military.
I’m mostly career Army.” This man had served as a non-
commissioned officer and his artwork told the story of
“The Emblem of a Career Army Soldier”.
After a few minutes his wife returned to the room, and
I presented her with her husband’s words. She was so
grateful, and she said that the artwork was “a gift of
gold”. The couple’s adult son was also quite moved, and
he shook my hand firmly, twice. Later that evening, this
man passed away peacefully at M. D. Anderson.
3.3. I’m a Fighter
Another day I met a middle-aged man who suffered from
an aggressive Stage 4 sarcoma with pronounced lym-
phedema on one side of his body. Yet perhaps most
striking of all was that, despite the extreme pain and dis-
figurement of his illness, this man continued to see and
describe himself as a warrior. As we visited he told me

M. Brennan / J. Biomedical Science and Engineering 6 (2013) 1-7 5
that he loved sports, especially basketball and football,
and that he had played football in college. I asked him
where he went to school and he told me that he went to
West Point. To our mutual surprise, we discovered that
we knew some people in common. This experience was
very moving, and at the end of our visit this brave man
told me to be strong and to pray for him. As he said:
I’m A Fighter
Cancer is a fight,
And I’m a fighter.
I love sports,
And I played football in college.
At West Point, I played on the defen s i ve line .
I’ve had cancer for a few years now.
They thought they had caught it,
But it came back,
Which means that it is really aggressive.
I should probably be more wary and upset,
But I feel patient and good.
I believe God has sent me here.
If my time is up,
I’m willing to go.
I’m a devout Christi an ,
And I’m a fighter.
I’ll fight it to the end.
Whatever it takes, I’m going to do.
I told this to my doctor,
Because he’s a fighter, too.
3.4. Do You Mind If I Fly This Thing?
When I first entered this man’s room, his wife and his
friend were at his bedside. When I introduced myself and
asked if he would like to visit with me, the man consid-
ered the question carefully and he almost said no. But
then he decided that this was important, so his wife and
his friend “stepped out to get a Coke”. Afterward, he told
me that he was really glad that he decided to do the art-
work.
We ended up having a lengthy, wonderful visit. It
wasn’t until afterward that I learned from the attending
physician and the ch aplain that contro l was a major issue
for this man, and that up to this point, he had resisted
opening up and talking to anyone. Yet frankly, once he
started talking, it was difficult to get him to stop. There
were various interruptions during our visit as the phone
rang several times, and members of the nursing staff
came in to do some procedures, but our exchange was
too precious for the man to stop talking. In short, this
man needed to be heard and to express himself in this
way.
He had spent several years in the Army, and he had
also served in Viet Nam. As he told me, flying was the
most fantastic experience in his life. Being a pilot gave
him a sense of freedom and power that he truly loved and
missed very much, particularly now that he was confined
to bed with Stage 4 metastatic cancer and investigating
hospice option s .
This man spoke softly with a gentle southern accent,
yet a few times during our visit, his voice notably
changed. This first happened when he told me about the
time his “Battalion Commander chewed us out royally
for my doing something I wasn’t supposed to be doing—
flying illegally”. At another point, he described being a
pilot and giving orders to his crew. As he did so, his
voice changed and it was as though he was speaking to a
subordinate soldier, and I could feel the power of com-
mand go through him.
In addition to these themes, his artwork provided a
means for this man to express his spiritual insights and
visions, and his language centered on the leitmotif of
flight:
Do You Mind If I Fly This Thing?
When I was a boy,
I would look up at the sky and see a plane,
And I thought, “One of these days,
I’m going to fly one of those things.”
I’ve been flying ever since I could.
I was in college, and they offered me
A ground school course,
And I thought, “That sounds interesting.”
Time progressed, and along came Viet Nam.
I we nt in to th e Army,
And I got assigned to the Artillery.
Part of my job had to do with flying.
My pilot was a captain, and a good pilot.
I was a junior lieutenan t
And a Forward Observer, an F. O.
Then I passed m y test and got my pilot’s license.
One day, over the intercom I asked him,
“Do you mind if I fly this thing?”
And he said, “Are you a pilot?”
I said, “Yes,” and he said,
“Okay. How about the next time we’re ready to go up,
I’ll show you how to put the stick in
And how to pull the pedals up.”
He showed me, and I got the idea
As we went upstairs in a J3 Cub.
With flying, there’s physical power,
And there’s horse power.
When you’re up there,
It’s just fantastic.

M. Brennan / J. Biomedical Science and Engineering 6 (2013) 1-7 6
You can get an imag e of God
From the beauty you see as a pilot.
On a clear, steel blue day—
Yes, you can get it all from that.
4. AIR FORCE
We Supported Each Other, Top to Bottom
Another day I visited with a man who had spent his ca-
reer as an Air Force pilot, and who was leaving the hos-
pital later that day with hospice. He was a young man
with several visitors in his room, so I was a bit surprised
when he immediately said yes, he would like to produce
an artwork together. Much like the man whose story ap-
pears above, this man also began our conversation by
telling me, “I can remember that I’ve always wanted to
fly. I love the sky, and the sea.” While he was laconic
and reserved, he did tell me about his experiences flying
combat missions over Afghanistan, and the spirit he felt
while working with his crew:
We Supported Each Other, Top To Bottom
I can remember
That I always wanted to fly.
I got a chance to go to the Air Force Academy,
And I’ve got an active duty commission,
And a pilot’s commission.
Flying is what I’ve always wanted to do,
And what I like doing.
That’s been the nicest thing,
The ability to do all that flying.
I was flying T-38s
And then I got into heavy C130s.
I’ve been flying up there
With a crew over Afghanistan.
When everything is in synch,
And everybody just knows where to go,
You don’t need to say anything.
We’re all doing our job,
And doing it well.
I was an Air Craft Commander,
So it all began and ended with me.
If they were on my crew,
Then we supported each other
Top to bottom.
5. CONCLUDING DISCUSSION
This article demonstrates the various ways in which ap-
plied aesthetics can help to provide comfort and clarity to
patients and family members during key moments of
transition [6,7]6. Notably, the production of the artworks
can significantly enhance an individual’s creative and
spiritual self-expression, and promote personal and group
communication at the end of life [8]7. Such artistic inter-
actions have the potential to engage deep bodily memory
and to evoke poignant subjective associations, which in
turn can help to renew the spirit and perspective of peo-
ple at the end of life and their caregivers.
In particular, the stories presented in this article exem-
plify the power of aesthetics to prov ide a common meet-
ing ground by making concrete representations of the
extraordinary—and often highly elusive—states of con-
sciousness and spiritual insight that can, and do, arise at
the end of life. By expressing these inner states out-
wardly, the artworks can help to facilitate communica-
tion and promote a sense of mutual understanding be-
tween the person and the world around them. Without
such a tangible mode of expression, these inner visions
might otherwise remain invisible. In addition, this crea-
tive modality of expression may provide an instrumental
means to help relieve pain. Once, after I presented my
work at a scholarly talk in the Texas Medical Center, a
senior palliative care physician made an extremely gen-
erous comment. He remarked that, in all of his years of
providing palliative care, he has found th at he can write a
prescription to alleviate pain, but that he can’t write a
similar prescription to relieve suffering. This presenta-
tion showed him how the work of the Artist In Residence
can help to address human suffering, which in turn can
help to ease pain [9]8.
In the extremely challenging circumstances of end of
life care, preserving the integrity of personal identity
amidst the fragmentation of terminal illness itself repre-
sents a type of heroism. In this context, the artist per-
8Regarding the connection between human suffering and various types
of pain, Dame Cecily Saunders, the founder of the modern hospice
movement who pioneered the treatment of pain for dying patients,
specifically identified four distinct types of pain that people encounte
r
at the end of life.They include not only the physical pain of the body,
but the social pain of financial and cultural crises, the emotional pain
associated with feelings of helplessness and isolation, and the spiritual
p
ain that arises from the need to feel safety and find meaning in life.
Each of these factors represents a dimension of what Saunders termed
“total pain”. As Saunders observed: “It isn’t enough to treat the physi-
cal pain alone, although this is important. The whole person is suffering
so the whole person must be treated” so that care “can reach the most
hidden places”. See Cicely Saunders, “Other components of total pain”
in Living with Dying: A Guide to Palliative Care, 3rd ed. (Oxford: Ox-
ford University Press, 1995), pp. 45-58. Notably, Saunders ends this
b
ook with a discussion of the pain experienced by the medical staff and
the corresponding need for support at the professional level.In my own
academic work, I reflect on the various ways in which the humanities
can contribute to addressing human suffering within a medical context
which, in turn, can help to shape an overall model of care.
6For extended discussions of the end of life in our contemporary culture
see James W. Green, Beyond the Good Death: The Anthropology o
f
M
odern Dying (Philadelphia: University of Pennsylvania Press, 2008);
and Allan Kellehear, ed., The Study of Dying: From Autonomy to
Transformation (Cambridge: Cambridge University Press, 2009).
7Regarding the ways in which death can shed light on the intrinsic
uniqueness of human beings, see Jacques Derrida, The Gift of Death,
Trans. David Wills. 2nd ed. (Chicago: University of Chicago Press,
2008).

M. Brennan / J. Biomedical Science and Engineering 6 (2013) 1-7 7
forms something like a witness function, a critical affir-
mation in which people tell me their stories so that there
can be a surfacing to consciousness of something that is
often lying just b elow the conscious lev el. People tell me,
so that they can tell themselves, through the words and
images that surface to the surface at the end of life. As I
noted at the beginning, these powerful images strength-
ened these men’s spirits, and at the end of life, each man
told his story with pride.
REFERENCES
[1] Brennan, M. (2013) The angels in between: The book of
muse. Axis Mundi Books, Winchester.
[2] Brennan, M. (in Press) Words beyond words: Finding
language at the end of life. Intellect Books, Bristol.
[3] Watson, M., Lucas, C., Hoy, A. and Wells, J. (2009) Ox-
ford handbook of palliative care. 2nd Edition, Oxford
University Press, Oxford.
http://dx.doi.org/10.1093/med/9780199234356.001.0001
[4] Ariès, P. (1985) Images of man and death. Lloyd, J.,
Trans., Harvard University Press, Cambridge.
[5] Fenwick, P. and Fenwick, E. (2008) The art of dying: A
journey to elsewhere. Continuum, London.
[6] Green, J. (2008) Beyond the good death: The Anthro-
pology of modern dying. University of Pennsylvania
Press, Philadelphia.
[7] Kellehear, A. (2009) The study of dying: From autonomy
to transformation. Cambridge University Press, Cam-
bridge.
[8] Derrida, J. (2008) The gift of death. Wills, D., Trans., 2nd
Edition, University of Chicago Press, Chicago.
[9] Saunders, C. (1995) Living with dying: A guide to pal-
liative care. 3rd Edition, Oxford University Press, Ox-
ford.
A NOTE ON THE TEXT fying details relating to specific individuals have been
omitted or altered, thereby assuring HIPPA compliance
and preserving issues of confidentiality, particularly as
specified under “The Privacy Rule”, The Belmont Report,
and the Department of Health and Human Services Of-
fice for Human Research Protections, including The
Common Rule and subparts B, C, and D of the Health
and Human Service specifications as outlined in the
Code of Federal Regulations (CFR) at 45 CFR 164 and
165, which specifies the “safe harbor” method of de-
identification. As noted above, all names have been
changed to preserve the privacy of the individuals in-
volved. Finally, it should be emphasized that the art-
works are not presented as sentimentalized fictions in-
tended to romanticize the end of life or to support a lar-
ger cultural narrative regarding what it might mean to
“die a good death”. Some of the stories represent con-
densations of two or more patient encounters in which
closely related narratives emerged during the visits. All
of the events I describe actually occurred and the words
are the patients’ own.
The accompanying illustration was commissioned from
the West Coast visual artist Lyn Smallwood. The artwork
was not produced in situ at the patient’s bedside, or from
a photograph or any other type of derivative material.
The image contains no recognizable likeness that bears
any resemblance to any individual with whom I have
worked, nor does the illustration resemble any artworks
now in the possession of survivin g family members. The
artwork thus complies with the standards associated with
patient privacy and confidentiality. In addition, this pro-
ject has been favorably reviewed by two independent
Institutional Review Boards (IRBs) at Rice University
and at the M. D. Anderson Cancer Center. Notably, the
subjects of this project are universal, human, and deeply
important; as such, they raise a host of compelling issues
regarding subjectivity, sensitivity, visibility, representa-
tion, and compassion that must be processed within our
culture. At the same time, due to privacy concerns, the
narratives presented here are abstracted sketches that are
intended to be generic and anonymous. Particular identi-