Silent Breath
Author: Kyōko Minami
Specifications: ISBN  978-4344029996
325 pages
13.0 x 18.8 cm / 5.2 x 7.5 in (WxH)
Category: Fiction
Publisher: Gentosha Inc.
Tokyo, 2016
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This novel follows the footsteps of a doctor who works for a health clinic serving terminally ill patients who wish to die in their own homes rather than in an institutional setting. Although surveys indicate that most of Japan’s elderly wish to live out their final days in the familiar surroundings of home, lack of the necessary support infrastructure means that the vast majority continue to die in hospitals. This work delves into the gap between patient wishes and the current state of end-of-life care.

As the story opens, Dr. Rinko Mito, 37, is ten years into her career as a physician and working at a top-ranked university hospital known for its advanced-care capabilities in central Tokyo’s Shinjuku district. She is a thorough doctor who explains things carefully to her patients and tries to give them as much time as they need to understand their situation and options, but in a university hospital setting that stresses speed, she often finds herself being chided for inefficiency by both peer physicians and nurses. One day her supervisor, Dr. Ōkōchi, transfers her to a small satellite clinic in the suburbs that specializes in delivering healthcare through home visits. The clinic was opened experimentally just three years before as a way for the university hospital to get a better handle on community health needs. It occupies an ordinary apartment unit that patients rarely if ever visit, and is staffed by Rinko, the only doctor; a male nurse named Kōsuke Takeda, who is also the driver of the clinic car; and a medical clerk named Junko Kamei, who handles administrative matters and holds down the fort while Rinko and Kōsuke are away. Although Rinko is at first deeply disappointed by the transfer, which she views as a demotion, she soon gets caught up in visiting patients and tending to their needs, and as she gains new experience and skills and reevaluates the importance of what she is doing, she comes to embrace her role as a specialist in end-of-life care.

The story details five of the cases Rinko is involved with over the next two years. As a rule, her patients are all terminal, with no hope of recovery. In some instances the family wants treatment to proceed, but the patient refuses any and all life-extending treatments that run counter to nature. The case of Isao Gondō, 72, an emeritus professor who was once director of the university hospital, provides a representative example. At the height of his career he reigned as the leading specialist in gastrointestinal cancers, but he has now been diagnosed with pancreatic cancer and given just three months to live. His colleagues in the oncology department want to treat the cancer aggressively, just as Gondō himself had always recommended for his patients. To their surprise, he refuses all treatment, even palliative measures, and asks to be discharged so he can spend his final days at home, specifying that he wishes Rinko to be his attending home health physician. When she visits him for the first time, she finds him emaciated and weak, and questions whether he’ll last even three days, let alone three months. He repeats to her that he wants no treatment, not even an IV drip, and tells her not to come again until he asks for her.

But he calls her back the very next day. “There are some things I need to do before I die,” he says, and asks for an IV drip and pain medication after all. A few days later, when he has regained a modicum of strength and in part with Rinko and Kōsuke’s help, he begins visiting a number of men and women at their workplaces or homes. Who the people are remains a mystery at first, but it eventually comes out that they are the “super-longterm” cancer survivors who are still living more than 20 years after going under Gondō’s knife. Gondō had decided that he wanted to visit each of these cancer survivors to see for himself how they had fared in their lives so he could declare to the world one last time that cancer should not be regarded as an automatic death sentence. Gondō completes his project, praises Rinko for how she has attended to him in his final days, and breathes his last. He had requested Rinko as his physician precisely because he’d heard good things about how she helped her terminal patients through the dying process.

In the last chapter, Rinko attends her own 78-year-old father as he goes into his final decline at home. Bedridden after suffering two major strokes, he had long been cared for in a nursing facility. He’d become completely unable to communicate three years ago, but neither Rinko nor her mother was prepared to withhold any available treatment so long as he still could breathe. Finally admitting to herself that they are only prolonging her father’s suffering, Rinko persuades her mother that the time has come to take him home and let nature take its course. This story, in which both the patient and family sides of the end-of-life decisions are personal for her, provides the final lessons for Rinko as she settles into her calling as a terminal-care physician.

Dr. Ōkōchi’s armchair detective work in solving a variety of mysteries keeps things entertaining throughout, but the varied set of cases together with the highly informative and precise clinical detail provided also allows the novel to do double duty as a kind of handbook to end-of-life care. It offers readers much to consider when contemplating how they would like to meet their own final days.