Patel, Kashyap. Dying Without Fear: The Pursuit of Eternity. Penguin Random House India; 2020.

Yes, I can defi nitely share my journey with you. I will also sharesome of my other patients stories with you, if you believe theywill help.When do you want to begin?

Maybe we can meet once a week at lunch time, here under thisbeautiful copper dome. Could we start tomorrow?

So beings a series of conversations which unfold in the captivatingrelationship between Harry Falls, a former pilot with theBritish Royal Air Force and later a fl ight instructor in the UnitedStates, and Kashyap Patel, MD, author of Dying Without Fear,which will be available soon from Penguin Random House India.Production delays due to coronavirus disease 2019 will require theApril 2020 launch date to be rescheduled. (See Cover.)

Readers of Evidence-Based Oncology (EBO) will recognizePatel as an associate editor and contributing author. Patel is amedical oncologist/hematologist and the chief executive officerof Carolina Blood and Cancer Care Associates, based in RockHill, South Carolina. Having grown up in India and practicedmedicine on 3 continents, he has devoted tremendous personaltime and travel to nourish his interest in world religions andculturesparticularly to gain insight into the universal humanexperience of death.

Falls, married to one of Patels colleagues, died within months ofa diagnosis of lung and liver cancer. Yet, amid the challenges of hisillness, Falls was incredibly fortunate. He had the rare opportunityto discuss his questions about death with Patel, a physician andfriend who was exceptionally well-equipped to help Falls prepare for what the aviator called his ultimate and infi nite journey.Throughout the last months of Falls life, the pair met weekly toexamine death from multiple vantage points: physical, emotional,relational, cultural, and spiritualreligiousphilosophical. Theirencounters provide the foundation of Dying Without Fear.

Patels medical facility was well-designed for conversationswith Falls. The doctor explains, My clinic, Carolina Blood andCancer Care, was founded on a holistic approach to the treatmentof cancer. We constructed the building with a U-shaped designthat allowed all patients to look out onto a healing garden witha gazebo topped by a golden dome. When weather permitted,patients could receive their chemotherapy treatments outside onthe patio or under the dome. It wasnt just for the patients comfort.During difficult discussions, a quick glance at the garden in bloomor the smile of a patient resting in the sun grounded me, put lifein perspective, and reminded me of my mission of service.Patelsclinic was an early adopter of the patient-centered cancer caremodel designed to serve holistic needs of patients, with a focuson palliative care.1 As described previously in EBO, Carolina Bloodand Cancer Care Associates has been one of the most successfulpractices in the country in executing alternative payment models(APMs), which gives practices more support to help patientswith advanced care planning.1,2 But when Patel and Falls were having their conversations years ago, these ideas were still new,and support systems like the one that Patel created for Falls wereharder to find.

The healing garden is the recurring setting where readers ofDying Without Fear will vicariously accompany Falls along hisjourney toward death. Pondering his grim diagnosis, Falls decidesnot to pursue chemotherapy or any other treatments, becausethey would involve diffi cult adverse eff ects and would be unlikelyto prolong his life significantly. After evaluating where I standand how Ive lived all these years, I feel it would be best for me tostart packing my bags for the ultimate and infinite journey. God blessed me with a life that I have noregrets over Lets face it, Doc. From everythingyouve told me, treating my cancer is like trying tosave an exploding plane in mid-air. Chances areits not going to happen. I think of it like Ive justreceived an upgrade on a long fl ight. Ive collectedso many miles that God has granted me a charterflight to a destination unknown. Now the only issueis the waiting time.

Doctors have debated for more than 20 yearson how to engage cancer patients in the decision-making conversation once they have reachedthe terminal stage.3 The culture of care in theUnited States suggests that Falls is an exception,with language around treatment calling onpatients to fight cancer even when it cannot be cured. A 2019 study of 20 women with metastaticbreast cancer found that patients definitionof a good compassionate doctor was one whogives positive news and leaves room for hope.4Another study published last year found that 28%of patients with imminently fatal colorectal cancerreceived treatment , even though this can preventpalliative care.5

Patel writes, Even when I was seeing patientswith very advanced cases where I knew they werebetter off dying peacefully than going through thepains of chemotherapy, which bought them maybe afew more weeks, almost every patient I came acrosswas adamant about hoping for a miracle. But Harrywas different.

Falls decides he will not pursue extraordinarymeasures to avoid death, but he has an extraordinarycuriosity about the dying process, which Patelstrives to appease. Upon receiving his terminaldiagnosis, Falls says, Doc, Im not a religious orritualistic individual. Im somewhere between anon-believer and an agnostic. But I have somefundamental existential queries that are hauntingme. I want to know how death has been definedall these millennia. How do people die? Did ourancestors understand death in a similar fashion toour understanding? How did they treat the bodiesafter death? How was this diff erent across cultures?What about the afterlife? What is a good death, orrather, what does it mean to die well? I can handle amid-air somersault and navigate the worst turbulence.But I am totally incapable of even remotelyimagining my own mortality and afterlife.

Patel responds, I wish everyone facing death,which is in fact everyone someday, would spendtime thinking about these questions.

Patel comes to the conversations with immensecross-cultural knowledge. The reader is drawn in bypoignant stories of a doctor and his terminal cancerpatients, which stimulate Falls discernment abouthow to spend his final days meaningfully, and aboutdisposition of his body after death. For example,Patel introduces the Indian custom of a funeralpyre, and describes how he fulfi lled the traditionalceremonial role of igniting his brothers funeralpyre. He explains beliefs and rituals associated withdeath in ancient Egypt, Greece, Rome, and Australia,and in Hinduism, Buddhism, Judaism, Catholicism,evangelical Christianity, and Islam. He delves intotopics not normally covered in a physicians training,such as the human soul, possibilities for an afterlife,and the meaning of suffering.

Although his cancer is not cured, Falls satisfieshis human need to prepare for a peaceful death.Readers will not want to put the book aside until they learn how Harrys story ends.

Patels purpose for writing Dying WithoutFear, described in an interview with EBO, is toprompt communal and personal preparation for aprofound human experience that is unavoidable,yetparadoxicallytoo seldom a subject of openconversation. Patel thinks humans will have moremeaningful and comfortable experiences of deathif their community does not treat death as a taboosubject, or an event to be delayed through extreme,often painful measures that yield meager improvement in longevity or quality of life. He writes:

I see it every day; patients in their last few daysenduring horrifi cally painful therapies when wehave already informed them that the end resultof that dreadful suff ering will be maybe twoor three more weeks of life spent in agonizingpain. The pain and the therapy do not allowthem to spend time with their loved ones or enjoy the comforts of life. Those few weeks are spentchained to a hospital bed. We are too willing, itseems, to bargain away quality time with thosewe love and freedom from debilitating pain inexchange for fourteen to twenty-one more dayson earth. And in that last leg of the marathon,instead of preparing and planning for a graceful and pain-free departure surrounded by those wehold dearest, we prefer to ruin those last, mostprecious moments in pursuit of a farfetched cure,ensuring that the fi nal days we spend on earthare the most miserable of our entire lives. It isthis fate that, as a physician who has been at thedeathbed of countless numbers of my patients, Iwant to help people avoid.

As Patel shares stories of his deceased patients,its evident that they have benefi ted from a highlyattentive physician. He accepts their calls to hiscell phone at all hours; he visits their homes;he attends their funerals. Readers who havestruggled to schedule appointments with theirphysicians may be astonished at the generosity of the time spent with Falls. Yet, from an ethicalperspective, Dying Without Fear raises serioussystemic concerns about empowering patients toexercise genuine informed consent. How much isinformed consent for end-of-life decisions underminedor impossiblefor countless patientswho begin the dying process as Falls did, but neverhave the opportunities for education and reflectionthat he received?

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