The Year of Magical ThinkingBMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7526.1208 (Published 17 November 2005) Cite this as: BMJ 2005;331:1208
Relatives. Rellies. One of the relatives wants to speak to you. Heartsink. Fair enough, we say—bring them on—but what if the daughter in bed six with the subdural had an international normalised ratio greater than four before she came in? What if said rellie has bought various textbooks on neurosurgery and checks out the New England Journal of Medicine online? What if mum is one of America's most astute and gimlet eyed commentators of modern times? What if mother is none other than the acclaimed US writer and novelist Joan Didion?
Fourth Estate, £12.99, pp 240 ISBN 0 00 721684 X
“If you want to manage this case I'm signing off.” So concludes one stressed out intensive therapy unit (ITU) medic at UCLA (the University of California, Los Angeles), and Didion brilliantly delineates here why she has provoked such a response, why relatives can often become irrational, how her reasoning “was demented, but so was I.” Didion's husband, the writer John Gregory Dunne, had a cardiac arrest at home on 31 December 2004. Resuscitation by paramedics was unsuccessful. Meanwhile, her daughter, Quintana, was across town in another Manhattan ITU with pneumonia and septic shock. This was later complicated by pulmonary emboli and then subsequent brain surgery two months later on the west coast. The Year of Magical Thinking is Ms Didion's achingly honest record of these drastic events and her reaction to them. Unsparingly she breaks her bad news and its lesson for us all.
Didion's legendary detached approach, her restraint, is alluded to unknowingly by the social worker allocated to her shortly after the arrest team conclude their efforts. He laconically observes that “she's a pretty cool customer.” All too soon, though, her ultra-rationalist marshalling of the facts of her husband's death breaks down as she faces what she calls “the vortex effect” of grief, the look of which she recognises as “one of extreme vulnerability, nakedness, openness” akin to “someone who wears glasses and is suddenly made to take them off.” Didion struggles throughout the events to put her specs back on, to get the traumas into focus, and by doing so begins to see more clearly as if she had wiped the dirty windscreen of life clean again. Confronted by her comatose daughter she is bluntly forced to accept that “things happen in life that mothers could not prevent or fix.”
She uses her forensic skills in linguistic analysis when confronted by medical obfuscation. She is alert to the fact that a drug is “struggling to overcome its problems in the sepsis market” according to one business newsletter. A Joan Didion will notice the banners declaring UCLA “the number one in the west, the number three in the nation” and wonder exactly whose ranking this was and what does it really mean? When her daughter has the embolism you read the terse sentence “no chest x ray was taken” with a chill. And she is aware of the froideur her behaviour causes: “I had noticed a stiffening when I used the word oedema.”
But Didion is no less merciless in the dissection of her own cul de sac of self pity. Initially she was “so determined to avoid any inappropriate response (tears, anger, helpless laughter…) that I had shut down all response.” She accurately understands that she “just can't see the upside in this” and crushingly tells us, “I cannot count the days on which I found myself driving abruptly blinded by tears.” The great chronicler of the Californian paradise in crisis now finds herself in a lonely hell, one where she is somehow still capable of appalled insight. She writes, “So profound was the isolation in which I was then operating that it did not immediately occur to me that for the mother of a patient to show up at hospital wearing blue cotton scrubs could only be viewed as a suspicious violation of boundaries.”
For Didion “grief turns out to be a place none of us know until we reach it.” More troublingly, she devastatingly concludes, “Nor can we know ahead of the fact (and here lies the heart of the difference between grief as we imagine it and grief as it is) the unending absence that follows, the void, the very opposite of meaning, the relentless succession of moments during which we will confront the experience of meaninglessness itself.”
The abandonment of the automatic, those habitual quotidian events that accompany life with one you have lost, such “craziness recedes,” but Didion still craves clarity. She delivers it here in what is for me the saddest, truest, most frighteningly throat clenching account of loss I've ever read. Reporting a conversation with her husband she tells us, “As we would say to each other to the point of whether something was accurately reported or perceived, ‘Get it right.'” And that's just what she does here, as a relative, as a survivor. She gets it right.