That Good Night: Life and Medicine in the Eleventh Hour

That Good Night: Life and Medicine in the Eleventh Hour consists of 13 chapters divided into three parts titled Between Two Dark Skies, The Unlearning, and Infinity in a Seashell, respectively. Puri begins the memoir by recounting her time at the University of California San Francisco School of Medicine palliative care unit where she was completing her last few months of medical school. During this time, Puri details a series of interactions with a terminally-ill patient suffering from kidney failure who decides against further dialysis treatment due to the worsened quality of life that it brings them. In trying to understand the patient's wishes, Puri begins to acknowledge the conflict that exists between medicine's inclination to prolong life at all costs and alleviate patient suffering. This marks one of the defining moments in her decision to enter palliative medicine.

The book recounts many similar conversations with patients about end-of-life decisions and goals of care, through which Puri also weaves in her own childhood and family memories. A prominent recurring memory about Puri's family involves memories about her mother, an anesthesiologist, and how Puri and her brother, Siddhartha, would frequently miss her while she was working.

Part 1 of the memoir culminates with Puri being accepted into a fellowship program in palliative and hospice care at Stanford University while she finishes her last few months of residency in internal medicine at the University of California San Francisco School of Medicine. In Part 2, Puri transitions into her role as a fellow, which begins officially on July 1, 2013. She acclimatizes to a higher degree of autonomy while still working under the supervision of an attending physician. During her residency, she rotates between three different hospitals to help treat patients with serious illnesses. Her work involves treating patients' symptoms such as nausea, cancer pain, and shortness of breath while discussing goals of care with patients and their families. Such conversations typically commence with Puri explaining her role as a palliative care specialist to the patient, determining the patient's definition of suffering, and further discussing what kinds of medical decisions could be made (or avoided) in order to minimize such suffering should the patient be too ill to voice his/her wishes in the future.[2] Many times, medical decisions befall on the patient's family members in the book.

In Part 3, Puri recounts her first job as an attending physician where she sees hospitalized patients in the morning before conducting patient home visits during the afternoon. Her team consists of a palliative care nurse and a social worker. Puri's work as an attending still leaves her longing for a sense of permanence. She finds that working primarily in a clinical setting leaves her feeling exhausted and rushed during patient encounters. Thus, she takes on a new job with more teaching opportunities at the Keck Medical Center of University of Southern California. During her last week as an attending, Puri recounts an experience where she helps take care of a terminally-ill patient who reminds her of her mother. The experience prompts Puri to think about her own parents and how she could discuss their wills and advanced healthcare directives should a similar issue arise. Puri promises herself that she will begin to devote more time to activities that she wasn't able to complete during her hectic medical training years, such as learning how to cook, going camping, and reaching out to relatives in Mumbai. Additionally, Puri finds new comfort in her spirituality and readings of the Gita, which helped teach her how to accept death. In addition to seeing patients, Puri's new career involves teaching fellows in the oncology and intensive care medicine units, as well as fourth-year medical students. Puri's memoir ends with a recollection of a lecture she presented at USC about the field of palliative care followed by a tender memory of time spent with her mother.

While growing up, Puri's family involvement with spirituality catalyzed her awareness towards the impermanence of human life and suffering.[3] Puri's mother, an anesthesiologist, inspired Puri to complete her medical school training and internal medicine residency at the University of California San Francisco School of Medicine, where Puri's interests naturally gravitated towards palliative medicine and hospice care. Thus, Puri's personal outlook on mortality, coupled with her experiences in helping and talking to terminally-ill patients during her years in medical school, residency, and fellowship at Stanford University, ultimately drove her to write the memoir.[3] During the development of the book, Puri consulted with professional colleagues, patients, and the family members of patients in order to properly recount yet preserve the identities of the individuals in her stories.[1] While writing her memoir, Puri hoped that the situations described in the memoir might help others patients and families feel less alone in their navigations of mortality and end-of-life decisions.[3][4]

Prolonging Life: Puri highlights that many physicians are trained to try and prolong patients' lives, even if such medical interventions and procedures come at the cost of a patient's comfort or quality of life. This issue is brought up regarding terminally ill patients many times throughout the book. The issue has created a gap within medicine between the deeply ingrained effort to extend life and the acceptance of the possibility of death that comes with focusing on alleviating a patient's suffering and symptoms.[5][6]

Spirituality: Puri shows how an individual's spirituality and culture may be able to provide them emotional relief and comfort during their last moments of life or during their struggles with overcoming a disease.[2] For example, Puri reveals that her mother, who was an anesthesiologist, commonly asked patients if they preferred to pray together before surgeries. Such moments of prayer would bring comfort to many of her patients.

Communication: Another theme within the book involves communication surrounding death. Puri highlights how opening honest and clear discussions about the possibility of death with patients and family members may help make it easier for patients to focus on enjoying a good quality of life.[4] Puri calls attention to how the overuse of euphemisms in clinical settings may lead to unclear conversations that further confuse patients and/or their family members about the possibility of death. Furthermore, she upholds that honesty is important for such sensitive topics, especially in the field of palliative medicine.[7]