Book Club Discussion Questions for Knocking on Heaven's Door by Katy Butler

1. Where do you draw the line between saving a life and prolonging a dying? Has your family included a member who "lived too long"? Do you think it is okay to "let nature take its course"? How do you distinguish that from suicide?
2. How did you feel about Valerie Butler's choice? Was it brave, or not? Do you think it caused her children more or less suffering than her husband's death? What were the blessings and drawbacks of her unexpectedly rapid death? What were the advantages and disadvantages of her husband's protracted death, from the point of view of his survivors?
3. Butler writes, "I don't like describing what the thousand shocks of late old age were doing to my father—and indirectly to my mother—without telling you first that my parents loved each other and I loved them" (p. 2). In this passage she drops her journalistic point of view and turns directly to the reader, using the word "love." Discuss Butler's relationship to each of her parents and their relationship with each other. How does each change throughout her father, Jeff's, illness? Is there redemption? Reconciliation?
4. Dr. Sherwin B. Nuland said of Knocking on Heaven's Door, "Katy Butler's astute intellect has probed deeply and seen into the many troubling aspects of our nation's inability to deal with the reality of dying in the twenty-first century...This elegiac volume is required reading for every American adult; it has about it a sense of the universal." What do you think makes Knocking on Heaven's Door feel universal? What aspects of the "reality of dying in the twenty-first century" surprised you?
5. When Katy's mother, Valerie, asks for Katy's help getting Jeff's pacemaker turned off, Katy says, "I felt like my father's executioner, and that I had no choice" (p. 5). How do you explain this sentiment? Why does Katy agree to help her mother? What resistance do they run into when trying to get his pacemaker turned off?
6. What is palliative care, and how does it differ from hospice care? When Jeff is able to get into a palliative care program, what is the effect on the Butler family?
7. Jeffrey Butler's "stroke devastated two lives" (p. 31). How? What are the burdens that are placed on Valerie as caregiver? Valerie attends a caregiver support group only once, saying that she cannot spare the time. Do you think that's the real reason that she decides not to return?
8. If Jeff had lived before the pacemaker existed, Butler notes that "nobody would have called his heart diseased—just worn out" (p. 57). How did the invention of the pacemaker affect modern medicine? How else did medicine change following World War II?
9. When Katy visits her father in the hospital following his stroke, she recounts watching an orderly shave him, saying "he paid close attention to what he was doing and invested the moment, the room, with a presence I can only call sacred" (p. 21). Why is this moment so profound for Katy? Why do you think the orderly's actions teach her how to love her "helpless, broken, and infinitely slowly dying father" (p. 21)?
10. What were your initial impressions of Valerie? What did you think of her decision to refuse treatment when facing her own illness? How did your view of Valerie change during the course of the book? Did she show courage when she refused open-heart surgery? Should we redefine courage at the end of life to mean allowing a peaceful passing rather than fighting an endless battle against cancer, for example?
11. How did Valerie's relationship with her daughter evolve? Do you think this constitutes "redemption," despite the partial nature of their reconciliation? Katy frames this as a common inter-generational conflict; is it true to your own life?
12. In Knocking on Heaven's Door, Katy Butler describes the "Slow Medicine" movement. What is it? Discuss the ways that Slow Medicine differs from "Fast Medicine." Why do you think Slow Medicine has gained in popularity?
13. Does technological medicine's aim for maximum longevity have some benefits? For example, do you have relatives who have benefited from late-life surgeries? What has been your family's experience, good and bad?
14. Of her actions during Jeff's illness, Butler says, "maybe the best thing I did was write my father love letters" (p. 93). One of the themes of the book is the balance between trying to "fix" things and accepting the unfixable with love and grace. Katy spends a lot of time trying to fix things for her parents. Do you think she comes to any self-awareness about the limits of fixing or the value of unconditional love?
15. Butler writes, "Love can look heartless" (p. 211). What decisions do she and Valerie make regarding Jeff's end-of-life care that could be construed as "heartless" to someone on the outside? Why do they make those decisions? Katy says, "I wanted him to die because I loved him" (p. 195). What do you make of this?

1. Butler chose to include Makeda, Queen of Sheba, translated by Jane Hirshfield, as an epigraph in Knocking on Heaven's Door. Discuss the poem as it relates to your life. Was there a time that you "dived into the great sea" and came up with a pearl of wisdom? Was it worth the pain?
2. Valerie and Katy made the difficult decision to turn off Jeff's pacemaker. Was there a time you went with your gut when experts were telling you otherwise? How did you know you were doing the right thing? Or did you only know later? Share your story with your book club if you feel comfortable doing so.
3. Can or should we redefine the meaning of hope at the end of life? When hope of extending life (with good quality) is no longer wise, are there other sorts of honest, meaningful hopes for friends and relatives? What kinds of family healing have you seen when it was known that death was imminent or wished for?

1. How can you empower your doctor to have an honest conversation with you rather than avoiding the issue, giving treatments that won't work, or offering dishonest hope?
2. Butler cites Francesco Fiorista, a practitioner of Slow Medicine, as saying "To do more is not necessarily to do better" (p. 59). Keep this statement in mind when speaking to doctors about the proposed course of treatment for your friend or relative. Ask about the pros and cons and any alternatives to suggested treatments and tests.
3. Before agreeing to a test, ask: Will the results change future treatment? Is this appointment necessary?
4. What about doing nothing? It is often taken as a given that one's decision is not of how but when to treat. Ask first whether treatment is necessary. What are the goals of the treatment? How will the quality of the patient's life be affected? Can you watch and wait? Provide comfort care only?
5. Ask: What is the typical trajectory of the diagnosis? What can you expect next? Is palliative care an option? Can your friend die at home?
6. On page 277, Katy lists the stages of the last chapter of life: fragility, decline, disability, failing health, and active dying. Ask your doctor where your friend or relative is on this path. Have they reached the point where they are likely to return from each hospital stay worse rather than better?
7. Before agreeing to surgery, ask about: Recovery time, and whether home assistance or rehab will be required; Risks to cognitive functioning. Get a cognitive assessment before any open-heart surgery or general anesthesia; Level of function after recovery

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Unless otherwise stated, this discussion guide is reprinted with the permission of Scribner. Any page references refer to a USA edition of the book, usually the trade paperback version, and may vary in other editions.