My father had a cardiac arrest at 2:45 p.m. on the afternoon of April 12th, 2006. My wife paged me as I was coming home from work at the Montreal Neurological Hospital to tell me that he had collapsed and been taken to a hospital in Winnipeg, the city where I grew up and my parents still live. He was alive but unconscious -- that was all I knew as I changed course and headed for the airport to try and get a flight.

When I called my wife from the boarding gate to say goodbye, she commented on how calm I sounded. She had been crying and our five-year-old son was similarly upset. I didn’t have an explanation for her, but even on the flight, with nothing to distract me from thoughts of what lay ahead, I felt no sense of panic that I imagined would come with the illness of one of my parents. Perhaps it was because in my job as a neurologist I regularly saw patients who had become suddenly, gravely ill, and it was natural for me to think of these situations in their most material sense. In that way, what would happen to my father would be independent of anything I thought at that moment. Rather, it depended on a series of variables, conditions met or unmet, the skill of the people who would care for him. His future was now one of discrete probabilities.

For instance, I knew that his chance of surviving an out-of-hospital cardiac arrest was less than 15% and that if he did not wake up quickly, the odds of a meaningful recovery would be increasingly slim. The next seven weeks, during which my father illustrated the limitations of such predictions, would see my family grapple with the meanings of a prognosis and make me examine how and why I arrived at such judgments. On the flight to Winnipeg, it didn’t occur to me to grieve or pray. I was thinking of him, but I was thinking of the numbers.

Welcome to the Intensive Care Unit. Pass through the doors (which will open automatically, a pneumatic whooshing as a plate of tempered glass slides past your nose) and you will be confronted by an onslaught of stimuli: banks of monitors, the background huff and purr of ventilators, the alarms that chirrup like birds in this strange forest. The ICU is that most extreme junction of technology and illness, and to an outsider it inspires a familiar mix of dread and awe. Reassured it exists, it is still a place most people hope to avoid.

In the clamor of the ICU, it is not unusual to see a neurologist like me examining a comatose patient. Coma, officially a state of unarousable unresponsiveness, can be caused by many medical conditions, but what they all have in common is that they lead to the malfunction of parts of the central nervous system responsible for alertness and attention (specifically a region of the brainstem called the Ascending Reticular Activating System, or both cerebral hemispheres). It is the frequent task of a neurologist to document a critically ill patient’s condition and help to diagnose the cause of coma, but more often than not, the diagnostic work is already done. By the time the neurologist arrives in the ICU, the reason for the consultation has changed, and the question has become singular and explicit—what is the patient’s prognosis? What are the chances that this patient will wake up and if they do, what impairments will they face when they awaken?

These questions arrive in the wake of a catastrophe, a patient suddenly and gravely ill with a brain riven by hemorrhage or damaged after a cardiac arrest, and the shock and anguish of the family is palpable. A witness might also reason that making such a determination—one that establishes the course of treatment and therefore the patient’s likelihood of survival—is emotionally difficult for the doctor involved, whether they be a seasoned practitioner or a resident in training. But if you listen to the discussion of doctors around such cases, any sound of hand wringing is drowned out by the quotation of statistics and the repeated mention of one name—Levy.

Levy isn’t anyone I have worked with, or even met. But Levy always enters the discussion. D.E. Levy co-authored a seminal paper, first published in the Annals of Neurology in 1977, on prognosis in non-traumatic coma, providing neurologists and intensive care physicians with a framework to better predict which patients would get better and which ones would not. Levy’s paper dealt with the natural history of coma (excluding those patients who were in coma because of overdoses or trauma), trying to determine if features of the physical examination could help predict which patients would have a ‘good recovery’ or ‘moderate recovery’, defined as having an improvement in their condition sufficient to allow them to return home. The study’s final results were published in the Journal of the American Medical Association 1985 and offered a simple and robust method of predicting how a comatose patient would fare. The results were distilled into an algorithm and from this emerged what seemed to be several incontrovertible truths: twenty-four hours after being in a coma, if the patient’s pupils were not reactive to light, the chance of moderate or good recovery at one year was zero. Similarly, at three days, if a patient did not respond to a painful stimulus by withdrawing from the pain, again, the chance of recovery was zero. In the years that followed, other studies have confirmed that the possibility of awakening decreases dramatically in that first week—50% on day one, 20% on day three and 10% by the end of the first week—and those who do awaken after more than three days of coma often have severe disability.

The Levy study was a landmark: useful and widely applicable, it quickly became a vital resource for neurologists and other doctors who were called upon to deal with these challenging situations. During my neurology residency in the mid-1990s, I worked with a colleague who carried a summary of the Levy study everywhere she went in the hospital and had the algorithm laminated to make the information more durable, in a literal sense. And even though the study has been superseded and its conclusions refined by more recent studies, the Levy paper is still cited today. I have always liked to think that I handled the question of prognosis in a comatose patient with sensitivity and diagnostic rigor. While I’ve never deluded myself that I could make the patient better, I always felt I was of assistance to the family. Reassuring them that their loved was in no pain was an important and humane thing to do. I felt I was adept at explaining the reason for coma and, using the information, including the Levy data, estimating the chances of survival, transforming the unknown into the known. There was a certainty to the statistics that, as a physician, I was glad to impart to the families. And even if the statistics were grim, I reassured myself that I used the numbers to give comfort to families, when necessary, reassuring them that the outcome could not be altered, that they were not prematurely giving up on their relatives, that prolonged efforts would only cause their loved one to survive in a state that offered no degree of consciousness nor hope of improvement.

Neurologists are well aware that we are having these discussions in a culture where people are often portrayed as magically awakening from prolonged comas. A study in the British Medical Journal in 2006 reviewed the outcome of prolonged coma on soap operas and found that 89% of characters experienced a full recovery (as opposed to the typical quoted statistic of less than 3%). To compound the error, the television characters usually emerged from their comas as though awakening from a long and restful sleep, fully refreshed and neurologically intact. I was doing my duty by saving families from false hope, knowing the stark difference between popular perceptions of a patient recovering from coma and reality. To deal with such misperceptions, I, like my colleagues, would come to those bedside meetings fully armed with physical facts. And Levy.
My tone was always reassuring and empathetic. I was truly sorry for their loss, giving my condolence for a family member who wasn’t yet dead. While I may have done this intuitively, my actions mirrored what was becoming a more articulated approach, ratified by the American Academy of Neurology, whose 2006 Report of the Quality Standards Subcommittee on prediction of outcome in comatose survivors contains similar words intended to reassure-----“The neurologist can explain that the prognosis is largely based on clinical examination with some help from laboratory tests. In a conversation with the family, the neurologist may further articulate that the chance of error is very small.”

The conversations with families of comatose patients were never pleasant, but I was always surprised at how well I could handle the situation. Until recently, I didn’t fully understand why giving a bad prognosis and discussing the end of a patient’s life wasn’t more difficult for me. All I knew was that the statistics helped. Levy helped.

It seems obvious that we are awash in predictions about our health. In the first minutes of our lives as we are wiped and weighed and taken from our mothers, the rate of our heart and respirations are measured, the tone of our muscles and duskiness of our skin is evaluated, and we are given an Apgar score, which has been found to be a valid predictor of whether a newborn will survive its first 28 days. This is our first prognosis, if we haven’t already had some form of prenatal screening.
Some predictions about our future health don’t necessarily require knowledge of us as individuals; our demographic identities can be affixed with a life expectancy, influenced by the country in which we are born, by our sex and race. In this way, every person can be branded with a rough approximation, an actuarial estimate, of how long a life they can expect. The rise of randomized clinical trials and evidence-based medicine as the basis for making therapeutic decisions have made doctors increasingly conversant with certain expressions of prognosis—the distillation of information that constitutes the Levy data or five year cancer survival rates or age-adjusted life expectancy—but these seem crude estimates of natural history, endpoints rather than full discussions of what awaits a patient with a particular illness. To most people, a prognosis needs a personal, immediate context—a prediction in the face of an illness, there must be context and personal immediacy. A prognosis is thought of as a judgment, delivered as the doctor looks at you, right after discussing the name of the illness and the available treatments. Outside of personal musings, a prognosis may be the first acknowledgment of our mortality, the limit attached to our otherwise undecided futures, and it carries all the mystery and weight of a prophecy.
It is classically taught, and intuitively understood by the public, that prognosis is the third leg, along with diagnosis and treatment, in the triad of a physician’s essential responsibilities to the patient. So it comes as a surprise to most that the discussion of prognosis between doctors and patients occurs quite infrequently: a study published in The American Journal of Medicine in 2001 looked at the charts of patients with terminal cancer and found that discussions about prognosis were documented in only 38% of the patients’ charts and in those cases the patient and the doctor were involved only 52% of the time. In his 1999 book Death Foretold—Prophecy and Prognosis in Medical Care, Nicholas Christakis, an internist and sociologist who teaches at Harvard University, contends that the low rate of discussions about prognosis is not accidental but rather reflects larger technological and cultural shifts in medicine. Perhaps the largest blow to prognosis has been, happily, effective treatment. It makes sense that when treatment is uniformly successful, recovery becomes a foregone conclusion and the need to even discuss outcomes is rendered unnecessary. The column space in medical textbooks devoted to discussing the prognosis of an illness like pneumonia has dwindled, largely replaced by a discussion of appropriate antibiotic therapy. Another reason for the waning of prognosis, Christakis purports, is that with the dawn of the twentieth century medicine moved from a notion of disease focused on the constitution of the sick person to one based on the illness itself. With greater emphasis being placed on a disease having a discrete existence and a ‘natural course’, prognosis was accordingly ‘clarified’ as something inherent to the diagnosis and therefore requiring less consideration.

Christakis also asserts that most doctors, trained to operate in a world of verifiable facts and material evidence, dread the uncertainty inherent in talking about prognosis and that professional norms and a medical culture have evolved to avoid explicit discussions of prognosis in medical practice. And so the discussion does not occur, or may devolve to the recitation of statistics from which the patient is left to draw their conclusions. But when a prognosis is invoked, Christakis contends, it is rarely without a purpose. The book features numerous anonymous anecdotes of physicians relating how they have at one time or another ‘emphasized’ certain aspects of a prognosis: a positive spin is put on a prognosis as a form of psychological support for a fragile patient in need of reassurance, a negative slant is used scare a non-compliant patient into adhering to a treatment regimen. The rationalizations for such behavior are clear in each anecdote: the doctor wants the best outcome for their patient and in a way is attempting to employ prognosis to alter prognosis. Through these anecdotes, and many others that we are familiar with from our own experiences in health care, one sees how prognosis can be used—and potentially misused—as more than an adjunct to therapy, but as therapy itself.

It is those particular situations where no effective therapy exists—the comatose patients in the ICU, for instance—that concern me most as a neurologist, and it is here that Christakis says prognosis has been used by the medical culture, and physicians in particular, in ways that extend beyond the mere calculation of outcomes. Formulating a prognosis may allow the physician to establish a semblance of assuredness and authority in a situation where the stakes may be high. (This observation is hardly new; in Part 1 of The Book of Prognositcs, Hippocrates wrote that not only will a skilled prognosticator be esteemed, but, ‘by seeing and announcing beforehand those who will live and those who will die, he will thus escape censure.’) It isn’t difficult to understand how prognosis may serve not just as a way of protecting or enhancing professional status but as a psychologically protective device as well, reducing anxiety and absolving guilt a doctor may have about limiting therapy. A prognosis can also provide the framework necessary to unite all those involved with the sick individual—doctors with differing opinions, nurses, families—into an agreed-upon plan of action. The plan of action, it goes without saying, is usually formulated by physicians and that raises the most troubling aspect of prognosis—that more than its use as a means of asserting control, it can be employed to actively determine outcomes under the premise of respecting the ‘natural course’ of an illness, that a prophecy tends to be fulfilled if it is the prophet who guides events.

Throughout Death Foretold, Christakis, perhaps because he is a physician or perhaps because he approaches the question with an academic’s detachment, never adopts an accusatory tone, and as a result the book is far more analysis than indictment, but it is hard for any doctor who reads it not to be forced into a reassessment of their own actions. My behavior with the families of comatose patients could be reconfigured as a response to a variety of demands: the use of authority as a neurologist to gain the family’s acceptance of a prognosis and provide certainty, the fostering of an atmosphere that allowed for a course of action to be adopted that may have involved withdrawing active treatment, and the deployment of statistics and a knowledge of natural history to alleviate any fears I might have had that I was making a mistake. In a way, it explained the calm I felt dealing with these situations. To put it more plainly, a prognosis can be used for a number of purposes, many of them utilitarian, some of them reasonably justified. Until recently though, it was a suggestion that would have stung me as false and unfair.

I arrived in Winnipeg and was met by my two sisters—the younger one a family doctor and the other an ICU nurse in the hospital where my father had been taken—who told me the details. My father was working when it happened. Two people—one a worker installing a stove, the other, the owner of the house undergoing some minor renovations—were there as he was helping to lift a stove into place. He was doing electrical work that day. It wasn’t his job to move the stove, and the other worker called back to the shop to get help but my father waved them off and said that he would lend a hand. The stove was heavy and they had to put it down once. The second time they put it down, my father stepped back and then fell face-forward, hitting his head on the frame of the stove before landing on a floor of kitchen tiles. His heart had stopped. That, of course, isn’t exactly correct—the rhythm of his heart, the organized electrical impulse, became suddenly disorganized and he went into ventricular fibrillation. His heart trembled ineffectively. His blood pressure dropped and so did he.

We met my mother at the hospital – the same one where she had retired ten years before from her job as a nursing supervisor -- and were taken to the ICU, where my father had been admitted. As part of a treatment protocol, he was on a cooling blanket and touching his limbs made me shiver. He had a pressure bandage on his forehead. He was intubated and unconscious. My mother pulled a small bottle of water from her handbag; on the label the word ‘Lourdes’ was written in her handwriting. She dabbed the water on his closed eyelids. I bent over my father and lifted one of his eyelids and then the other. In the light of the room I saw his pupils constrict.

We spent the weekend in the hospital, shuttling between my father’s bedside, the ICU waiting room and the cafeteria. My father wasn’t waking up. To counteract this lack of improvement, we were all mentally enumerating the possible reasons for this—he had hit his head in the fall, he was intermittently receiving sedation and he was already showing signs of infections that are so common in ICU patients, but it was an inescapable fact that during the times when he had been taken off his short-acting sedatives, he was not waking up. Not opening his eyes. Not moving at day three. At one point, during the time when the sedatives were stopped and we were watching for any sign of awakening, I stroked my father’s foot and watched as it withdrew, a rapid movement—the hip, knee and ankle flexing simultaneously. I was shocked and momentarily elated at seeing this, fatigue and hopefulness conspiring to allow me to believe that it was a sign of improvement before reminding myself that I was looking at a reflex movement commonly seen in someone who had sustained a brain injury. I remember being upset at making such a rudimentary mistake, at allowing my judgment to be so clouded by my hopes.

Later that day, outside my father’s room, I ran into the neurologist who was on call that weekend. I imagined he had already been told that his patient had children who were doctors and nurses; this sort of information is invariably conveyed, often invoking wariness among the treating physicians who can foresee the second-guessing, the multiple briefings. He seemed to know that I was from Montreal and that we shared a specialty, shared this particular task in the ICU. He shook his head when he discussed the case with me. ‘You know the numbers,’ he said.I had to return to Montreal, but before I left, we all sat down with the Intensive Care physician who outlined my father’s condition. My father’s CT scan showed no evidence of damage from a lack of blood flow (a pacemaker made a more accurate magnetic resonance scan impossible) and his EEG showed slowing of the electrical activity of his brain. Another test, called Somatosensory Evoked Potentials, which register the brain’s response to a particular stimulus and which is increasingly used in the prognosis of comatose patients, had not been available during the Easter long weekend when all of this occurred. There were no tests that unequivocally pointed to a negative outcome, but the fact remained, the Intensive Care doctor repeated, that he was not waking up. My mother, who had up to this point always maintained a steadfastly optimistic outlook, appeared not to understand what was being implied. The Intensive Care doctor—knowing I was a neurologist, knowing I had summarized this sort of information for families many times before—turned to me expectantly and I duly told my mother that while there were many circumstances that made a prognosis difficult, it was a fact that he was not waking up, and every day that passed made it less likely that he would awaken to anything resembling a normal state.

I left for Montreal that day, prepared that it could be the last time I saw my father. After I got home, I spoke with my mother and sisters nightly, and listened to them become increasingly exhausted as my father continued to survive but did not improve. I didn’t envy them, having to see him in that condition, having to wait for the improvement that never seemed to happen. He developed infections and cardiac arrhythmias. His limbs swelled. Investigations to determine why he had the arrhythmia were postponed. Days went by and nothing changed.

I began to have trouble sleeping and my work suffered. There was no other way to explain it except to say that for a time I lost confidence in my ability to do my job. With patients in my clinic I felt like I did that day I had seen my father’s leg move reflexively and misinterpreted it as something positive. Those moments of uncertainty became increasingly frequent until they clouded the entire working day with doubt.

Ten days into his illness, with no change in his condition, my sisters and my mother and I had a formal discussion with his treating doctors about the limits of treatment. We began to take those small steps that his condition demanded, agreeing that should his kidneys fail we would not want him to receive dialysis, but that infections and arrhythmias should still be treated. We agreed with the recommendations that he would have a tracheostomy, a surgically-made hole in his trachea for patients who may require a respirator for an indefinite time. A feeding tube would be placed in his stomach. It felt like the preparations for a siege.

Although we all agreed on a course of action, enough time had passed for my family to exhibit differences in the way they reacted to my father’s condition and his still uncertain prognosis. My mother was the most fervently optimistic, habitually filtering through opinions for the most favorable, ignoring what I felt should have been obvious to someone who had nursed all her life. But after being retired from nursing for more than ten years, she must have found the hospital a foreign place where unqualified hope and holy water made as much sense as anything. My older sister, the ICU nurse, was also hopeful, although her mood was tempered by her experience with cases like his. She was also keenly aware of the realpolitik at play in an ICU, the continual pressures to make beds available; the necessary prioritizing that would see cases with no hope of recovery transferred out to the ward where the next pneumonia would claim them. I thought that when this discussion came, I would have most in common with my younger sister, a physician as well, that our similar temperaments and training would declare themselves. But I was far more pessimistic than she, unable to acknowledge that he could get better. I remember saying to my sisters and mother that if Dad could see what was happening to him, he would tell us to stop everything. It was a difficult conversation. I thought that if he survived, it was unlikely that my father would ever leave hospital and that he would probably face a life with significant impairment. I remember holding my tongue, knowing that whatever I said next would further undermine their slim hopes.

Another week went by without any real change. At the same time, the attending physicians in the ICU changed. The new attending reviewed my father’s case and stated what was obvious to him: my father had not awoken in more than two weeks. In his opinion, he told my mother, my father had reached a plateau. Accordingly, he felt my father should not be in the ICU. While the neurologist who had taken over my father’s case was more guarded, his opinion was superseded by the new ICU attending, who also had the concerns of overseeing the management of beds in his unit. He explained to my mother that to have a patient in persistent coma was not an appropriate use of resources in the ICU. My father would therefore be taken off the ventilator and transferred to the ward. My sisters, already aggrieved at the abrupt change in philosophy, were further angered when the new attending said outright that such a move was overdue, and that my father had already been granted an extended stay in the ICU because his children were in the medical profession.

This was a turning point for my mother and older sister. Whatever anger they had felt at his illness and the intolerable, insoluble situation of his coma found a focus in this doctor. The prognosis this physician gave, more explicit and negative than any other before, had the effect of alienating my family while at the same time crystallizing their resolve to protect my father. While I didn’t agree with this physician, I found myself torn between wanting my father to receive the fullest possible chance to survive, and knowing how difficult it was to deal with the unrealistic optimism and the hostility of an entrenched family. I listened every day to the contempt they had for what they felt were the callous appraisals this man had made, and I couldn’t help but feel that someone must have said similar things about me at one time.

Amid considerable rancor, my father was transferred to the ward, where he deteriorated within hours and had to be rushed back to the ICU. I received a phone call from my younger sister telling me that his condition was worsening and I should get ready to fly back. But he survived, my mother and my sisters at his side, now even more resolutely advocating for his welfare. His complicating medical conditions stabilized and the sedatives that he had intermittently received were reduced and then stopped altogether. At one point he even began to open his eyes, but he was not fixing on anything, not giving any indication of improvement beyond a state where he would need constant medical attention for the rest of his life.

While we were all considering the possibility of long-term placement, twenty-five days after becoming comatose, my father’s condition changed. My older sister called to say that she thought he had looked at her when she came into the room, that he had responded to the fact that she was carrying a cup of take-out coffee. I told her I thought she was probably reading too much into what she saw. But he continued to open his eyes and look at my mother and sisters at his bedside. Within two days he was reaching for things, doing things that even a skeptical son had trouble dismissing.

A remarkable recovery ensued. In my professional life, I had never seen anything like it and needed to hear independent verifications of it from my sisters and mother to assure myself that what was being described was really happening. Within days after his initial improvement, he was moving all his limbs and was able to stand with support. He began to make the first attempts at communicating with those around him. The various medical problems — the head injury, the infections , the sedatives — all those details that my family clung to out of desperation (details whose frequent mention made me shake my head in the conviction that they were the bricks and mortar of denial) were now invoked as possible explanations for his astonishing improvement.
My father’s recovery defied expectation and for this he was accorded minor celebrity status, not unlike the rare person who loses sixty pounds on a diet or becomes wealthy with an infomercial investment scheme, the sort of achievement that must be qualified by the disclaimer ‘results not typical’. Even the ICU doctor who had said that my father had reached a plateau came back to see him, this time with students in tow.

My father illness occurred at a time when the data from studies like one that Levy authored—cohort studies which until recently have provided the only usable data from which clinicians have had to make prognoses in coma—have been coming under scrutiny for reasons ranging from questions of statistical uncertainty to whether the studies are relevant given the recent advances in intensive care.

To address this, in July of 2006—three months after my father became ill—the American Academy of Neurology released revised practice parameters for prediction of outcome in comatose survivors after cardiac arrest, still quoting the Levy data as useful, but recognizing the limits of the study and suggesting other tests, such as Somatosensory Evoked Potentials, be added to the evaluation of the comatose patient.

Everything that was done for my father—the initial resuscitation, the supportive care, the reconsideration of aggressive therapy, all of it was predicated on a prognosis, a prediction of the future. And yet his physicians (including his children) arrived at different imagined futures: some were guarded, others more certain, yet all of them were focused on the same case, ostensibly using the same evidence from the medical literature. To some degree, the prognoses reached were influenced by the reasons they were sought. The pressures placed on the ICU doctor with whom my family clashed were as understandable as the loyalty of my mother and sisters. His illness laid clear my biases. Even though I desperately hoped that he would get better, I had to admit that I had created a prognosis for him, in retrospect, crafted to influence my mother to avoid making decisions that would see him live on in a terribly impaired state, an outcome that I dreaded more than his death.

We had all seen some version of the future for him and acted in a way that would have achieved that end. The joy I felt with my father’s recovery was chastened by the thought that I had imagined a future for him circumscribed by my own fears and narrowed by my biases, and that I had let these fears cloud my judgment.

On the evening of the last day of May, the phone rang and my wife Florence answered it. I was upstairs bathing our children and with the sound of their voices and the splashing I hadn’t even heard it ring. She opened the door to the bathroom and handed the phone to me. She was smiling. I took the phone and my father said hello—the first word I had heard from him since he had become ill seven weeks before, a time when my younger sister stocked her fridge with beer in preparation for his wake and I considered what I would say to eulogize him. After that evening at the end of May, he would leave the hospital and not need rehabilitation; he would be left with short-term memory loss but be able to read again and look after himself and enjoy his backyard in the summer and a Christmas with his children and grandchildren.

Before that telephone conversation, I had prepared myself not to expect too much -- he might be too tired to talk or the words might not make any sense -- but his lucidity surprised me. He said he was feeling stronger and it was good to hear my voice again. In the weeks leading up to this moment, as he improved to the point where survival, and then recovery, seemed possible, I thought about why I’d been so pessimistic. Was it just an immature response to the way I’d believed hope had led me to lose my objectivity as a doctor and to misinterpret certain aspects of his condition early on? I like to think I did not give up hope as a form of psychic recourse for wounded professional pride, but it is something that still troubles me. I wanted to apologize to him, to explain that I felt I’d failed him and, if it was any consolation, that I had given much thought to my role as a doctor because of him.

But good sense prevailed and we just spoke. Two human voices engaging. Even if I told him what I thought, he was not the sort of person to admonish me. The circumstances of his recovery were admonishment enough. His words were halting and no louder than the static of a bad connection; he had to take a deep breath and block the tracheostomy tube with his finger in order to speak. But I heard him clearly.

Liam Durcan is neurologist at Montréal Neurological Hospital. His novel Garcia's Heart, a literary thriller exploring issues around new applications of neurology, will be released by Thomas Dunne in November.