Rewriting the Final Chapter (continued)
"It's been said that there are only two things
that motivate Americans: the accumulation of money and fear of cancer,"
says George Annas, director of the Law, Medicine, and Ethics Program at
Boston University's School of Public Health. "I would argue that
the two things that motivate physicians are the accumulation of money
and fear of lawsuits." Behind his confrontational claims lies a concern
that the medical establishment is obsessed with securing legal immunity,
sometimes at the cost of easing dying patients' suffering.
Caplan says the fears are justified, however, considering
the threats that today's doctors face, from "getting arrested because
you use too much narcotics" to reduce pain to "legal worries
that you can't stop treatment if there is no obvious guardian. [Doctors]
have to have some assurance that they have the ability to use their medical
judgment when things are futile, hopeless, pointless, or painful."
Another reason some patients linger past the point
of return, Annas says, is that we live in a youth-obsessed, death-denying
society. "People don't believe in death at all in this country and
somehow believe it is optional."
Dr. Terry Richmond, GrN'95, assistant professor
and director of the adult acute/tertiary nurse practitioner program at
Penn's School of Nursing, has a similar view. "Instead of seeing
death as a part of life, we see it as something mysterious that we hold
off into the distance," she says. And although Richmond believes
that patients and their families share with health-care providers the
same desire for dignified treatment at the end of life, she believes the
road often parts when it comes to attitudes about the meaning of
death. "I hate to say this, but I think health-care professionals
-- both physicians and nurses at times -- continue to see death as a failure
after striving so hard, for so long, to prevent it. I think some of us
have broadened the definition of what it means to be a healer in the technological
age. One hopes that we can grow from that."
What sometimes happens, though, says Dr. John Hansen-Flaschen,
INT '82, associate professor of medicine and chief of the pulmonary
and critical-care division of the Hospital of the University of Pennsylvania
(HUP), is that doctors provide the care that they think the families want
"because the families push and push them. Then the person dies two
months later and the family remembers it the other way. Sometimes while
the crisis is unfolding," he says, it's hard for families and doctors
to look "past that trajectory and shift the gears to letting go."
While some fault doctors for fighting too hard to preserve
life, others fear that they've become too eager to give up on patients.
A growing number of hospitals, including HUP, have begun to adopt futile-care
policies to spell out instances in which doctors could limit or discontinue
treatments which they consider futile, even over the objections of families.
HUP has never enforced its six-year-old policy, but
Dr. George Isajiw, a physician at Mercy Catholic Medical Center in Lansdowne
and a consultant to the Delaware County Pro-Life Coalition, warns that
such documents mark another step toward euthanasia. "We are on a
slippery slope," he says. "We are about ready [as a society]
to accept physician-assisted suicide."
Despite the publicity that end-of-life conflicts continue
to generate, only about one-fifth of adults have created advance directives
indicating what medical treatment they wish to receive or have withheld
-- or naming a person to make decisions for them -- if they become unable
to speak for themselves. But even advanced directives are not the solution
many initially hoped they would be. "They let us know who this [patient]
is, what they value, and they give us a foundation for discussions with
families," says Richmond. "But they did not take away the basic
angst of making those decisions, because every situation is unique and
That's why, Richmond recommends, "We should be
having ongoing conversations and discussions, not just at the end of life,
but throughout an individual's life. What I always tell people is, 'You
should be having dinner conversations about this with your families and
neighbors, so when the time comes, we've had these discussions.'"
Richmond has been shocked on occasion by the end-of-life wishes of people
whom she thought she knew well. "My next-door neighbor is a neuropsychologist
[who deals with] head-injury patients. I've always said that if I become
persistently vegetative, stop all my feedings and let me die. Give all
my organs away. He wants to be maintained forever in case they find [a
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