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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 different."
    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 cure]."
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