What is a good death? Sidney Wanzer, with help from Joseph Glenmullen, tries to address this question in his book To Die Well: Your Right to Comfort, Calm, and Choice in the Last Days of Life. Wanzer, through examples drawn from his personal and practice experience as an internal medicine physician, tries to empower patients and caregivers with the ability to achieve a calm, peaceful death on their own terms. He focuses on what he considers the two turning points patients face on this journey: the first is when a patient foregoes aggressive medical treatment to focus on comfort care; the second is when a patient who cannot achieve maximal comfort care turns to hastening death. Wanzer admits this second turning point is rare, but he unfortunately spends a large portion of this book defending his position on physician-assisted suicide. By doing this, and also by emphasizing these turning points, this book fails to fully explore what can be done for comfort and dignity along the whole journey a patient will experience with a life-threatening illness, so that he or she can indeed die well.
Wanzer is right on when he points out cases where patients die miserable, undignified deaths. This is a too-frequent occurrence in modern medicine. He starts with describing his own mother's last years of her life. In her 90s, living in a nursing home with dementia, she had a pacemaker inserted without informed consent and what he feels would have been against her previously expressed wishes. It is shocking that a patient with a son who is a physician would have medical procedures done without proper consent from family members, but it is [End Page 304] not an unusual occurrence in our present medical system. The emphasis in modern medicine and in medical education is on curing illness, fixing a problem, and preventing death. The expressed goal of modern medical research is to solve death's puzzle. The system is set up to respond quickly to prevent death, with teams of ACLS-certified medical workers prepared to bring back anyone whose heart or lungs have stopped, with questions asked later. Death has become the enemy: a failure in physicians' eyes. We even have Morbidity and Mortality Conferences to figure out what we did wrong.
Any method you can muster to promote control for the patient over this way of thinking is much needed, and I applaud Wanzer for trying to do this. Wanzer points out some ways a patient can advocate for more comfort care. He delineates rights he feels patients should fight for, like advocating for open communication, actively looking for physicians willing to agree to how they want to be treated and talked to. He also advocates for aggressive pain relief and for hospice care to help with comfort at end of life. This also is to be applauded. He even addresses some of the barriers the medical system has with proper pain control, although in some ways he overstates the negative effects of morphine and understates just what can be done with modern medicine to help comfort and pain.
Having been in palliative medicine for 15 years now, helping thousands of people at the end of life to achieve the comfort and dignity they desire, I see the enormous need for better palliative care in our health care system. Palliative care programs have been growing in the United States, and palliative medicine is set to be the next American Board-recognized subspecialty in Medicine this year. Still, however, recent medical education needs assessments show that although the interest and value is high, there is little exposure to palliative care in medical schools, almost no formalized courses in end-of-life care, inadequate education for physicians in communication on end-of-life issues, and that education in chronic pain control is poor (Meier, Morrison, and Cassel 1997; Ury, Reznich, and Weber 2000). Recent studies show that only 25-50% of pain is controlled in a hospital or nursing home setting, even with cancer pain (Cleary 2007).With the right knowledge, though, over...