Final Acts: Death, Dying, and the Choices We Make

Part Two: Perspectives

PART TWO Perspectives VVVVVVVVVVV 149 In Part Two, writers from diverse backgrounds and representing sometimes con- flicting points of view examine death and dying in essays less personal and more overtly political than those in Part One. We open this section with two powerful essays that present sharply contrasting opinions on what constitutes “the good death” and whether it is achievable or not today, when most of us will face slow dying. Award-winning journalist Stephen Kiernan details how and why the American way of death has changed. More of us will live longer, he writes: “by 2030, when the 1950s baby boomers reach old age, the number of people over eighty-five will have more than doubled, to 9 million.” And more of us will need end-of-life care that we cannot get at home: “according to geriatric-care specialists, 56 percent of Americans alive today will wind up in a nursing home at some point.” In light of this shift, Kiernan calls for a new approach to health care in America that moves from an overemphasis on acute and critical care to a focus on chronic care. He explains how treatment options—and resources—are dangerously misplaced: “In 1976 people struck by the major causes of death needed acute and critical care. They required aggressive interventions and techniques, responding to a sudden crisis and its immediate aftermath. That kind of treatment is precisely what an ICU is expert in delivering. And that expertise has been heroically successful. Today, though, when death is gradual, patients need a chronic-care model. They need more nonclinical services, greater consideration of their emotions, families, and finances. The ICU is as wrong a fit as using sports-medicine techniques to deliver a baby.” Kiernan advocates a more humane model for end-of-life care than he thinks hospitals and nursing homes typically provide. By treating pain aggressively through palliative care, while at the same time emphasizing the spiritual, emotional , financial, and psychological needs of the patient, as well as her physical needs, hospice cares for individuals, not cases, according to Kiernan. It thus represents a better option for the terminally ill. While many of the writers in this collection share Kiernan’s enthusiasm and optimism about hospice, Kathryn Temple disagrees.1 She acknowledges that hospice has helped many, but she charges that it offers more than it can provide: “Entangled as it is with the other problems endemic to the American medical system, problems involving the institutional needs of hospitals, managed care, and insurance company mandates, hospice often comes up short in its efforts to provide what it calls ‘a good death,’ a death marked by dignity, choice, and strong family connections.” For example, while dying in a hospital might not be the best option for most people, for others it is. And dying at home may not be viable. Describing the final months of her husband’s life, Temple makes her case: “He could not walk, use the toilet, or even manage the nurse’s call button, which he seemed to confuse with the TV remote. Two or three times, he somehow managed to shift his body weight enough to fall, and on those occasions six to eight hospital staff would be mustered to raise him from the floor back to the bed. Once he was left on the cold hospital floor for hours while the staff tried to find enough people to help. Every few days he developed unexplained massive bleeding, bleeding that would be ejected all over the floor and, once, a complete wall of the hospital room. These late manifestations of imminent death would have occurred at home or in a hospice. Unpreventable, no matter what palliative care might have offered, they fly in the face of the hospice ideal of the ‘good death.’” Both Temple and Kiernan discuss the economics of the hospice movement. Temple writes that although hospice claims to be “‘not a place, but an idea,’” nevertheless “it is an ‘idea’ supported by Medicare funds, covered by many health insurance plans, and relied upon by cancer centers, hospitals, and nursing homes to provide care for the dying.” She claims that hospitals push hospice because it is cheaper than keeping patients hospitalized. Kiernan charges that, even if hospice THE EDITORS 150 is cheaper, the bulk of the nation’s health-care dollars go not to hospice care but to “high-cost, low-quality end...