the Consumer's Point of View
© 2015 by James Leonard Park
by James Park,
existential philosopher and medical ethicist.
comments in red are the evaluations of
The books are organized by quality,
beginning with the best.
The Path to a Better Way of Death
(New York: Scribner/Simon &
2013) 322 pages
(ISBN: 978-1-4516-4197-4; hardcover)
(Library of Congress call number: not given in book)
This moving memoir of the deaths of two
Rather than turning off
illustrates many problems of the way we die.
Katy Butler's father suffered a slow decline into death,
unnecessarily drawn out by the fact that no one took the initiative
to end medical treatments and life-supports
in his case was mainly an implanted pacemaker.
By the time this became a serious option,
the patient himself was beyond the point of making his own medical
when the patient has come to the end of his or her meaningful life,
some doctors are willing to
let the batteries run low,
which will result in a random later death
when this form of life-support finally gives out
because there is no more electricity to keep it going.
Is such thinking mainly about the doctor's self-concept or reputation
rather than what would be best for the patient?
Katy Butler's mother took a different pathway towards death:
After exploring life-extending options, she decided not to take them.
Her dying was short and merciful.
Complicated family dynamics will often become involved in end-of-life
And this family was no exception.
Reading the details of one family's problems
might help us to do better planning in order to avoid similar problems
Because Katy Butler was already
a professional author,
she knew how to get this book
published and well-known.
She has been a tireless
campaigner for the ideas championed in this book.
And her high profile within the
has made her an important leader
in the consumer-health movement.
The author was not an expert on any end-of-life issues
when she went thru the traumas recounted in this book,
but after her parents' deaths,
she did considerable research to prepare this book.
And as a result of the success of this book,
she will be frequently called upon
to speak for the movement to improve the process of dying.
The title was poorly chosen (probably by the publisher),
since none of the people involved believed in anything after death.
There are no attempts to get into heaven.
And the author's father certainly did nothing to hasten his death.
A better title might have been: Too Much Medical Care:
Can We Find Better Pathways
Many readers will experience similar problems
if they do not take charge
of the dying process.
It is helpful to know how others have suffered on the way to death.
These can be cautionary tales, helping us to avoid similar pitfalls.
This book is written
well enough to be read aloud,
which is what I did, while my
life-partner did the dishes.
She also found it a very
And it led to discussions of deaths we have known.
has emerged since this book was published)
Notes from the
Managing a Loved
One's End-of-Life Hospitalization
Axiom Action: www.AxiomAction.com,
2008) 336 pages
(ISBN: 978-0-9801090-0-9; paperback)
(Library of Congress call number: R726.8.W56 2008)
under-achieving title might give the (false) impression
that this is a book scribbled in the hospital lobby,
recounting the unfortunate events that befell a dying relative.
This is a well-researched and well-written guidebook
for getting ready to manage dying in a hospital.
It did grow out of
the author's experiences
with the deaths of both of his parents.
And some details are shared about these ill-managed deaths.
But most of the pages are devoted to organized discussion
of the many issues that confront anyone who must die.
1. Being an effective proxy decision-maker for your dying relative.
2. Creating the necessary paper documents to achieve a good death.
3. Improving communication among all players—professional and lay.
4. Consumers taking control of the hospital processes to prevent
5. Planning for what is going to happen next and getting support.
6. Anticipating crises—and possibly changing providers.
7. Do Not Resuscitate and life-supports—advance plans, doctor's orders,
8. Signs of impending death—and dealing with the body.
9. Radical alternatives to standard dying-in-a-hospital.
As the author himself discovered, most laypersons
have little idea of what dying in a modern hospital involves.
But more than half of us will die in hospitals.
Thus, this guidebook should be read some years in advance
by everyone who knows that he or she will be called upon
to make medical decisions at the end of someone's life.
(If no one else, that "someone" will be the reader.)
This book gives
the impression that most hospital deaths are poorly handled.
Perhaps someone will do
research by asking relatives at
least a year later
what they thought in retrospect
about a dying-process they observed.
Perhaps there was no way to
postpone that death.
But what could have made
the process of dying easier for everyone
future patients and those
who will be at the bedside—
should read this book to get
ready for the end-of-life shocks.
But providers should also read this book.
Doctors, nurses, hospital
should take a professional
interest in improving the process of dying.
(All such health-care workers
will also be patients later.)
Most of the unfortunate shocks
of dying-in-a-hospital can be avoided.
Everyone who wants to improve
terminal medical care
could read this book as a catalog
Each reader who works in
will be able to find at least one
thing to improve this week
so that the tragedies described
in this book
do not happen to patients and
who are currently receiving
terminal medical care.
One of the possible Power
Documents missing from Chapter 2
is the POLST—Physician's Order for
In light of the known medical
facts, the doctor and the patient
create a document specifying which end-of-life treatments
will be provided and
which will not.
Sometimes called Medical Order
for Life-Sustaining Treatments (MOLST),
these written statements are
more comprehensive than
Do-Not-Resuscitate orders (DNR):
When should the patient be hospitalized?
including tubes and drugs, be used?
One provision of a comprehensive Advance Directive for Medical Care
might avoid much of the stress
and trauma of dying in a hospital:
Club is for patients who decide in advance
the last month of standard terminal care
and go directly into hospice
With careful preparations, we
can even die at home if that seems best.
A timely death (not too soon,
not too late)
might be better than standard dying.
Of the deaths you have
which were meaninglessly
prolonged by futile treatments?
Dying in a hospital is going to cost about $5,000
especially if we receive life-support in the Intensive Care Unit (ICU).
Bills from doctors not employed by the hospital will be extra.
If dying will take ten days, this amounts to $50,000.
Or if dying is prolonged to two weeks, the total will be about $70,000.
Many terminal hospitalizations
last three weeks, costing over $100,000.
Hospice care is only a few hundred dollars per day.
It should not matter to us who
actually pays the bills
—the taxpayers thru Medicare and/or Medicaid, a tax-supported hospital,
some private health-insurance, or our personal estates.
Thus, shortening the process of
dying is the most direct way to save
And at these prices, we
should be living like kings.
How would we like to organize our dying
so that we achieve the greatest meaning for the lowest cost?
If we are so inclined, we might plan to die in a right-to-die hospice.
Such a hospice program would openly embrace all legal
The publisher's website (link at the beginning)
gives the actual titles of the chapters and other contents.
A better title might have been:
3. Sharon R. Kaufman
And a Time to Die:
How American Hospitals Shape the
End of Life
(New York: Scribner/Simon
& Schuster: www.SimonandSchuster.com,
2005) 400 pages
(ISBN: 0-7432-6476-2; hard cover)
(Library of Congress call number: R726.8.K385 2005)
(Medical call number: BF789.D4K21a 2005)
anthropologist recounts her experience of watching
every aspect of dying as it takes place in the modern hospital.
The stories of the last days of several actual
forms the back-bone of this book.
How was each death handled by the patient, the family,
the nurses, the doctors, and others who became involved?
The overwheling impression left with the reader
is that hospital deaths are handled very poorly.
Each story shows how this process of dying could have been
Usually someone was not willing to acknowledge that
death was coming.
Either the patient, the family, or the doctors were in denial.
They wanted to try yet one more treatment,
even if the chances of success were remote.
In most cases, there was no written plan for this
Everyone involved was just muddling thru
---even those who had attended several deaths
as a regular part of their medical practice.
The patients had no written Advance Directives
for Medical Care.
The doctors had no written Physician Orders
for Life-Sustaining Treatment.
The hospitals were organized only for treating disease and injury,
not for easing the inevitable passage to all patients to their
Chapter 8 deals with a little-known
the life-support ward.
This is a unit of the hospital system that cares for patients
who are completely dependent on some form of life-support:
tube-feeding, ventilator, etc.
They are all chronic patients, rather than acute patients.
And their time in the life-support ward is measured in years
rather than days, weeks, or months.
Many have severe limitations to their mental
Some would be described as comatose.
Others are definitely in Persistent Vegetative State (PVS).
Most will stay in the life-support ward for the rest
of their lives.
But almost none has any written end-of-life plan.
Only very rarely does anyone decide to turn off the machines
and allow the patient to die.
The default 'choice' is simply to continue all forms of life-support.
would be an excellent place for a Medical Futility
to evaluate the reasons for
continuing such medical care.
4. Helen Stanton Chapple
No Place for Dying:
Hospitals and the Ideology of
(Walnut Creek, CA: Left
Coast Press: www.LCoastPress.com,
2010) 324 pages
(ISBN: 978-1-59874-403-3; paperback)
(ISBN: 978-1-59874-402-6; hard cover)
(eISBN: 978-1-59874-703-4; electronic)
(Library of Congress call number: R726.8.G4677 2010)
(Medical call number: WB310C467n 2010)
The medical care
industry has its own priorities for patient care.
And often these serve the interests of employees
who make their living from providing medical services
rather than the interests of the patients who receive care.
Acute-care hospitals are supposed to rescue patients from death.
Everything is designed to stave-off
to achieve at least one more hour of 'life' for this patient.
Only when all efforts fail is the patient declared dead.
A surprising number of 'medical' decisions
are actually made by considering costs and hospital politics.
Will the doctors be pleased by the decisions made in the hospital?
If not, they can usually take their patients elsewhere.
makes an extremely convincing case
that the modern hospital has no place
"The only thing we do here is cure the patients."
But, of course, many patients do
die in hospitals.
When they are declared "DNR",
they might be sent to back wards,
where they will be supported
with comfort care.
But this is no longer considered
the real work of the hospital.
This book is
mainly about the need for better patient care
---not any examples of such care
Because the last page of each medical record will read: DEATH,
there should be some better preparation for patients and families
whose hospital experience will end with the death of the patient.
Should we create for each patient a document called
"Pathway towards Death" or "End-of-Life Medical Orders" (ELMO)?
It is known with absolute certainty that each patient will eventually
So planning the best possible pathway will never be wasted effort.
If important choices are made in advance,
the usually confusions and conflicts surrounding death will diminish.
And we might make a meaningful
place for dying
within modern medical care for all patients who die---that is everyone.
March 26, 2014; Revised 4-1-2014; 4-2-2014; 4-3-2014; 4-7-2014;
5-7-2014; 8-21-2014; 10-21-2014;
1-3-2015; 1-20-2015; 4-22-2015; 6-28-2015;
Books on Terminal Care (from the Doctor's Point of View)
Directives for Medical Care—The Best Books
on Medical Futility
on Hospice Care
on Life-Ending Decisions
for Life-Ending Decisions—Best Books
Methods of Choosing Death
on Helping Patients to Die
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