A Good Death in America

An interview with Dr. Robert L. Martensen, who has written a book critiquing health care in the United States. Claudia Dreifus asks Dr. Martensen about the way people die in America.

Q. In your book, you particularly criticize the American way of dying. Why do you feel that this aspect of health care is on the wrong track?

A. Most Americans die in hospitals or nursing homes, and neither is configured to take care of dying patients. There’s little palliative care available, and often the payment structure of health insurance doesn’t support it.

So you end up with situations where a 90-year-old with organ failure is brought to an emergency room and the doctors go, “Let’s tune her up.” Or if the patient starts failing at the nursing home, they’ll say: “No one dies here. Let’s get her to the emergency room.” It’s not unusual in the last six months of a patient’s life that they’ll be shuttled between the nursing home and hospital 6, 8, 10 times and subjected to a lot of painful and expensive interventions. The patient is artificially maintained that way until their body gives out.

I’ve done ethics consults for hospitals where patients have been in the I.C.U. for six months. An elderly woman has gone from a serious neurological problem to end-stage renal disease, with no hope of ever being able to move a finger and no one told the family, “Your mom is dying.” When it was finally said, the relatives were furious.

Q. WHAT SHOULD DOCTORS SAY INSTEAD?

A. I think doctors should get comfortable with being realistic. If it is the case, the doctor should bring up the idea that this disease process might be fatal. Right now, we say, “I can’t take away a person’s hope,” as if doctors were bestowing life. You have to support those hopes that are realistic, not this fantasy land.

I’ve seen how a lot of these interventions are inhumane. If you resuscitate an older person, you may break their ribs during C.P.R. If you put them on a ventilator, you may end up sedating them so heavily they are barely conscious.

Q. CAN THERE BE SUCH A THING AS A GOOD DEATH?

A. My father had one. He was a systems engineer. In his 80s, he developed serious pulmonary problems, and he was very savvy about how things can go wrong in complicated systems, which hospitals are. To make sure that nothing was done to him that only technically extended his life, he made sure that his wife, doctor and hospital had copies of his medical directives. He didn’t have an extended period of dying because he avoided being put on a ventilator. My father died comfortable, surrounded by people who loved him. He was lucid till about five minutes before his death.

I think that’s what I’d want for myself, too. It’s not easy to get. I’ve seen situations where people leave specific directives and the hospitals still resuscitate them.