Don’t Blame the Doctors : The mission of hospitals is to keep people alive. Families should help their own to transit old age and die with dignity.
A withered gentleman in his 70s once told me how he had planned, as a robust young man, to cash in his chips when his muscles and other parts went into decline. “And now?” I asked, thinking he was contemplating suicide. “Hell, now I want to live as long as I can!” he replied, smiling.
Aging and death are part of life as much as is birth. A Mayan grandmother, dying slowly, is kept on a bed by the hearth and sees her daughter grinding corn and the grandchildren playing. Should she want anything, someone is always close by to provide it. In most nonindustrialized societies, the family is the social unit that provides care during life’s transitions. No wonder American birth control schemes are relatively unsuccessful in underdeveloped countries: Governments are not in a position to assume the responsibility of caring for the aged and infirm, so parents need a passel of children to do the job instead.
A recent article in the Journal of the American Medical Assn. makes me wonder if perhaps Third World people have it right and we’ve got it all wrong. This article, which received lots of attention in the press, showed that hospitalized patients’ wishes with regard to high-tech interventions, cardiopulmonary resuscitation and pain relief were not being attended to as consistently as was desirable. Moreover, active efforts to increase communication among physicians, nurses, family and patients regarding treatment met with little success. This study was used by some to flagellate hospitals and health care providers. But the real issue is a very different one and goes to the core of our social structure.
Hospitals are not designed as dying places. Sure, most Americans do end their lives in hospitals, but the mission of these facilities is to preserve life whenever possible. A person enters the hospital with the expectation that his disease process will be reversed, if only for a time. The surgeon, the anesthesiologist, the emergency room doctor see their mission as defying or at least delaying death and disease. Dying, when occurring as a part of the natural life cycle, is an intimate time for the person and his family, whereas reversal of disease or injury is a time when specially trained people must go into high gear; activity and intervention are the name of the game. When a person comes into the hospital, the unspoken contract calls for the hospital and its workers to pull out all the stops to get him better. Sure, the patient may be elderly and frail, but his very presence bespeaks a hope for the future. A physician who fails to use her best effort when a life-and-death event occurs is one who will find herself at the business end of a quality assurance committee or a subpoena.
Nontraumatic dying may be a one-time event, but like menopause, it normally takes place over months or even years, not days. The family should be the instrument that shepherds people through this phase of their lives. But because we in the industrialized world have decided that the government should provide during the Golden Years, the family often does not sense its important role till its member is well into the dying process. Family members are put in the position of needing to abruptly assume responsibility before they have had a chance to coalesce into a team. This means that decision-making and transfer of information from family to health care providers will be shaky, especially at first. And worst of all, most people don’t want to talk about this last taboo until an emergency forces the issue.
Early in the 21st century, lots of people will be getting old and dying, including you and me. We haven’t had enough children to care for us during our older years, as that Mayan woman did. We certainly don’t have a collective philosophy that sees virtue in all of life’s seasons. Form and function, however, can be preserved a lot longer than anyone guessed possible in the early 20th century, especially when seniors have active and important roles to play in the larger society. But the time will come for each of us to “pass over.” We and our families need to think and plan for that passage. A hospital may be the right place for people to be made well, but a home or hospice program is the right place to die with dignity and love.
