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Politics, Religion, Science, Culture and Humanities => Science, Culture, & Humanities => Topic started by: Crafty_Dog on December 27, 2011, 07:46:53 AM

Title: The Art of Dying
Post by: Crafty_Dog on December 27, 2011, 07:46:53 AM
Death Doula:

By Dawn Turner Trice, Chicago Tribune
December 27, 2011
Reporting from Sycamore, Ill.— A midwife is usually associated with the beginning of life — pregnancy, labor and delivery — but another type specializes in the end of life.

Ana Blechschmidt is a death doula — a death midwife.

"Most of the time, it's for people who want to stay away from hospitals and a sterile, mechanical world or machines and tubes," said Blechschmidt, 64, of Sycamore, Ill., who became a death doula four years ago. She is also a certified birth doula.

It's her job to make the environment as peaceful as possible for the person who's dying as well as for family members and friends, she said. She emphasized that she did not assist in suicides.

Unlike a hospice nurse, a death doula doesn't administer medicine or perform medical procedures, nor is a doula certified or licensed by the state, according to the Illinois Department of Financial and Professional Regulation.

Also, the death doula will stay — if the family wants — after the client dies to help with the funeral, which often occurs in a place other than a funeral home. That could be the person's home, a nursing home, an elder-care facility or even a hospital.

Blechschmidt said her primary job was to carry out the wishes of the person who is dying.

"The main questions I ask are: 'What do you want? How much do you want to spend? Do you want intervention by medical people or family?' '' she said.

"In many cases, when a person is dying, what they want is a quiet, peaceful exit. Some people want to die by themselves, but others may want their whole family there playing pinochle in the corner."

Blechschmidt encourages clients to have a will, a living will, a power of attorney for healthcare and for finances, and a written plan on disposition of the body. She suggests that everything be in writing.

"I talk with the family sometimes in the presence of the ill person," she said. "And then it's my job to make things happen as gently and harmoniously as possible."

Maintaining peace and harmony can be tricky, especially in families where relationships have been fractured. It's also complicated when family members are of different religious faiths and may have divergent beliefs about an afterlife.

"And, yet, to facilitate the end-of-life transition, I really don't need to know anyone's faith path except the dying person's," Blechschmidt said. "When everything is in writing, you can say, 'This is what Fred wanted.' That way, it's legal and the person who has the power of attorney has to carry it out."

Sometimes the death midwife has to play the heavy.

"There are harsh things that have to be said or done, and someone may need to be the bad guy — and that would be the death midwife," Blechschmidt said. "Family members can hate me and be mad at me because I don't have to show up at their holiday dinners."

A death doula or home funeral may seem unusual, but the concepts are rooted in the past.

Embalming became popular during the Civil War, but Blechschmidt said most American families still laid their dead out for visitations in their homes. Funeral homes were used mostly by the wealthy and were a status symbol until after World War II, when more middle-class people could afford their services.

"But that still wasn't for everyone," she said. "I was 7 years old in 1954 when my father's mother died. She died at home. She was laid out at home, and she was taken to the Methodist church for the services."

Today, she said, many people tend to isolate themselves when a loved one is dying.

"When you get caught up in grief and losing someone and all of that is going on, you need help," she said. "A hundred years ago, this is something that would have happened automatically. If I'm assisting in a death passing, what I'm really doing is assisting the soul to birth its new life. And that's such an honorable, necessary thing."

Title: How Doctors Die
Post by: Crafty_Dog on December 27, 2011, 07:51:41 AM
How Doctors Die

It’s Not Like the Rest of Us, But It Should Be

by Ken Murray

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.
To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.

Title: Hot Tuna: "Time to build my coffin"
Post by: Crafty_Dog on December 27, 2011, 06:27:39 PM
You may have to register to this absolutely awesome music site to get to this:
Title: Re: The Art of Dying
Post by: G M on December 27, 2011, 06:30:30 PM
I may have to get a "DNR" tat.
Title: The Top Five Regrets
Post by: Crafty_Dog on January 08, 2012, 06:35:16 PM
Title: Ben
Post by: Crafty_Dog on January 27, 2012, 12:22:59 PM
Title: Re: The Art of Dying
Post by: dreatx on May 28, 2012, 03:11:08 PM
Very interesting stuff.  I'm not a Dr but as a medic (civilian), I see death all the time and I also see and participate in the application of futile and torturous care.  I hope to die without all that rigmarole, myself.  I hope that "How Doctors Die" has been widely read.

I like the DNR tat idea.  I should get one myself.
Title: Re: The Art of Dying
Post by: dreatx on May 28, 2012, 03:13:11 PM
I shared that story for my friends on FB.
Title: Al Jazeera: Moral Maze
Post by: Crafty_Dog on June 30, 2012, 03:20:40 PM

UK man Tony Nicklinson has suffered from locked-in syndrome since he had a massive stroke. He describes the last seven years of his life as worthless. He has decided he wants to end his life. He is physically incapable of doing so -- and needs another person to do it for him. Under current British law this would be classified as murder. While this seems like just another "right to die" story, Nicklinson, who can only blink, has discovered Twitter. Technology has made it possible for Nicklinson to communicate -- which he does by blinking at a computer which turns his thoughts into words. He made his first tweet on June 13 and has reached almost 200 in the past two weeks.
An Al Jazeera essay commented on the case, pointing out that Nicklinson's newfound ability to speak to anyone on the internet serves two ends: it promotes the cause of assisted suicide but it also gives a victim of locked-in syndrome a reason to live: 
"So perhaps if there is something to hang on to in this moral maze it's this: technology has at least the capacity to alter peoples' opinions of themselves, even in desperation: and that things which until recently were scarcely imaginable are now facts of life. And if Mr Nicklinson's mind were to persuade him that life is still worth living then wouldn't that be a wonderful thing?" ~ Al Jazeera, Jun 18
Title: Re: The Art of Dying
Post by: Crafty_Dog on October 25, 2012, 10:56:08 AM
Title: 5 things you want said at your funeral
Post by: Crafty_Dog on November 15, 2012, 02:04:28 PM
Title: The Art of the Immortal Jellyfish
Post by: Crafty_Dog on December 02, 2012, 06:16:12 PM
First of nine pages

After more than 4,000 years — almost since the dawn of recorded time, when Utnapishtim told Gilgamesh that the secret to immortality lay in a coral found on the ocean floor — man finally discovered eternal life in 1988. He found it, in fact, on the ocean floor. The discovery was made unwittingly by Christian Sommer, a German marine-biology student in his early 20s. He was spending the summer in Rapallo, a small city on the Italian Riviera, where exactly one century earlier Friedrich Nietzsche conceived “Thus Spoke Zarathustra”: “Everything goes, everything comes back; eternally rolls the wheel of being. Everything dies, everything blossoms again. . . .”

Sommer was conducting research on hydrozoans, small invertebrates that, depending on their stage in the life cycle, resemble either a jellyfish or a soft coral. Every morning, Sommer went snorkeling in the turquoise water off the cliffs of Portofino. He scanned the ocean floor for hydrozoans, gathering them with plankton nets. Among the hundreds of organisms he collected was a tiny, relatively obscure species known to biologists as Turritopsis dohrnii. Today it is more commonly known as the immortal jellyfish.

Sommer kept his hydrozoans in petri dishes and observed their reproduction habits. After several days he noticed that his Turritopsis dohrnii was behaving in a very peculiar manner, for which he could hypothesize no earthly explanation. Plainly speaking, it refused to die. It appeared to age in reverse, growing younger and younger until it reached its earliest stage of development, at which point it began its life cycle anew.

Sommer was baffled by this development but didn’t immediately grasp its significance. (It was nearly a decade before the word “immortal” was first used to describe the species.) But several biologists in Genoa, fascinated by Sommer’s finding, continued to study the species, and in 1996 they published a paper called “Reversing the Life Cycle.” The scientists described how the species — at any stage of its development — could transform itself back to a polyp, the organism’s earliest stage of life, “thus escaping death and achieving potential immortality.” This finding appeared to debunk the most fundamental law of the natural world — you are born, and then you die.

One of the paper’s authors, Ferdinando Boero, likened the Turritopsis to a butterfly that, instead of dying, turns back into a caterpillar. Another metaphor is a chicken that transforms into an egg, which gives birth to another chicken. The anthropomorphic analogy is that of an old man who grows younger and younger until he is again a fetus. For this reason Turritopsis dohrnii is often referred to as the Benjamin Button jellyfish.

Yet the publication of “Reversing the Life Cycle” barely registered outside the academic world. You might expect that, having learned of the existence of immortal life, man would dedicate colossal resources to learning how the immortal jellyfish performs its trick. You might expect that biotech multinationals would vie to copyright its genome; that a vast coalition of research scientists would seek to determine the mechanisms by which its cells aged in reverse; that pharmaceutical firms would try to appropriate its lessons for the purposes of human medicine; that governments would broker international accords to govern the future use of rejuvenating technology. But none of this happened.

Some progress has been made, however, in the quarter-century since Christian Sommer’s discovery. We now know, for instance, that the rejuvenation of Turritopsis dohrnii and some other members of the genus is caused by environmental stress or physical assault. We know that, during rejuvenation, it undergoes cellular transdifferentiation, an unusual process by which one type of cell is converted into another — a skin cell into a nerve cell, for instance. (The same process occurs in human stem cells.) We also know that, in recent decades, the immortal jellyfish has rapidly spread throughout the world’s oceans in what Maria Pia Miglietta, a biology professor at Notre Dame, calls “a silent invasion.” The jellyfish has been “hitchhiking” on cargo ships that use seawater for ballast. Turritopsis has now been observed not only in the Mediterranean but also off the coasts of Panama, Spain, Florida and Japan. The jellyfish seems able to survive, and proliferate, in every ocean in the world. It is possible to imagine a distant future in which most other species of life are extinct but the ocean will consist overwhelmingly of immortal jellyfish, a great gelatin consciousness everlasting.
Title: A Path to Oblivion
Post by: Crafty_Dog on December 11, 2012, 09:20:10 AM
This could go under the Politics of Health Care too , , ,
A path to oblivion?
Jacqueline Laing | 11 December 2012


In 2008, a year after the Mental Capacity Act 2005 came into force, the Liverpool Care Pathway was recommended as the Department of Health’s end-of-life care strategy. Only a year later 300 hospitals, 560 care homes and 130 hospices in England had rolled out the programme.
Around 130,000 people a year now are reported to die on the Pathway (29 percent of the annual 450,000). Freedom of Information Act requests performed by one enterprising journalist subsequently revealed financial incentives to hospitals and care homes that implemented the programme.
Millions of pounds were paid to roll out the regime. The sub-programme, Commissioning for Quality and Innovation (CQUIN), requires that local NHS commissioners remunerate trusts for meeting “Gold Standards” targets in implementing the Pathway. In certain areas, targets are set specifically to increase the numbers of people in their hospital dying on the Pathway.
More worryingly, some hospitals had set targets of between a third and two-thirds of all the deaths to be Pathway deaths. Certain hospitals doubled the numbers of patients dying on the Pathway in one year. Eighty-five percent of NHS trusts have implemented the programme. Of those, 62 percent revealed that they had either received, or expect to receive, financial recompense for meeting targets associated with the implementation of the Pathway.
Concerned health professionals insist that there are indeed problems with the regime. Professors Patrick Pullicino, a neurosurgeon, and Mark Glaser, an oncologist, and other doctors have suggested that there are both difficulties of diagnosing imminent death with any certainty and grave dangers surrounding the institutionalisation of this relatively recently implemented national end-of-life regime.
Families and doctors tell of having intervened to take patients off the Pathway then to find that the patient recovered. Many were not told their loved ones were on the Pathway while others fear the programme has a homicidal character not acknowledged by its proponents.
The Pathway was, until recently, widely advertised as a model of good practice in the last hours of life by successive national Department of Health policy frameworks.
It is praised by health professionals who formulated or have implemented it. Academic articles abound in which professionals using the programme are shown to find it constructive. Indeed, when a patient is clearly in the last hours of life, it may well be that acts recommended by the strategy are entirely appropriate.
The problem arises when they are not indicated, ie, on the strength of misdiagnosis, or when the sedation and dehydration regime is implemented to satisfy managerial targets or countless other unjustifiable possibilities.
Reversing the burden of proof
Part of the difficulty is that, where a patient is diagnosed as terminal and imminently dying, the combination of morphine and dehydration is likely to undermine a patient’s capacity. Persistent dehydration of even the fittest sedated patient will kill him.
This was the problem with the Pathway from the very outset. It reversed the burden of proof, on the strength of a diagnosis that is not always certain, so that an increasingly incapacitated patient would have to speak on his own behalf in favour of water. Even assuming he was healthy enough, in an environment in which the Pathway is normal his pleas may not be heard.
Recent revelations of financial incentives and staggering compliance in rolling out the managerial programme radically alter the debate. Diagnostic concerns in the context of arguably self-fulfilling sedation-dehydration regimes and overarching financial and political pressure to implement the Pathway, suggest that the regime may have acquired a lethal power of its own.
This lethal character is almost certainly one that exists independently of the best intentions of those who formulated or apply it. Some of history’s most important lessons highlight the problems of institutionalising programmes that invite homicide and reverse burdens of proof in ways that undermine the vulnerable.
Controlling death
Critics have been warning for many years of the numerous financial, medical, political and research interests there are in controlling death whether passively or actively*. The independent inquiry sought by Baroness Knight of Collingtree and many families, healthcare professionals, journalists, academics and lawyers is both judicious and timely.
However useful the Pathway may be in individual cases properly applied, incentivised and managerialised death targets become problematic in the context of uncertain diagnosis, a steadily ageing population, spiralling healthcare costs, and the philosophical dehumanisation of the vulnerable pervasive in contemporary bioethics.
The targets themselves constitute improper pressure on healthcare professionals’ employment and livelihood. As such, they predictably invite and rationalise grave human rights abuse with tragic consequences for the defenceless incapacitated in hospitals and care homes.
Dr Jacqueline Laing, BA, LLB (ANU) DPhil (Oxon) is a barrister at the High Court of Australia and a senior lecturer in law at London Metropolitan University. This article was first published in the New Law Journal.
* Notes
J. Laing, “Food and Fluids: Human Law, Human Rights and Human Interests” in Artificial Nutrition and Hydration Ed C Tollefsen (Springer, 2002)
J. Laing, “Vegetative” State—The Untold Story” 152 New Law Journal 7045, p 1272
J Laing, “Mental Capacity Bill—A threat to the Vulnerable” 154 New Law Journal 7139, p 1165
Title: Grow into a tree after you die
Post by: Crafty_Dog on May 18, 2013, 11:15:38 AM
Title: Re: The Art of Dying
Post by: ccp on May 18, 2013, 09:01:44 PM
trees are good idea.  soak of some the excess atmospheric CO2 and make more 02.  OTOH the bodies in the soil eventually will fertilize the Earth.
Title: Top 5 Regrets
Post by: Crafty_Dog on June 25, 2013, 04:49:40 PM
Title: If death catches you unaware, what is the last thing you did?
Post by: Crafty_Dog on October 05, 2013, 06:27:17 AM
Title: Re: The Art of Dying
Post by: Crafty_Dog on January 05, 2020, 06:45:50 PM