And a Time to Die: How American Hospitals Shape the End of Life [Hardcover]

"And A Time To Die" is definitely not light summer reading. Instead, it is a serious and revealing look at the way people die in this country. Fifty years ago most people died at home. For a whole host of reasons detailed in this book this is no longer the case. The simple fact is that most folks find themselves ill-prepared when faced with life and death decisions involving themselves or close family members. Author Sharon R. Kaufman has done us all a great service. "And A Time To Die" brings the reader up to speed on the issues, the terminology, the technology and the players involved in various end of life scenarios. Just what is meant by the term "persistant vegetative state"? What are the advantages and drawbacks of CPR? Is hospice care really a better alternative to a conventional hospital for many of these patients? What happens when the patients wishes are at odds with the wishes of the family? And just what role does religion play in the life and death decisions people are forced to make? These issues and a great many others are presented in clear, concise and easy to understand language.

Sharon Kaufman, a professor of medical anthropology at the University of California, spent two full years observing and interviewing terminally ill patients and their families. She also spent considerable time speaking with doctors, nurses and hospital staff who must struggle with these issues on a daily basis. She presents the stories of 27 patients who find themselves in ICU's (intensive care units) or in other specialized hospital units. To be honest, a good many of these stories are downright disturbing. One cannot imagine what many of these patients and their families are forced to endure. And what is so frustrating is that the structural deficiencies of the American health care system are largely responsible for so many of these problems. Reading this book will surely convince you that there is so much that needs to change.

Admittedly the issues are complex and the subject matter is not particularly pleasant. But as a practical matter, it is extremely important for people to get up to speed on many of these issues. I can only conclude that I found "And A Time To Die" to be a very worthwhile use of my time. I would wholeheartedly recommend this book to you as well.

The author of this book goes inside the modern American hospital system as an anthropologist, and reports what takes place there when the system is confronted with a terminally ill patient. She examines what cultural imperatives are being brought to bear there to make this an increasingly problematic and decidedly "unnatural" process.

You will get a few definite insights from this book. The author includes interviews with a variety of patients and their families. And she sits in on hospital conferences as all the people treating and speaking on behalf of a dying patient wrestle with the problem of what measures to take to prolong the patient's life, or less euphemistically, to prolong his dying.

There is also an interesting chapter on specialty care units that are either attached to some hospitals or that are hospital owned, but exist in their own removed compounds. These units maintain patients who only survive with the aid of artificial/mechanical aids. Some of them are in a vegetative state. Some are conscious to varying degrees. Most of the public still isn't aware of the existence of these adjunct facilities, despite the movie Coma - which featured a sinister version of such a high-tech "warehousing" center. The actuality, as Kaufman describes it, is infinitely more benign. The staff at these institutions sincerely care for their patients.

A few good summary points emerge from Kaufman's treatise. Insurance has largely shaped our medical care system by mandating that hospitals treat specific conditions in order to justify a patient's stay there. So generic old age can't be attended to. A patient must receive a diagnosis of something like "superlobar emphysema" and must be put on the pathway of aggressive treatment for that condition, if the hospital expects to be compensated.

Another point: Our system of so-called choice makes it difficult for the dying and their families. People don't know "what to want" in these life-and-death situations. The onus is on them to say when to pull the plug. Choice has replaced nature.

Kaufman explains how our far-reaching, albeit still limited, control over nature has left us without any way to anchor moral decisions. Whereas we could once let a person die "naturally," now we have transformed and become nature, so the decision can't be left outside ourselves. This is perhaps the main thesis of the whole book, and should have been stated at its beginning to orient the reader a little better.

In general, this book is five times longer than it needs to be. It's like a bird that circles and circles, riding the lofty currents of air, without ever swooping down to make a catch. At the end of the book's 300+ pages, we really don't know much more than when we started. Most of what Kaufman writes in between interviews is abstract and obvious.

Kaufman might have considered going beyond her passive role of anthropologist, and might have envisioned some more substantial solutions to the problem of medicalized dying if she had incorporated the works of philosophers such as Ivan Illich (author of Medical Nemesis) in her thinking. Illich approached the problem of our entire medical care system as a problem of glut and hubris. Just as we demand too many goods in this society, so we demand too many services. We insist on being serviced to the hilt, and institutions abound to sell us service, service, service. These institutions then take on a life of their own, and there's nothing any of us can do, client or provider alike, but go along for the ride. Kaufman's need to maintain cordial relations with hospital staff and patient families in order to conduct her research may explain some of her lack of critical perspective in this regard though.

As it is, her book is worth reading as rehearsal for what each one of us might face some day. But I would speed-read it, in order to avoid prolonging the process.

This is an excellent book about a difficult subject: The ambivalent attitudes and approaches to dying in the culture of US hospital settings. Sharon Kaufman is professor of medical anthropology at the University of California, San Francisco.

Kaufman observed that time was the factor which most influenced many of the interactions and experiences of the participants in the drama of dealing with serious health challenges. Institutional pressures on the staff demanded that care be provided in the most efficient and economic manner. The staff were constantly faced with decisions around the timing of interventions and the pacing of the therapies and their effects and consequences. Staff had to deal with obstacles to the most efficient provision of care and with the timing of death. Patients were often unconscious, leaving relatives to have to make extremely important and difficult decisions - ones that they would have to live with for the rest of their lives, and ones that might set them in conflict with other family members who could not be present at the time.

The control that modern medicine has over the timing of death brings the patients, staff and families into discussions and negotiations over physical, psychological, relationship, moral, ethical and religious issues and concerns. When there is no living will/ directive, an urgent situation is created in which decisions of major consequences must be taken.

Much suffering seemed incredibly unnecessary, like octogenarians with living wills discovered after the fact, or aggressive surgeries on debilitated and chronically ill people who had not a fighting chance of surviving these insults.

This powerful book should be read by every student and caregiver dealing with seriously ill patients, and by families with people who are approaching the last stages of their lives. It would make an excellent focus for caregiver discussion groups.

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