In Defiance of Death: Exposing the Real Costs of End-of-Life Care

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Death is a natural part of life. But it has become a painful, protracted, humiliating process that is often inappropriate for the healthcare patient, puts an undue financial and emotional burden on the family, and provides a model of improper care for physicians in training. And it's expensive� about 22 percent of all medical expenditures are for people in the last year of their lives. Further, while studies show that 90 percent of all people would prefer to die at home surrounded by family and friends, the reality is that more than 70 percent die in institutions. As Dr. Ken Fisher argues so passionately in this book, it's time for a change.

End-of-life care in the U.S. has evolved over the years into a nightmare for patients and family members, and it has created a near-crushing financial burden on the medical system that is not just excessive but unsustainable. It has driven the cost of healthcare out of reach for many people, and it is a large factor in preventing the creation of universal coverage. In Defiance of Death reviews the current state of end-of-life care and highlights its many problems from a variety of economic, political, and social perspectives. Fisher and Rockwell illuminate the ethical dilemmas we all face as technology allows us to prolong life� but at a huge human and financial cost. This book documents these problems and provides a historical perspective of how our medical system evolved. It argues that America's defiance of death is far too costly and recommend that all stakeholders� including the public, medical community, Congress, and business leaders—join together to create a system that improves end-of-life care for everyone involved. This book, with workable solutions to improve our medical system, helps point the way.

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In Defiance of Death: Exposing the Real Costs of End-of-Life Care Review

Drs. Fisher and Rockwell along with free-lance writer Scott have written a compassionate, extensively researched appeal for rational end-of-life care. Their long over due discussion has the potential to improve the quality of medical care, while at the same time help eliminate wasting our wealth on futile treatments.

We spend a very large proportion of our health care dollars at the end of our lives. The reasons for this are multiple, but include an inadequate legal definition of death, the shifting of decision-making away from medicine and into the legal realm, lack of adequate communication between patient and medical care-takers about end-of-life wishes and realities (aggravated in part by the Patient Self-Determination Act), unrealistic expectations of what medical science can accomplish, and the divorcing of medical decisions from economic considerations.

Dr. Fisher offers some very intriguing solutions which are worth further discussion.

Death should be defined not as "absence of all brain activity" but the absence of cerebral cortex functioning. This would clarify the futility of continuing to keep bodies alive when the person who once inhabited them no longer exists.

Hospitals could form Appropriate Care Committees to assist families and physicians provide the best possible care for individual patients. We must actually apply what we already know about which interventions are futile in which contexts, and when further treatment is merely prolonging suffering and death. Where I part ways with Dr. Fisher is his recommendation that these committees extend into a government-managed hierarchy. I can see them as a selling point for hospitals ("We provide only the best, appropriate care.") but it frightens me to think of the government making those determinations.

Another idea of Dr. Fisher's is to eliminate CPR as the default action for cardiopulmonary arrest. Upon hospital admission, each patient fills out a fresh advance directive form (a good idea), and if CPR is desired, an order for its use would have to be expressly written. The danger, of course, is that the order for CPR could be absent due to oversight rather than as a true reflection of the patient's wishes--and potentially lead to an irreversible error. Dr. Fisher points out that CPR-as-default was instituted when most hospital patients had acute, reversible problems. That is no longer the case. A growing proportion of hospitalized patients are admitted with debilitating chronic illnesses and aggressive treatment is frequently not beneficial. I am still not sure what to think on this issue--but it is a discussion which needs to occur.

A useful clarification in the book is the differentiation between the absolute right of individuals to refuse any and all treatment and the non-existence of a right to demand treatment that is not medically indicated. The tricky part is who gets to define what is "medically indicated." Dr. Fisher recommends only limiting treatments which are not controversial (such as attmepting to keep an anencephalic infant alive via mechanical ventilation.) These non-controversially futile actions are where there is no right to demand treatment.

Dr. Fisher also calls for more training of medical personal in end-of-life matters and palliative care. The goal is to do our best to assure patients do not pointlessly suffer by receiving futile treatments, and families do not deplete life savings for inappropriate care. As a physician, a patient, and daughter of aging parents, I heartily agree that a deeper understanding of this aspect of medicine is sorely needed.

Dr. Fisher presents much valuable information accompanied by a number of concrete practical actions we could take to address a very real and serious problem within our current health care system. This book is an excellent place to start several long over-due conversations.

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