Demystifying Medicine One Week at a Time

A Good Death

In America, too many people die in the hospital.

I don’t mean that they die due to medical error or incompetence, though that’s always a hot topic of discussion amongst doctors, researchers, administrators, and regulators.

What I mean is that if you ask most people, they say they’d rather die at home, surrounded by their loved ones, drifting off to sleep painlessly after having had last rites administered (feel free to plug in your religious/atheistic ritual of choice here).

Why, then, do so many who want this type of death instead die medically, here in the hospital, undergoing painful treatment and the deprivations and degradations of medical care?

The answer has both simple and complex aspects.  But I’ll start by sharing something that most medical professionals believe:

When my time comes, the last place I want to be is in the hospital. Don’t get me wrong–I like GlassHospital–it’s a good place to work, teach, and learn. But when the grim reaper is calling my name, I want to be as far away from here as I can.

No IVs.  No needle sticks to test my blood.  No waking me up to check vital signs every shift. No hospital food.  No fluorescent lights.

No feeding tubes; no bladder catheters (ouch!); for Heaven’s sake, no breathing machines (‘mechanical ventilators’).

These technologies have allowed us to extend life, by keeping people breathing and metabolizing as long as the heart can pump (we can even take that over for some time with machines now).

But what they don’t do is keep us alive in any meaningful way.  I’ll admit that this is a judgment call, that how you define meaningful is the key element. Because what I think is not meaningful life, being strapped to a bunch of machines keeping me alive, is very meaningful to others. Alive is alive, no matter what people like me have to say about it.

There’s a big disconnect between what health professionals see and what people not in the field perceive about death.  Presumably, for folks not ensconced in our world, a lot of death imagery comes from TV or the movies.

The simple reasons that people die in the hospital are:

  1. Some people prefer it.  Battlers to the bitter end.
  2. (For those that don’t prefer it:) They aren’t empowered to do it any other way.

This second group is the one for whom death in the hospital is a shame.  And though we’re getting better at comforting the dying, hospitals (believe it or not) are just not set up to deal with the dying process very well.

Hospitals are like giant factories where all the focus is on process: diagnosing, treating, rehabbing, and discharging.  Death, while a natural endpoint, is still too frequently viewed as medical failure.  Nothing could be further from the truth.

I’d like to empower the folks in that second group, and especially their family members and loved ones, who will be called on to help with decision making, to take the initiative and die at home.  Or in hospice.  Or on a mountain top in bright sunshine.

How can we do that?

Verbalize what you think you want.  Write it down.  Share it with your family and friends.  When your time comes and you have a life-threatening illness, push your doctors to be candid in their appraisal of your chances for recovery or the imminence of death.

Here’s the other thing:  You can change your mind.  If you become old and feeble and decide that you want to fight until the last breath is taken from you, you can. And in fact, this happens a lot.

But having these discussions for the first time when you’re at death’s door is a surefire way to wind up dying in a way that you probably never envisioned.

One last note:  Though I and most of my colleagues want no part of this place when we’re dying, you still have every right to come here and use our services.

We really do want to honor your wishes.


  1. Excellent thoughts. I heard yesterday that the number one verbal association people make when they hear the word “hospital” is “processing plant.” Interesting that you used those words yourself in your post. Doctors, by contrast, are associated with the word “hero.” How did that disconnect happen?

    What about advising patients to fill out POLSTs, Values History Forms, and Advance Healthcare Directives? (I don’t think Glass Hospital’s state has a POLST program, but maybe it should?) How often are these used in practice? Are they only used with terminal patients, or everyone?

    • glasshospital

      February 25, 2010 at 4:51 pm

      To be quite honest with you, until your comment, I’d never heard of a POLST before, which stands for Physicians’ Orders for Life-Sustaining Treatment. Looks as though they’re used in a dozen or so states in the U.S.

      Advance directives are the tool with which I’m most familiar, but if there’s one piece of advice I’d give it’s this: Choose someone you trust to execute your wishes should you become incapacitated. Designate them your health care proxy, and make it known to others so it’s clear.

      As to heroes working in processing plants, hey–even factories need their heroes!

      Thanks for your comments.

  2. Thank you for this look into death as a doctor sees it. I’m sure you’re right that we who don’t deal with death regularly imagine it differently. It’s good to hear real-life (er, death) stories. Also, I appreciate how you considered both points of view. Though you fall into one camp, you respect that other people feel differently. Interesting and thought-provoking post.

  3. Brilliant post…I couldn’t have said it better myself! Well, actually I just said it in a longer form without all your medical training and fancy degrees. My Last Wishes…A Journal of Life, Love, Laughs & A Few Final Notes is the book I wrote about this very topic. If people would simply show your article to their loved ones and have a single conversation it would save millions of families a great deal of unease and anguish. We all are going to die, a GOOD DEATH is a blessing.

  4. This piece is brilliant in its clarity. People talk this kind of talk casually but then don’t bother to put their wishes in writing. Then there is the unhappiness of family not knowing what to do when the time comes.

    Another tool — and these tools vary by state, I believe — is the Power of Attorney for Health Care. It doesn’t give the executor any power but for making health care decisions when the patient is unable to do so. It doesn’t lock the patient into a decision in advance, but lets the executor decide as things change.

  5. Love the post and the poster. I will do everything in my power to be at home by your side when the time comes (in 70 years. . . )

  6. Other medbloggers who have recently written eloquently about death are internist Dr. Charles (The Examining Room of Dr. Charles) and nurse-turned-medical student Albinoblackbear (Asystole Is The Most Stable Rhythm).

    You’ve been added to my RSS feed; I’ll try not to comment to excess.

  7. Hit POST too soon.

    I also meant to give you an applicable Southern colloquialism in the form of a question that is typically asked of someone who attended a buryin’ by someone who didn’t:

    “Was it a *good* funeral?”

  8. Do internists make the discussion about end-of-life decisions part of ‘routine care’ of their well patients? Is there a check-box for it (Atul Gawande would be proud)? I’m a pediatrician, so thankfully usually don’t have to approach such discussions and decisions, but as my patients are getting ready for what’s next (adulthood), I counsel them on how to approach their medical care for the future. Seems like this should be done for adults also. I’m just not sure how else the average person would know how and when to do it.

    For the record, I’ll be running as fast as I can away from the hospital if I end up there…

    • glasshospital

      February 28, 2010 at 8:21 am

      Yes, one of the many things internists *should* do; not surprisingly, we mostly deal with what’s at hand given the time constraints. An ethicist colleague loves to get roomfuls of people talking by asking them to raise their hands in response to the question, “How many of you have an advance directive?”

      She’s usually the only one, or one of a few–showing that we’re *not* good at holding these discussions.

  9. Don’t forget that religious people tend to be the ones who say, “Do everything you can to keep him/her alive.” Religion increases the cost of medical care tremendously since this end of life aggressive action is expensive:

  10. As an ICU of over 20 years I’ve witnessed many “institutional deaths” where the patient died alone in the hospital.
    I recall one night when I had two patients: one I was busy keeping alive, the other was on “comfort measures” (DNR, let them pass without heroic measures and keep pain-free as possible).
    As my time was devoted solely to the patient fighting to live, my thoughts were with the patient on the other side to the curtain, dying alone…
    A colleague who had some time to spare asked if she could help—my request was to make sure the guy didn’t die alone. She spent the better part of the night holding his hand and singing quietly to him.
    I will never forget her loving gesture to help another human being from a cold intuitional death. He passed away later that night…

  11. I agree! The process of a good death is very different than what a hospital, usually can give. Last December, my mother died home. I wrote a blog about the experience of being with her the last week and giving her the gift of a good death. You can find it here.

    • glasshospital

      March 15, 2010 at 8:16 pm

      Carol: Thanks for sharing your experience. It does sound like your mother was fortunate to have had you and your sisters help her achieve a good death.

  12. Kate Hildebrandt

    March 16, 2010 at 8:03 am

    Thank you so very much for your writing on this very sensitive subject. I couldn’t agree more !
    If you don’t know about it already, there is a lovely book titled “Living Consciously, Dying Gracefully” by Nancy Manahan and Becky Bohan. I read about it in the New York Times and have read it twice. After reading it, I felt like I knew Nancy and was part of their family and circle of friends. It’s about their sister-in-law Nancy who was a nurse and her husband who is a physician.
    Anyone interested in this topic will find it beautiful and truly inspirational.

  13. Good post. Tough issue.

    Agree with you that for the 2nd group of people it’s a tragedy.

    Dying isn’t easy. But we can try to make it as comfortable as possible.

  14. There’s also a third category, those who don’t know there is an alternative and those that know that they want a ‘good death’ but are so very profitable the hospital keeps them in as long as possible. The dying part is a bummer for the hospital, the revenue stream stops.

  15. $dollarsdownthedrain

    May 22, 2010 at 4:22 pm

    All “Glass Hospitals” have electronic medical records. Mine does. Why can’t a patient have a very specific legal health directive, be scanned and be part of the patient demographics. I think that no one wants to die in an ICU. This document will include the contact information and should be updated at the yearly physical.

    A nationwide health record system will help, in case anything happens when you are out of the “glass hospital” area or in another “glass hospital”.

  16. Sometimes I wonder whether the discussion surrounding a “good death” isn’t a bit skewed. Let me write from different perspective.

    In 2003, I had a double lung transplantation that didn’t go very well. After having had a tracheotomy and having been on the vent for 2 months, as well as hooked up to all the other apparatuses that are part of existence in an ICU, my life was clearly ebbing. There came a day when I was fairly sure that my case would land in the statistics with those 20% who don’t survive the first year following that difficult surgery. I assumed that I would probably not survive to see the next day, and almost certainly not to see the day after.

    Frankly, the thought of dying in the hospital, where I’d spent the previous 9 months, was not in the least bit painful. I did feel somewhat sorry for my family, because they were all on the other side of the world and couldn’t be with me. They would have to deal with my having died “alone” – I would be dead and would have to deal with nothing at all.

    Yes, in those hours, in my imagination I walked through my father’s garden, I sat on my sister’s terrace, I drove the country lanes with my sweetheart. But I didn’t need to be at home in my bed.

    My condition deteriorated, I yearned to finally die. But I couldn’t. After about a week of standing on the brink, I started my recovery. After 4 months, I was discharged.

    That week of staring at my own demise has rewarded me with the loss of fear of death. I learned that when the time has come to let go, you can. And that when you let go, it doesn’t really make much difference where you are.

    • Thank you.

    • emr thank you very much for the comment you made on “THE GOOD DEATH.” Having worked many years in a well-funded TEACHING AND RESEARCH HOSPITAL, I always thought I would rather die in a Hospital. Now that I am older (74) I am slowly changing my mind thinking that hospice death might not be so bad. However, your comments regarding the other side of the “Good Death” arguement has added to my slow change of mind about dying in a Hospital. In my mind the “Hospital Death” provided a greater degree of comfort during the ptocess of dying. Your comment about “Letting Go” really touched me. It was truly a “light-bulb moment”. However, I am glad you were discharged after four months.
      thank you,

  17. An honest and raw account of one woman’s trials and tribulations while taking care of a loved one at home:

    I stumbled across this anonymous blog by accident, but her story was so vivid and compelling, I soon found myself reading it from beginning to end.

  18. Moshe Luckman

    June 22, 2012 at 9:38 pm

    Helpful information. Fortunate me I discovered your web site accidentally, and I’m stunned why this accident did not came about earlier! I bookmarked it.

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