The Good Death: The New American Search to Reshape the End of Lifeby Marilyn Webb, Joanne Lynn (Foreword by), Timothy Quill (Foreword by)
The Good Death is the first full-scale examination of one of today's most complex issues: the profound change in the way Americans think about and confront death. Drawing on more than six years of firsthand research and reporting, noted journalist Marilyn Webb builds her account around intimate portraits of the dying themselves. She explains why some deaths become shockingly difficultand needlessly painfuland how the struggles over end-of-life decisions can pit patient and family against hospitals, doctors, insurance companies, religious groups, and the law.
But there is good news as well. Webb describes many extraordinary programs and individuals who are changing the face of dying. An abundant source of comfort and hope, The Good Death shows how the essential elements of humaneeven uplifteddeath are available to all of us, if we know what is possible, where to go for help, and how to prepare.
Originating as an article called "The Art of Dying" for New York magazine, this work draws on research into both the dying process and the right-to-die controversy. Webb, a former editor-in- chief of Psychology Today, argues with considerable passion and great effectiveness that "if we are to have good deaths, the culture of dying must change." She attended medical training seminars, visited hospitals, hospices, and palliative-care centers, and interviewed numerous dying patients and their families, doctors and clerics, lawyers and ethicists, conservatives and liberals, and such prominent figures as Dr. Jack Kevorkian and Elizabeth Kübler-Ross. That dying well is possible is shown in her first chapter, featuring a young woman who, after a roller coaster ride of hope and despair prompted by various treatments for her cancer, chose to die at home, in peace, surrounded by her family. That such a death is difficult to achieve is demonstrated by most of the remaining chapters. Pain management is not well understood by many physicians, extreme treatments can prolong the dying process, families of the terminally ill often bear heavy financial and emotional burdens, the wishes of dying patients and their families are frequently overlooked, and hospice care may offer too little too late. Webb spells out the details in human stories. She also tackles the legal isues, from the Karen Ann Quinlan case of the 1970s to the latest Supreme Court decision that assisted suicide is not a constitutional right. Webb concludes with the ten major reformsincluding legalization and strict regulation of assisted suicidethat she believes are essential if a good death is to become the rule, not the exception.
A noteworthy contribution to the continuing public debate over an issue that touches everyone.
Mitch Albom, author of Tuesdays with Morrie
"Transforming death to a subject discussed openly by the dying, their families and the medical community is the greatest value of this book. The Good Death receives my strongest endorsement and should be read by physicians and laypersons alike."
S. Jay Olshansky, Ph.D., The Journal of the American Medical Association
"Webb reminds us, through her firsthand observations, clearly and compellingly presented, that dying need not be a time of frantic terror, or terrible suffering."
Robert Coles, The Washington Post
"An intelligent and compassionate look at one of our last taboosand a hopeful message."
Daniel Goleman, Ph.D., author of Emotional Intelligence
"A noteworthy contribution to the continuing public debate over an issue that touches everyone."
"A sweeping overview of dying and end-of-life care in contemporary America. The poignancy of these stories and the clarity and force of Webb's investigation provide a foundation from which to explore what 'dying well' can mean."
Ira R. Byock, M.D., author of Dying Well
"Webb deftly analyzes the major themes in the contemporary debate about how, where, and when we can, and should, die."
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Read an Excerpt
One night in the fall of 1989, Sally woke up terrified. Hale had gotten out of bed and collapsed unconscious on the bedroom floor. Frantically, she called 911. The ambulance came for him. Once he was in the emergency room and admitted into the hospital, doctors went full tilt to save him. State and federal law required them to do so.
Sally hadn't known all that, but if she had it wouldn't have mattered anyway. As with most caregivers, her middle-of-the-night instinct was to call 911. She didn't realize that if she called, doctors would "do everything possible" to save him, even if "everything" wasn't really what she wanted them to do. And if she had realized, she would have called anyway. She could not have sat and watched Hale die on the floor.
This time Hale's sons and daughters made a special plea. Among them were a psychiatrist, a media executive, a college history professor, a special education teacher, a Wall Street analyst. They were PTA presidents and Ivy League graduates, professionals who were married to professionals; they were accustomed to making the system work for them. They asked the doctor not to give Hale antibiotics, not to do any surgery, not to give him fluids. They wanted Hale just to have pain medications to keep him comfortable and let him go. But his family doctor and the specialists he enlisted refused.
These adult children insisted that if things kept on, Sally might be so worn down that she would be the first one to die. They saw Hale's medical treatment as no different from physical abuse. One son, speaking on behalf of Hale's family, threatened to sue the doctors and the hospital for physical and emotional assault and battery, but heand his siblings backed down when they realized that Sally was too distraught to withstand a trial.
Demented as he was, Hale tried to pull out his own IV and catheter tubes. His children and stepchildren and their spouses all thought he was trying to make his wishes clear in whatever way he could. The hospital staff tied his arms to the bed. Finally, Hale was medically stabilized. His doctor told Sally that it was time for a nursing home. Hale had always told everyone he never wanted to go to a nursing home, that he hoped he would die long before that.
Sally was torn. She wanted to take care of him, but she wasn't physically able to anymore. Hale had been a dignified man, and now everything about his condition was so undignified. It was as if the real Hale had actually died years before. The doctor gave Sally some Valium to calm her down. Then she said she'd look around.
It took time to find Hale a nursing home bed. Sally said that she'd consent to a home only if they could find a place nearby, so she could be with him every day. She didn't want him to go; she felt guilty, responsible, dutiful. Finally she reasoned that he'd only be sleeping in the home, that professionals would be caring for him, and that she'd be with him all the time anyhow, just as before.
Meanwhile, the family was told that Hale had to leave the hospital. He had used up the Medicare days allotted for intestinal bleeding, and there was nothing more they could do to treat him. Since he didn't yet have a nursing home room, he was taken by ambulance from the hospital back home, and put to bed in his and Sally's room.
That's when all five of Hale and Sally's daughters and stepdaughters and one daughter-in-law decided to come--from Maryland, from New Hampshire, from Texas, from the suburbs of Chicago and New York. They came together as women--without their husbands and children--for the first time in many, many years.
They spent nearly a week spelling Sally in caring for Hale, sitting up late together in the living room, and spending long hours talking around the old, round kitchen table. The normal issues in their lives seemed to evaporate as they focused intently. They realized how very desperate Hale's situation was and the enormity of care that Sally had been trying to provide. Finally, a consensus among the daughters, at first emotional and unspoken, boiled to the surface. It was as if in this state--all female, all daughters, all unleashed from the moorings of what others might say is just or right--a higher sort of rightness took over.
The night before he was to go into the nursing home, Hale lay under a cream-colored down comforter in his and Sally's antique, four-poster bed, moaning in apparent pain. He recognized no one. The daughters called another doctor for advice, a friend of the family who was a hospice physician. He had told them that in hospice it's common to increase the pain medication when it's clear that someone is in terrible pain and ready to go (though he didn't say whether that meant "ready to die" or psychologically ready). They thought Hale was as ready as anyone, and they decided to help him.
They called Hale's own doctor and asked him for pain medication. He told them he would write a triplicate prescription for Demerol and they should come pick it up. "How many of these pills would be so much that it would kill him?" they asked. And the doctor told them how much was too much, so they'd "be sure not to exceed that dose."
Hale had always loved homemade applesauce. While one daughter went to the drugstore to fill the prescription, another stopped at a local gourmet shop and bought organic Granny Smith apples. The daughters and the stepdaughters and the daughter-in-law gathered downstairs in the kitchen. They peeled and cored the apples one by one, cut them into one-inch chunks, and boiled the chunks with lemon juice, sugar, cinnamon, nutmeg, and a little vanilla. Then they dumped the entire bottle of Demerol onto the butcher block counter, mashed up the pills by grinding them between two spoons, scooped up the powder with a butter knife, and blended it in with the applesauce, stirring constantly.
They wanted to be sure the mixture wouldn't burn Hale's lips, so they waited until it cooled slightly. Then two daughters sat on either side of their father in the bed, and two stepdaughters sat by his legs. One daughter and the daughter-in-law took turns stirring the pot down in the kitchen, to keep it warm--the way Hale liked it--and to maintain its potency. They shifted positions, all of them switching off with each other. Hale's head rested on three pillows, his thin face surrounded by 330-thread-count linens trimmed in delicate lace. They kissed and stroked and talked to him. His own daughters talked most--of their childhood, their mom, how much they loved him. All of the women told him they loved him. He didn't know who they were, not even his own daughters, but he seemed comforted.
Then his daughters explained what they were about to do and Hale began to open and close his mouth. There was something there inside his brain, but it was hard to tell what. Suddenly he whispered. "Go," he said, "I want to go." He opened his mouth like a baby wanting to be fed. Those were the last intelligible words he ever said.
One daughter, then another--daughters and stepdaughters and daughter-in-law--began spooning the drug-laced applesauce into his mouth. Sally stayed on the third floor, collapsed in sleep in one of the guest rooms, knowing, but not really wanting to know, what they were doing. Hale wasn't able to swallow very well by then, so the applesauce began dribbling out the corners of his mouth, down his cheeks and chin. They worried that he'd choke. They sat him up. They wondered why they were worried, when what they wanted was to help him go. All six of them cried and cried.
They stayed up all night, and by morning, Hale was still breathing. As the nursing home attendants came in with their gurney and wheeled him off, they were consumed with a terrible feeling of defeat. They felt they'd let him down. Luckily for them, no one did any blood tests when, in late October 1989, D. Hale Cobb III was admitted.
That had been Hale's--and the family's--last best chance. Once Hale became a nursing home patient, he could no longer have his own family physician. When Hale entered the home, he was assigned one of their doctors. Sally was asked if she wanted a doctor who would "do everything possible" for him. She said yes.
She didn't understand medical euphemisms. The new physician was even more aggressive about prolonging treatment than their family physician had been. To Sally and the children, "doing everything possible" meant taking good care of Hale and keeping him free of pain or other uncomfortable symptoms. But after they realized that wasn't what the doctor intended--that he'd meant far more than that--they were not permitted to change physicians.
Hale stayed in that nursing home--an expensive private nursing home in an exclusive Connecticut neighborhood--for ten months. Medicare and the health insurance policy that Hale and Sally had both had a per diem coverage; even together that rate was far lower than what Sally had to pay.
Hale recognized no one. The only thing he could still do was sing old songs with Sally. She liked that, because it made her feel the warmth of still having a spouse she loved. They would sit holding hands as they sang. For some reason, the memory of old songs was the only part of Hale's brain still alive. The rest of the time he was nearly an animal.
He was often strapped to his bed or his chair. He was diapered. He cursed and yelled and wailed. He was more violent than ever. Each time he got ill, they'd rush him to the hospital to be treated. It was always the same thing: antibiotics, fluids, heart medications, whatever they needed to do to keep his body alive, despite what Hale's family might say. And then they'd return him to the home, always worse than when he left.
In September 1990, Sally's brother persuaded her to visit him and his family in Maine for a weekend. They'd tried to get her to visit for two years but she'd felt guilty about leaving. Hale had just been sent to the hospital for pneumonia, treated, and returned to the nursing home--this time nearly unconscious, almost totally unable to swallow, and with tubes coming out of veins in his legs and arms. This time, in her exhaustion, Sally said yes.
While she was in Maine, Hale's son came to see him, as he'd promised, so Hale wouldn't be alone while Sally was gone. Hale died during the night, after his son spent the day with him, holding his hand as he lay in bed.
The morning of the funeral, as the children gathered around the kitchen table again--this time with Sally--they got into a big fight. Feelings that had been building all those years Hale was ill finally burst out. Hale's children accused Sally of holding on to him longer than she should have. Sally said she loved him; she hadn't known how to get the nursing home to stop treating him; she couldn't not rush him to the hospital whenever he got sick.
His children said they did not understand why Sally had a physician who was as aggressive about treating Hale as the nursing home's doctor was, nor why she couldn't just change doctors. They accused her of being selfish in wanting Hale to continue being treated.
Sally's own children were angered both by these attacks on their mother and by the physical and emotional toll the whole situation had taken on her.
And the financial burden had been staggering. By this time, Sally had spent what would have been Hale's entire share of their joint marital investments on his care, except for his portion of the house where she still lived. During his final year and a half, Sally had also spent $100,000 of her own assets on his care. The nursing home alone cost $72,000 a year, not including many doctors' bills, which somehow didn't seem to all be covered, nurses' aides and private nurses whenever he went into the hospital, since she felt the regular nursing staff needed help with the intensity his care required.
In the end, it wasn't clear what was or wasn't covered by Medicare or the private health insurer. The mountain of paperwork required for reimbursement simply overwhelmed Sally. She worked at it diligently, but she probably failed to claim some reimbursements that might have been covered; her health insurance would pay after Medicare covered a portion, and after the health insurance sent a check, she often would have to file multiple appeals. Weary and under stress, Sally filed claims; but she also just paid.
"I foolishly listened to Hale when he kept pushing me to stop working," she says, "and I lost a lot of money because of that. If I'd worked five years more I would have had a much better retirement package and I could have built up our savings even more." But by then, the Hale she had known was gone, and their investments were mostly used up. He'd wanted to leave his wife and his children well off, but now his children would get nothing, and Sally was left with little more than their home when he died.
Instead of a legacy of wealth, Hale's long and frightful dying process left his family a legacy of sadness. The resentment Hale's children felt toward Sally for what they believed was her role in extending his life into indignities he'd never wanted created a permanent rift that has carried on to the grandchildren as well. Sally's children are equally as angry at Hale's children. They are all still polite to one another, but in the end Sally was left grieving not only the loss of her husband but the loss of family closeness and of the solid financial base that she and Hale had spent a lifetime building. The way Hale died left his wife in financially reduced circumstances and ripped apart the family support she would need for her own aging.
Meet the Author
Marilyn Webb's articles on dying have appeared in New York magazine, Ladies' Home Journal, Parade, The New York Times and USA Today. A former editor-in-chief of Psychology Today who has taught at the Graduate School of Journalism, Columbia University, she is currently speaking nationwide at professional conferences and community organizations about the topics in this book.
Joanne Lynn, M.D., is the Director of the Center to Improve Care of the Dying, George Washington University.
Timothy Quill, M.D., is the author of Death and Dignity and A Midwife Through the Dying Process.
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