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Modern Death: How Medicine Changed the End of Life by Haider Warraich

This interdisciplinary study of death and how we can improve–not avoid–it is highly readable and timely.

modern-death

In Modern Death: How Medicine Changed the End of Life, Haider Warraich explores how human death has evolved over the course of history and offers recommendations for its future. A medical doctor, Warraich supplements his research with anecdotes from his personal experience, and draws on literature, theology, statistics and legal theory as well as the hard sciences. The resulting expert opinion is heartfelt, convincing and well informed.

Warraich begins with the mechanics of how cells die and the opportunities for analogy they offer: cells choose to die to promote the good of the organism; not dying on time is as bad as dying too soon. He recounts the medical advances that have increased human life spans astronomically in the last two centuries. Chiefly, people now die far less frequently from infection and simple injuries, instead living long enough to die of cancer and heart disease. Because of both medical and cultural shifts, more people die in hospitals or nursing homes than at home.

This is the story of how medicine learned to save and expand lives–especially through procedures like cardiopulmonary resuscitation–and then how medicine learned not to resuscitate. Warraich shows what modern death looks like, how it works, its achievements and shortcomings–and then investigates what a good death could look like, and how we can do better. Science has lengthened lives so successfully, delayed death so thoroughly, that our new problem often is not staying alive, but letting go.

In what comes to feel like the real heart of Modern Death, Warraich then studies the nuances of euthanasia, assisted suicides and the withdrawal of life support systems, and their legal histories in the United States and worldwide. He finds that these three categories of death are far less distinct than generally believed. Finally, he advocates strongly for patients’ control over their own ends of life and exhorts his readers–patients and physicians alike–to discuss death openly.

These conclusions form the book’s central purpose. Along the way, Warraich explores different cultures’ and religions’ approaches to death. He also discusses the philosophical and legal difficulties in defining death and life. Warraich’s chief goal is a better end-of-life experience for everyone.

If Modern Death occasionally uses a few more words than necessary, the inclusion of Warraich’s anecdotal experiences enliven what could have been a dry academic text. For readers interested in its thesis–that death is an important part of life, and medicine and society could do a better job of delivering this experience–it is a sincere and thorough examination of an often overlooked subject. Well served by Warraich’s professional expertise and earnest emphasis, this is an indispensable entry into the conversation about death.


This review originally ran in the January 6, 2017 issue of Shelf Awareness for the Book Trade. To subscribe, click here.


Rating: 7 cells.

book beginnings on Friday: Modern Death: How Medicine Changed the End of Life by Haider Warraich

Thanks to Rose City Reader for hosting this meme. To participate, share the first line or two of the book you are currently reading and, if you feel so moved, let us know what your first impressions were based on that first line.

I do enjoy learning more about end-of-life issues, medical and legal and ethical. This one seems to be for me.

modern-death

The opening chapter, “How Cells Die,” begins:

It had been the longest of months–in both the best and the worst possible ways. Brockton is a small town about a half-hour drive south of Boston, but in many ways it seems a world apart.

A little out of context, it seems, but we are just beginning. I like that it’s not a dry, thesis-sentence sort of beginning. Reading on, Haider Warraich does seem to grasp the idea of narrative writing, making his storytelling immediate and personal; and he does have a personal story to tell, being an MD. I am optimistic.

Modern Death is forthcoming in February. Stick around!


This quotation comes from an uncorrected advance proof and is subject to change.

Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital by David Oshinsky

This fascinating history of New York’s famous public hospital provides a microcosm of national and worldwide medical history.

bellevue

Bellevue is one of the oldest and most famous names in United States hospitals, known for housing violent criminals and mental health patients, the homeless and sufferers of rare and exotic diseases. The incredible, multi-layered history told by David Oshinsky in Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital covers medical and general history both national and global. This thorough narrative is wide-ranging and endlessly gripping.

The institution began in 1736 as an almshouse, where the indigent were housed and given rudimentary medical care. From these earliest days, “Bel-Vue” had a reputation for dealing with society’s unwanted. And as Oshinsky shows, in its many incarnations, this reputation is intact. The flipside is that this public hospital has always attracted service-minded professionals pursuing innovation. Before modern considerations of medical ethics, this often meant experimenting on Bellevue’s impoverished patients and their diverse range of ailments: in exchange for charity medical aid, the thinking went, they offered themselves for clinical trials–as painful and medieval as they could be at times. Nevertheless, the hospital became central over the years in battling the yellow fever epidemic of the 1790s, the “Great Influenza” of the 1910s, the AIDS crisis of the 1980s, the September 11 attacks and Superstorm Sandy. Bellevue would see hospitals shift from being considered a last resort, only for those too poor to afford a private doctor’s home visits, to becoming the best medical care available (the development of anesthesia, germ theory and infection control being crucial).

The hospital has enjoyed affiliations with several medical schools, among the U.S.’s earliest and best, including its continuing relationship with New York University. NYU students get training in a premier teaching hospital that still treats an enormous and diverse patient population, while Bellevue gets talented, passionate residents and interns, many of whom remain and make their careers there. The history of Bellevue reflects social struggles, as women, Jews and African Americans gradually gained access to the medical profession, and anti-immigrant vitriol was aimed in turn at Irish, Italian and Jewish populations, among others, as waves of struggling immigrants contributed to Bellevue’s patient population. Bellevue successfully treated New York’s sole Ebola patient in 2014. Its tenuous funding situation (mostly public, and always under attack), high standards of care and public service mission continue.

Bellevue’s beauty and staggering scope lies in these historic, social and interdisciplinary connections. William Burroughs, Sylvia Plath, Charlie Mingus and Lead Belly passed through Bellevue’s history; its physicians have traveled the world and played roles in the scientific advances that have shaped modern medicine. Bellevue hosted the invention of forensic medicine, and major developments in medical photography, child psychiatry and AIDS treatments. Oshinsky (Pulitzer Prize-winner for Polio: An American Story) generally adheres to an impersonal, journalistic style, but his moving portrayal can’t hide his admiration for this longstanding institution. Bellevue is that rare, page-turning history: engaging, smart, clearly written and of broad general interest.


This review originally ran in the October 14, 2016 issue of Shelf Awareness for the Book Trade. To subscribe, click here.


Rating: 9 five-gallon containers of fuel.

The Conversation: A Revolutionary Plan for End-of-Life Care by Angelo E. Volandes, M.D.

A physician’s fervent quest for better information about medical options for patients nearing their end, and the steps necessary to make those choices clear.

conversation
In The Conversation: A Revolutionary Plan for End-of-Life Care, Angelo Volandes, a medical doctor for decades, focuses on the extensive, intensive, intrusive medical interventions that patients routinely receive at the end of life, many of which extend life by a matter of hours or days or not at all, while decreasing its quality substantially. He earnestly argues that every patient should be offered the option to choose among three broad categories of care: life-prolonging, limited medical and comfort care–in other words, the choice between quantity and quality of life. The Conversation advocates for all patients and families to receive information about what end of life care looks like within these three categories, and firmly states the importance of patients, families and medical professionals having what he calls the Conversation about end-of-life wishes openly and often.

To make these points, Volandes describes his upbringing as the child of Greek immigrants and the impact it has had on his life: from his start as a student of Socrates and a Greek diner cook, his stint as a philosophy major and then his work as a medical practitioner, he has been interested in what good life (and good death) are. Appropriately, Volandes neither attempts nor claims to be impersonal or unemotional about this charged topic; rather, he brings his personal and professional experiences as well as research to his impassioned argument.

The majority of the book is devoted to stories of patients, families and circumstances–and Volandes’s own attempts, good and bad, at approaching the Conversation. With names changed, these are real-life anecdotes of choices made with more or less preparation and knowledge of what a decision will entail, or what an incapacitated patient would have wanted. The last quarter of the book is composed of several appendices and a lengthy, narrative notes section, all of which provides substantive hands-on advice aimed variously at the patient, or the patient’s spouse or children. The Conversation is a how-to manual, enlivened by engaging–if occasionally painful–true stories. Volandes makes his points succinctly and convincingly and offers readers the tools to make change within their own lives.


This review originally ran in the January 6, 2015 issue of Shelf Awareness for the Book Trade. To subscribe, click here, and you’ll receive two issues per week of book reviews and other bookish fun!


Rating: 7 people.

book beginnings on Friday: The Conversation: A Revolutionary Plan for End-of-Life Care by Angelo E. Volandes, M.D.

Thanks to Rose City Reader for hosting this meme. To participate, share the first line or two of the book you are currently reading and, if you feel so moved, let us know what your first impressions were based on that first line.

conversationThe Conversation focuses on a subject near and dear to me, after a little time spent in a hospital setting myself – although never in the position held by this author, a medical doctor.

It was a blustery March morning at the crack of dawn, and my medical team was refueling with ample cups of coffee in the hospital cafeteria before reviewing our list of patients. Just as I took a scalding sip, the overhead speaker blared.

“Cold Blue, Greenberg Five! Code Blue, Greenberg Five!”

I like that these opening lines really grab our attention. Shocking, perhaps? But also a realistic way to get into his head, I’d wager.

This quotation comes from an uncorrected advance proof and is subject to change.

Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital by Sheri Fink (audio)

five daysWell. This one is a lot to tell you about.

Sheri Fink is an award-winning journalist and holds both a PhD and an MD. In Five Days at Memorial, she examines fateful, famous and controversial events at Memorial Hospital in New Orleans in the five days following 2005’s Hurricane Katrina. Forty-five bodies were recovered from the hospital, with about 9 of them (depending on your source) suspected of having been euthanized by hospital staff during evacuations. I had been looking forward to reading this book but was leery going in, because this subject was clearly going to be emotionally fraught, depressing, poignant. I was quickly mesmerized, though: these events, while troubling and difficult to take in, fascinated me deeply. I have been increasingly interested (outside my reading of this book, for some time now) in the subjects of end-of-life, advanced directives, and our culture’s approach to death. And I am always intrigued by ambiguity, situations in which it is clear to see black-and-white or right-and-wrong. If ever there were such a situation, this is it.

Roughly the first half of the book is dedicated to relating the events of these five days, as revealed by Fink’s investigations. (Recall, as I mentioned in my book beginning, that she describes her copious research. I am fairly well convinced of its virtue.) We get to know a number of characters in the story: doctors, nurses, managers and administrators, patients and their family members. We know the ending, in a sense: the hurricane will be far worse than anyone imagined; the hospital will not be evacuated in one, two, three or four days; there will be crimes investigated. But the way the events unfold were unfamiliar to me in their details. Although this is a journalistic account, Fink also imbues it with suspense, which feels very natural: imagine the terror felt by those inside the hospital throughout. Not knowing the whereabouts or well-being of friends and family, isolated by rising floodwaters, without electricity, and plagued by rumor (on which more in a minute), a number of those inside Memorial feared for their lives. And some lost their lives.

The second half of the book describes the investigation of one doctor and (centrally) two nurses. Dr. Anna Pou was eventually called before a grand jury, which (some two years after Katrina) declined to indict her for multiple counts of second degree murder. In this section, we meet new characters, most notably two investigators who work as a comfortable team together. Fink also explores the history of euthanasia as a concept in different cultures and different legal understandings today, and the approach of bioethics, as well as post-Katrina attempts to establish emergency standards for triage, including the allocation of limited resources that will save some lives while ending others.

I was impressed by Fink’s style. I felt, in the end, that she let the facts (as she discovered them) stand alone. Many times throughout it felt like Fink’s voice spoke on one side of this painfully difficult controversy, but pages later she lent that voice to the other side, so that the effect was… shall I say, appropriately discomfiting. The fact is, I strongly feel, that none of us can perfectly know what happened in those five days, what anyone’s real motivation or intention was, and probably that none of us has the right entirely to judge actions taken in such profoundly weird circumstances.

Many questions remain, and I can easily understand and sympathize with divergent views: family members whose loved ones were (allegedly, possibly) euthanized are angry that they weren’t evacuated; hospital workers with no options left to them felt it was better to euthanize than to abandon patients to die slowly, painfully, and alone. I see it both ways. But the details, I think, are lost to me – someone who lived none of it, who’s just read the book. Dr. Pou, it appears, does not find this book’s treatment fair at all. While it’s true that Fink doesn’t exonerate her, I felt that she wasn’t condemned, either. It’s just… so complicated.

One of the more disturbing elements, to me, was the power of rumor and euphemism in the hospital and the accusations bandied about afterward. Doctors and nurses allegedly spoke of “making patients more comfortable,” or said “we won’t leave any living patients behind.” I don’t see how these vague phrases can be used to accuse someone of murder (or euthanasia, or what you like) – what if they literally just meant make someone comfortable? What if they meant that we will evacuate all living patients, thereby leaving none behind? I don’t think these statements necessarily point to killing people – certainly not beyond a reasonable doubt. And then the rumors: New Orleans after the storm saw violent crime and looting, but not (writes Fink) to the extent that it was rumored, within the hospital and more generally. Some of this fear and rumor was racially charged. Such a circumstance serves no one well.

In fact, the most damning evidence in Fink’s book for me was not the evidence that euthanasia had taken place – frankly, my value system allows for euthanasia as a fine option in certain circumstances – but the evidence that other hospitals faced similar challenges (loss of power, rising waters) and functioned better. I can’t recall the name at this moment (and the audiobook format is bad for looking up such things), but there was a hospital under analogous conditions that ran regular shifts – encouraging staff to sleep when not caring for patients – and sternly disallowed the spreading of rumors. (I think the phrase was something like “if you didn’t see it, don’t say it.”) Memorial saw a decidedly higher level of panic, and that was one of its critical failures. This can’t possibly be Dr. Pou’s fault: she’s just one person, incapable alone of preventing or inciting panic. In fact, as Fink presents it, if she did commit certain acts, she wasn’t alone; she was just singled out in investigations.

I can draw no conclusions after reading (listening to) this book, other than to say I think it was well told – visceral – and I am emphatic about the persistent ambiguity of this situation. In other words, I can’t judge, and I think it’s a little outrageous that anyone would try to. But I guess the justice system feels it has to try…

Narrator Kirsten Potter was well up to this task; full credit for the narration. I enjoyed this format for this book, but the major drawback for journalistic work is that I can’t flip back and check names, dates, etc.

Recommended, if you’re up for some tough topics and hearing about suffering.


Rating: 8 sleepless nights.

book beginnings on Friday: Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital by Sheri Fink

Thanks to Rose City Reader for hosting this meme. To participate, share the first line or two of the book you are currently reading and, if you feel so moved, let us know what your first impressions were based on that first line.

five days

I have been intrigued by the idea of this book for some time now. I have some perspective on Katrina, to begin with. Not that my personal life was profoundly effected, but Houston residents saw the consequences come our way. For one thing, in the form of Katrina evacuees, and for another, because when Hurricane Rita was forecast for us just a few months later, the response was quite different than it might have been if our neighbors to the east had not just been so badly beaten. And then I suppose my interest is piqued as well because I work at a hospital now. Finally, I got to see Anna Deavere Smith perform last month (at the Medical Library Association Annual Conference in Chicago), and she did a short piece on the conditions at Charity Hospital in New Orleans that was – naturally – very moving. So here we are, finally.

Five Days at Memorial begins with an Author’s Note in which Fink describes her research methods (lots of interviews & other primary & secondary materials) and notes that she wasn’t at Memorial during the storm, although she visited later. She makes it clear that this is a journalistic work, and that she has been faithful to what she learned in her research – all dialog in quotations comes from interview, etc. – and that she has made an effort to keep her own reactions (“any book reflects the interwoven interpretations and insights of its author”) clearly delineated from the facts. I appreciate this.

I’d like to share two bits for your book beginning today. First of all, “Part I: Deadly Choices” begins with a quotation:

Blindness was spreading, not like a sudden tide flooding everything and carrying all before it, but like an insidious infiltration of a thousand and one turbulent rivulets which, having slowly drenched the earth, suddenly submerge it completely. РJos̩ Saramago, Blindness

And then the Prologue:

At last through the broken windows, the pulse of helicopter rotors and airboat propellers set the summer morning air throbbing with the promise of rescue. Floodwaters unleashed by Hurricane Katrina had marooned hundreds of people at the hospital, where they had now spent four days.

And that, I think, says enough for today.

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