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

Think you or your parent don't need a health care proxy? Think again, and use Sharon Kaufman's AND A TIME TO DIE to help you realize just how important it is to determine the direction you want your life to take at its conclusion, and to have someone who understands your wishes and can speak for you. It's not a pleasant subject, but it's one that healthcare professionals deal with every day. I can certainly agree that the cases depicted here are unvarnished in their presentations, completely accurate. I've watched some of these same scenarios play out over and over again--only the patients are different. The text maintains a certain distance from the patients and their families. There is not the in-depth interviews and emotional content of some other books of this type. However, I appreciated stepping back from the patient in order to see how the system had succeeded or failed in each case. The author does a good job at showing just how we arrived at this current state of affairs, and why dying in America has become driven by treatments rather than by compassion. Medicare reimbursement is at the heart of some of the problem for the elderly. If you want to change the system, to have compassion for the dying, to practice better medicine, or even to have a peaceful end for yourself when that time comes, this is a good place to start in understanding how we've come to this place, and to think about what we can do to create change.

I am a medical ethicist, and as I read Kaufman's "And a Time to Die" I found myself thinking back to the hospital case consultations I've been involved in. Her observations and conclusions helped me to piece together a much more detailed picture of what's really going on in those situations. Her discussion of pathways, time pressures, reimbursement concerns, and the use of language all ring true. Those who are familiar with hospital settings will recognize much of what Kaufman has observed (a fact that another reviewer objects to), but I believe that she is able to take a "bird's eye view" of these issues in a way that organizes and extends our understanding. This book is a must-read for families who are facing end-of-life decisions, and for those in the health professions who try to help families through this 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.

"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.