...AND A TIME TO DIE

How doctors, nurses, patients, and their families experience hospital deaths—and how hospital systems move such matters along through set pathways.

In 1997 and again in 1999, Kaufman (Medical Anthropology/Univ. of Calif., San Francisco) put her professional research tools to good use at three California community hospitals. She followed the course of over a hundred critically ill patients, speaking frequently with their families as they waited for a relative to die, observing and interviewing the various health professionals involved, and attending rounds, staff meetings, and family-staff conferences. From tapes and verbatim notes, she has reconstructed the death scenarios of 27 patients whose stories represent a range of problematic experiences. Kaufman finds that the deathwatch of former times has been transformed into a time of waiting for procedures to be performed and for decisions to be made about what to do next. The very old and very ill are commonly placed on one of two pathways: the heroic intervention pathway or the revolving door one. In the latter, patients are repeatedly shuttled from home or nursing home to hospital and back again in the weeks or months before they die. Kaufman examines the complex practices surrounding life support, how various interpretations of the patient’s suffering, dignity, and quality of life are invoked to control and arrange death by either promoting or stopping aggressive treatment. When the hospital system directs that it’s time to switch pathways, patients and families, she says, are expected to conform to the change—to move from prolonging life to preparing for death. These stories of individual patients illustrate the strains and tensions inherent for everyone involved and demonstrate why the goal of “death with dignity” is so illusive. (Kaufman also looks at those patients hovering in a “zone of indistinction,” such as a coma or a persistent vegetative state.)

A revealing look into a troubling world, and a valuable contribution to our understanding of the forces at work behind the culture of hospital death.