How today's hospitals prolong life and delay death's time of occurrence.

Death today is medically and politically malleable and open to endless negotiation. This means the death can be timed, and timing has become the crux of the matter. While the primary task of medicine is to deny death, everyone also knows that, ultimately, death cannot be denied. But medicine can manipulate when death occurs.

In America's hospitals, we take into account the patients decision-making power over when they will die and how long we will prolong life.

In American society, with its strong emphasis on the ideal of individual rights, the decision-making power of a person facing death is deemed necessary and central. The importance of listening to the patient's point of view, the need for others to intuit that do when the patient's voice in silenced by disease, and judgments about all along the life of a very sick patient should be maintained by medical means all become essential factors in the timing of his or her death.

We want to extend life but also to have no pain - and these are often contradictory expectations.

In the United States because, while many claim to want that elusive "good "death for themselves and their loved ones, they also want -- equally or more strongly - that their loved ones not die. These contradictory emotions emerge from a particular who owns medical progress -- that the tools of contemporary medicine can effect more and more cures, stop (for a while at least) the process of growing old or repair a failing bodily systems that accompany very late life, and deny death indefinitely.

Thus a great many people experience -- as patient, family member, friend, or clinician -- the seemingly insoluble tension between, on the one hand, the desire to extend someone's life and the expectation that it can and should be extended using the tools of medicine and, on the other, a contrasting value of allowing death to occur "with dignity" or without artificial technological prolongation.

On how we shifted from the home to an institution to care for our dying. How medical specialization fragments patient care.

Early in the 20th century and doctors cared for patients in their home and knew patients in relation to their families and communities. They could cure relatively few diseases. When therapeutic advances led to a shift from caring for the patient to a focus on specific organ systems and curing the disease, clinics and hospitals, rather than home and community, became the primary locations in which physicians examined and knew patients, their symptoms, and their problems. Doctors specialized and then sub-specialized. Fragmentation of care and of the patient became popular complaints

On treating the dying as self aware human beings. On death's ability to be a catalyst for our deepest feelings.

Psychiatrist Elisabeth Kubler-Ross extended the transformed medical logic about "speaking truth and "hearing experience" to the dying person, who she emphasized, is more than just a body in physiological decline. After conducting more than two hundred interviews with hospitalized terminally ill patients, she concluded that a dying person is a self-aware and, most important, an interactive and psychological being. Dying is a psychological process in which a narrating self is central and essential. The physician, Kubler-Ross informed us, not only can assist that process but also has the responsibility to do so. Nearness to death does not obliterate personal identity, the essential quality of the being human. In fact nearness to death can be a catalyst for expressing some of our most human qualities such as compassion, forgiveness, and the review of ones life course.

On how hard it is for families to make rational decisions at the hospital bedside of a dying loved one.

Despite differences and even contradictions among specific research findings, the personal impact of critical illness unquestionably changes one's perception of the relative importance of invasive, aggressive medical treatments. It also changes one's ideas about the value and quality of life itself. In the widespread quest for "better dying," the debates center on how much treatment is too much and when aggressive interventions should be stopped. But what kind of care counts as too aggressive or too lengthy, and how can anyone know that in the midst of trying to stabilize a critically ill person? Why should a spouse, child, parent, or doctor reject a treatment or procedure that has the potential to add days, weeks, or months to the prescious life that each person has? The public, medical, and ethical debates about "good" versus "bad" deaths tend to emphasize and rationalize self-conscious decision-making during the illness, as if free choice - unencumbered by fear, grief, guilt, confusion, fatigue, lack of knowledge about medicine, the hospital and the body, and the power of the pathway itself -- were possible, given the task at hand. As if rationality, objectively weighing one discrete option against another were possible. Rational decision-making may or may not play a part in the patient and family experiences in the hospital, and that debates fail most of the time to capture the urgency and disorientation the family's experience...