“Extremis” means the crucial point before death.
It’s measured by the level of stress and the length of time patients suffer as they die. You often hear people express consolation to the family with the kind words “at least he didn’t suffer” or “she died with dignity.”
In the short-film “Extremis,” Dan Krauss brilliantly depicts how patients endure tremendous suffering and loss of dignity through the efforts of well-intentioned physicians and family members.
The documentary begins with Dr. Jessica Zitter, an intensive care and palliative physician, who is trying to determine a patient’s wishes. The anonymous patient can’t speak and appears to be incompetent. Dr. Zitter’s creative attempts include having the patient scribble answers on a clipboard and spell out words in the air. These efforts are futile and border on being cruel. Is it ethical to question patients in extremis? Why ask a patient anything when the physician knows the appropriate answer?
The documentary allows the viewer to peek in on several ICU patients at Highland Hospital in Oakland, Calif. Two are on life support with family members at their bedsides.
The ICU is often described as a place of limbo. Strong doubts exist as to whether any of these patients will recover, yet hope abounds. Hope, however, comes at a cost – the amount and time a patient has to suffer and the increasing risk that a patient’s dignity will not be respected. Subjecting terminal patients to this level of care appears more like punishment than palliative medicine. Yet, this has become standard practice for end-of-life care. The documentary should leave viewers frightened and shaking their heads – saying, “ain’t it a shame – someone ought to do something.”
Dr. ZItter offers a resounding story about a nurse who challenged her practice of medicine. Dr. Zitter was inserting a large IV into the neck of a critical patient when the nurse standing in the doorway looked her straight in the eyes and shouted, “Call the police. The doctor is torturing the patient.” The bombshell that saving certain lives is criminal gives viewers a wake-up call. The ignorance and bullying that exists in the healthcare care system is overshadowed by the claim that “This is for your own good.”
Patient autonomy and self-determination allow patients to formulate a personal statement, “Someone ought to do the right thing for my own good.” A self-respecting person completes an advance directive. An intuitive husband understands how to love his wife as he does himself. An astute physician has the wisdom to know the difference between torture and respect.
Having to contend with God, physicians, and family members in the moment of extremis raises issues the patient needs to address well before admission to the ICU.
A person who wants to be responsible for their own their end-of-life care must do so when they are of sound mind, body and spirit. What to think, do, and feel after watching “Extremis” can leave you feeling helpless. But consider it a valuable lesson.
In this four-part series over the next three issues of Dr. H’s Clipboard weeks, I’ll discuss a holistic approach to “Extremis.” You’ll learn about mindful considerations, practical considerations and spiritual considerations that dictate how the patient should be treated, or left to die.
Being of sound mind, body, and spirit insists that you are prepared for the inevitable. Believing that you are invincible is foolhardy and adds to pain and suffering. Only you can guard against the loss of dignity that so often occurs during extremis. Take the steps necessary to make sure that you receive compassionate end-of-life care through advance care planning.
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Mom spends most of her days doing enjoyable things like “nothing.” She gets up early in order to be dressed and ready when breakfast is served in her assisted living apartment. After my father died, she became used to this additional attention even though she is able to shuffles to the dining room for lunch and dinner. She faithfully takes her medication after breakfast, straightens the corner table next to her recliner and is now good for the day.
Prior to taking her to dinner to celebrate her 90th Birthday, I walked into her apartment and caught her napping. She could barely sleep at night before the age of 85. She now naps three times per day. She was delighted to show-off new shoes that made her feet look dainty and felt comfortable – “I feel like I am walking in slippers.” She was quick to hike-up one pant leg and reveal how sleek her ankles appeared in the tanned support hose, following the increased dosage of her water pill.
While at her birthday dinner, Mom’s eyes lit up when the server inquired if anyone cared to have a cocktail. As she normally drinks Root Beer when taken to lunch, Mom’s birthday was motivation for her to go for the jumbo-sized Texas Margarita. Although it only took a few sips for the alcohol to reach her toes, this provided a great photo-op. My Mother, “the Immaculate Mary”, could no longer defy “depravity” with age.
I learned that she no longer ate everything on her plate and refusing to eat something new, like Brussel sprouts, had become acceptable. While exercise classes were conveniently being missed, walking and tumbling have become her new routine. Her priest has pointed out that her attendance at the monthly Mass needs improvement. I thought my mom lost it when she failed Grieving 101. She could not remember all the stages of grief and was admittedly glad that my dad was at peace. She seemed eager to join him.
When asked if there was anything significant to her life, she was speechless. She neither wished to dwell on the past or express gratitude. I wondered if aging gracefully had something to do with not talking about sacrifices as being successes. That might be viewed as boastful and perhaps her idea of a cardinal sin. Redemptive suffering might well have been her ticket to paradise throughout life. And believing that she actually had a good life might risk her salvation. Aging gracefully is standing strong in your conviction.
My mother may not be boastful, but I can still brag about her accomplishments. Her claim to fame was being college educated at a time when women rarely completed high school. She became a medical technician, meeting the high achievement of being “registered.” To this day, the password that unlocks her computer is not a wedding anniversary or child’s birthday, it is the random number given to her by the medical registration board. She carries this honor as a cherished memory. Becoming her own person is an everlasting lesson on how to age gracefully.
Self-determination often escapes patients while not feeling well and being hoisted onto a stretcher:
Ms. Lacy was 86-years-old and barely weighed 80 pounds. She had an anxious look in her eyes while having difficulty breathing. Her lung cancer was resistant to chemotherapy and had gradually destroyed her sense of well-being for 2 years. Her oncologist had recommended three more treatments before stopping. Ms. Lacy seemed agreeable to this plan of action and ongoing misery.
While fate had determined her lot in life, had she considered drawing a red line to receiving unnecessary medical intervention? Was this red line preset, left to her doctor’s discretion or arbitrarily established in the ER? Patients dealing with life-threatening conditions are often angry or anxious, triggering a chaotic response. They rarely maintain control of these situations.
Three simple guidelines can help patients draw a red upon admission to the ER:
Ms. Lacy’s medical condition had progressed beyond any hope of survival, making further medical intervention futile. She knew the end was near, but seemed to be distracted by the promise of more treatment. In the meantime, she was experiencing a nervous breakdown. She was used to playing by the rules and having her doctors determine her plan of action. Ms. Lacy had never considered the prospect of a carefree existence. Breaking the rules was difficult for her to imagine.
Ms. Lacy’s arrival in the ER was a commencement exercise. A clear demarcation between the past and the future. It was time for her to take an inventory of her life and reset her priorities. Instead of minding follow-up appointments with her oncologist, she could tend to some personal files that she had been neglecting to organize. She was encouraged to create another type of nesting phase in anticipation of much-needed relaxation and enjoyment during her final days.
Did Ms. Lacy prefer the doctor listen to her medical history or focus more results from lab studies and x-rays? Self-determination requires forethought, while being exploited appears to be an afterthought. The tourniquet had been placed on Ms. Lacy’s arm to draw blood as per protocol, yet the need to pursue abnormal lab findings at the end of life rarely makes sense.
After being given the option to defer another needle stick, Ms. Lacy was beginning to appreciate the benefits of drawing her red line. The concern about mission creep at the end of life –whereby patients receive unintended care/consequences – might be traced back to the very moment that the invasive needle slithers under the skin. This procedure crosses the red line between using common sense and relying on evidence-based medicine.
There is always room for improvement, but not perfection. Ms. Lacy was lead to believe that if her lung cancer did not improve, she was a failure or a goner. Life happens and cancer occurs as a natural part of living. No one is perfect, yet Ms. Lacy was led to believe that she would be good if her cancer was cured. However, there was nothing truly wrong with her. She was actually being given the opportunity to feel fulfilled in life. She also deserved to be given reassurance, like receiving a badge of honor.
With drawing a red line to further treatment, the mission was directed toward calming her anxiety and alleviating suffering. She was offered medication to help her relax, which she accepted. Almost immediately, life no longer seemed miserable. With her husband and daughter at bedside, Ms. Lacy expressed overall gratitude for her good fortune. She was able to regain control of the situation by taking a different perspective of thanksgiving. By not crossing the red line in the ER, Ms. Lacy was able to retreat and say to herself, “Mission Accomplished!”
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Spread the word: September is National Yoga Month.
I’ve practiced emergency medicine and yoga for 15 years and often sing its praises to coworkers and patients. Yet it has been difficult to describe this invigorating experience in words until I read “Contagious: Why Things Catch On“ by Jonah Berger.
Why is yoga so popular?
Because, Berger proposes, anything that goes viral –like flu, iPhones or videos — have similar infectious aspects that create a shared experience.
One contagious aspect in life is the loss of a loved one. My father died four months ago, and I’ve found yoga to be a powerful coping skill to handle grief. Grief, like stress, can stream through the body unconsciously and result in muscle tension and chronic illness.
Here are three reasons yoga is contagious, especially in coping with grief.
It stirs deep-seated tension and feelings. Yoga positions trigger an internal tug of war. While my limbs are being pulled in opposite directions, my mind is screaming, “Good Grief!” This mental breakdown opens the door to a spiritual breakthrough.
Quieting the mind awakens the heart. The blood, sweat and tears you suffer while stretching allow muscles to release and rebound. In one simple breath, my mood swings from feeling tormented to feeling liberated. As breathing becomes deeper and more deliberate, my heart pumps stronger and redistributes the pain.
You can apply its principles to daily life. Most yoga students attend their first class for a reason, usually to feel better or fill an empty hole. They restore the missing pieces to the puzzle through a through a holistic connection of mind, body and spirit.
The discipline to stay present and create awareness by breathing in and out consciously for one hour teaches me how to ease pain and suffering. From child’s pose to corpse pose, I have learned to use yoga to acknowledge grief, stir it up and let it go.
Whether it’s a mom trying to release the cares and worries of the day or the son losing his father, yoga is exactly what the doctor ordered.
It connects us to others. Students enter the studio as individuals but leave feeling a bond with others in the room and can’t help but feel on the top of the world: relaxed and free. People who grieve tend to isolate until they get over “the bug.” Grief counselors often advise those mourning to “go through it” and “find your own way.”
Strength in numbers can hasten recovery because it helps you draw energy from other people. Similar to group therapy, yogis grieve together and share the four elements necessary to grieve: earth, wind, fire and water. While perspiring, breathing, stretching and feeling grounded in the child’s pose of virtual powerlessness, the four elements unite harmoniously. An opportunity to bask in serenity. While in corpse pose, I pictured myself being connected to my father –resting in peace.
Who knew grieving could feel so good?
During National Yoga Month, share this post with someone you know who’s grieving or needs recharging.
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Brad was different after he returned from the warzone, having completed the second deployment of a stem cell transplant to combat multiple myeloma. He looked good despite his generalized battle fatigue, carrying both the scars of a dialysis fistula on his left arm and a chemotherapy port under his chest wall. Brad had received support from his family during this time and a great hurrah from coworkers upon his triumphant return to the office. Nevertheless, he had become marginalized through feelings of no longer fitting into mainstream society. He had been through a disease process that few experience and many shun.
People are often called upon to serve their country or serve their God, but there is always a price to pay in being “out there.” During this process one can become separated from the herd. While Brad loves time spent with his family, he particularly loves spending time with others with whom he can truly relate. Prior to his multiple myeloma diagnosis, Brad attended spin classes three times a week. Now he faithfully uses this same time assisting in church functions that aid the poor and visits others who also sit in the same dialysis chair he used to occupy. Brad is living proof that anything is possible through faith.
Similar to Middle East deployment, treating multiple myeloma takes a leap of faith. Naturally, the uncertainty of what lies beyond the horizon and the possibility of not returning home is very frightening. Brad did not know much about his enemy [multiple myeloma] and quickly realized that the fight is rarely with one enemy at a time – multiple medical diagnoses typically gang up on patients. Brad had to contend with a heart blockage during his first deployment and a blood clot in his leg following the second. Nevertheless, Brad’s leap of faith became an opportunity to deepen his faith while exploring his spirit connection to others.
Through faith, we are called upon to love our enemy (disease). Brad took this to heart by reaching out to others engaged in a similar fight with cancer. He believes this to be the path to glorify God and express gratitude. Brad never imagined God having abused him through striking him with multiple myeloma. God was truly using him. Following this battle, Brad continues to walk in the light of having formed a partnership with multiple myeloma based upon mutual respect – respecting his enemy as his greatest ally in personal fulfillment. Through confronting his mortality, Brad has become an enlisted foot soldier in the spiritual conquest of making a difference in other’s lives.
Second deployments give soldiers the opportunity to brag and state, “Been there, done that.” Having raised two successful children, Brad can also proudly claim victory as a parent. Although he looks forward to becoming a grandfather someday, he is simply grateful for each and every day. He thrives in being a grandperson who has been blessed by God and called to help heal the sick on an extremely personal and profound level – similar to that of raising children. Brad’s bout with multiple myeloma has seemingly increased his strength as a great father and shining example of Our Father, Who art in heaven.
In many respects, Brad represents the many fathers who are marginalized and perceived as being the lesser of two parents through spending more time deployed than at home. There exists a childish misunderstanding that Dads are less concerned about the well-being and value of those dear to them. Sadly, respect is mostly paid to fathers in retrospect – similar to how homage is often paid to our troops. We may poignantly look for ways to make amends to our fathers through supporting our troops, while hailing the visionary crusade, #DadsLivesMatter. The Wounded Warrior Project provides one opportunity to celebrate dads and the more personal is Team Brad. Truthfully, #KidsLivesMatter to the extent that they honor their fathers’ deployment and service.
Ruth was a spry, but frail 98-year-old woman who was stiff and sore following the 6-hour drive from California to Arizona. She had suffered a recent wrist injury and was not recovering well after spending three weeks in a rehabilitation center. She was in the midst of upheaval and discontent – in the throes of relocated to an assisted-living residence closer to her son. The facility’s coordinator had begun to evaluate Ruth’s aptitude and appropriateness for assisted living, but thought it best to have Ruth seen in the emergency department.
Ruth was hungry, but did not wish to eat. She felt like her bowels needed to move, but did not wish to use the bedside commode. While still engaging, Ruth wished to be left alone. Ruth had explained that she used to be able to tell herself not to be sick, but her higher power seemed to be failing her now. When a patient feels abandoned by a higher power, what hope is there for patient satisfaction? When patients are uncertain of what is in their best interest, how can physicians succeed at meeting their expectations? Does it become the physician’s duty to tell Ruth that she is not doing well and further deflate her self-image?
The breakdown in patient satisfaction often occurs when physicians cannot view the situation from the patient’s perspective. When the ED staff does not see the emergency, misunderstandings and missed opportunities frequently happen. There is a propensity for ED personnel to become defensive and stand their ground regarding standards of care and appropriate patient conduct. The parental cry resounds: do things my way or else. Coercion and entitlement rarely lead to patient satisfaction.
Having the right to care for others is risky business – particularly when patients might be on the fence as to their desired care. Rather than healthcare personnel digging in their heels of righteousness, these types of situations often call for personnel to dig deeper into self-awareness and question, “What would Jesus do?” The healer of all healers would show compassion and treat people with kindness, similar to how those with special needs are treated. Ruth was in delicate position and needed to be treated with kid gloves rather than sterile gloves. Given her stage in life, there was little hope of making her situation better. Doing more would most likely worsen her state of mind and lessen her satisfaction.
As situations often spin out of control in the ED, physicians are often called upon to soften their tone and maintain professionalism without authoritarianism. Through reassuring patients that we are in this together rather than working in opposition, hope springs eternal regarding patient satisfaction. Ruth simply needed to be reminded that she had the inner strength to weather the storm front at the end of life and that there was nothing really wrong with her. Nevertheless, she remained indifferent to the whole life-and-death conundrum. While this might be the best anyone hopes for, Ruth’s ED experience remained less than satisfying.
Self-expression is rarely easy for patients because words often cannot articulate how patients feel inside. Children are often asked to draw pictures in order for psychologists to gain insight into perceptions surrounding particular life experiences. Paul, a 57-year-old patient with a provocative and morbid sense of humor, stunned the ER staff with a tattoo on his left forearm depicting how he felt on the day he had a heart attack (05/08/2004). This was a day marked in infamy and a declarative moment of Paul’s legacy: My heart’s been stabbed, but my spirit remains defiant.
While laughing in the face of danger and standing before the grim reaper, Paul’s mockery of death was lighthearted and balanced. His ability to wrap his head around having a heart attack with a twisted sense of humor was actually an effective coping mechanism that offered an inspiring message. Others can easily identify and become uplifted by Paul’s apparent vulnerability and survivability. While possibly taunting the grim reaper, Paul clearly allowed this satanic force to get under his skin and permeate his being.
Male ego prompts the slogan, Never let them see you sweat. Each of us is threatened by our own mortality and a predictable sense of betrayal by our bodies. Naturally, one of the major organs is destined to fail and ultimately be the cause of our own death. As unsettling as this may seem, we still have the ability to maintain composure. We can make the best of a bad situation while not allowing devastation to get the better of us. The real crime of passion, stirred by betrayal, is allowing anger to become passive aggressive and self-sabotaging.
While dissecting and digesting this tattoo, Paul mentioned that his cardiologist was particularly drawn to the gross anatomy and attention to detail that the artist gave to the image of the heart. A heart attack can be both a real life situation and a spiritual awakening. In Anatomy of the Spirit: The Seven Stages of Power and Healing, Caroline Myss, Ph.D. brilliantly describes how the seven sacred chakras are integral to understanding the mind-body relationship. The more mindful and in tune we are with our bodies, the more we hear our hearts speak. This “intuition” releases the tension inherent to living and unleashes the power to heal.
Tattoos might be seen as a form of self-mutilation – self-mutilation understood as an intentional release of psychological stress. While some people often feel that self-mutilation represents a danger to self, others find mortification of the flesh sanctifying. Through wearing his wounded heart on his sleeve, similar to the stigmata, Paul proclaimed himself to be the sacrificial lamb representing all who are at the mercy of the grim reaper. Once the grim reaper ultimately removes the stake from Paul’s heart, his life will end. In the meantime, he has continued to live his life fully through the gift of self-expression and by leaving a lasting impression on others through his spiritual revelation.
When Letting Go Becomes a Luxury
Silva was sitting in a wheelchair next to her husband, John, who had been admitted to the emergency department due to chest pain and dementia. Silva herself was recovering from hip surgery which had necessitated their downsizing and moving to assisted living just five days prior. While John resided in the memory care unit, Silva qualified for the independent living quarters. The stress was tearing the two of them apart and no less than ten family members were at bedside, caught in the middle of this heartbreaking upheaval.
Despite John’s tears and agitated state, he seemed to be destined for a better place. He had a weak heart and a history of a previous stroke and PTSD, yet he maintained the demeanor of a soldier when called to attention by the ED staff. Unbeknownst to Silva, she had become the primary focus of John’s treatment plan. John did not wish for or require hospitalization; he needed palliative care. Silva needed to be able to let go of the metaphorical handle that was preventing others from entering her domain.
The gift of receiving palliative care is that it is less about letting go and more about allowing others in. As a physician, I am often called to woo patients and entice them with the latest, greatest care plan. At my work station, Silva and her son listened intently to my sales pitch regarding palliative care. Building upon the premise that assisted-living is where the living is easy, I explained palliative care bridges advance care and end-of-life transition. It often allows patients the luxury of staying home after they let go of the need to be hospitalized.
Silvia had the choice of doing this the easy way or the hard way. The hard way involved admitting and schlepping John through the tumultuous maze of the hospital, ultimately having him admitted to a skilled-nursing facility. This would leave John even more separated from Silvia. The luxurious way was to have John maintain his footing and dignity through remaining as nearly and dearly as possible next to Silvia. When couples cannot bear to be apart, they suffer undo stress in the long run. How to make the best of a difficult situation is realizing upfront what is important to hold on to and what to let go of.
A recent Fox News article commended the bravery of 14-year-old girl named Jerika Bolen on her decision to forego living with spinal muscular atrophy and withdraw ventilator support at the end of summer. Bolen’s physician, a pediatric palliative care practitioner, stated that the standard of care for patients with spinal muscular atrophy is to provide comfort measures. Reportedly, Bolen expressed that she was “super happy” and no longer needed to think about anything bad.
Similar to Jerika, Silva had to let go of the need to prolong John’s life in order to grant him peace of mind and offer less heartache for everyone involved. A palliative nurse was consulted in the ED and arrangements were made for John to return home. John seemed to be all smiles as I bid farewell. We mutually thanked each other for our career service and the family expressed gratitude. The state of great comfort – luxury – is the quintessential wish to die for and the appropriate accommodation for those near the end of life.
John was an 88-year-old ranch owner who struck gold when he sold his homestead in Wyoming. His “golden years” in Arizona were spent struggling with back pain and caring for his 80-year-old niece with dementia. He ran out of pain medication and presented to the ER for another “handout” of hydrocodone. He admitted that life was taking its toll and he was beside himself from aging. Was it time to stop doing for others and start allowing others to do for him? Might it be time to disavow “survival of the fittest” for the chance to ease his suffering?
It seemed survival of the fittest had cost him dearly. He proudly told the physician that he had $300,000 in the bank and told the nurse that he had sold his ranch for 10 million. He had recently spent $15,000 for both himself and his niece to have a get-well-quick remedy of electromagnetic alignment in a Mexican clinic. In addition, he was not sure if the “male booster” that he was receiving monthly through the mail was doing him any good at his stage of life. Nevertheless, it was being sent by the powers that be for free. The physician suggested that he check his monthly credit card statement for this “free” product.
Survival of the fittest might default to having money to burn, expending large amounts of treasure and energy on the losing prospect of anti-aging. Physicians need to continually remind patients and family members that it is not necessary to prove anything after the age of 85 – survival of the fittest does not apply and is not grounds for advocacy. The “golden years” are meant to be as carefree as the school-aged years. These age groups similarly assume some responsibility, but do require a guardian. Care provided to persons near the beginning and end of life needs to be mindful, conservative and less damaging over the long run.
Survival of the fittest is reflected in the headline article from Medscape – Letting Go: No Reduction in Aggressive Care for Advanced Cancer. Ronald Chen, MD from the University of North Carolina at Chapel Hill conducted a study that involved 28,371 patients with metastatic cancer who died from 2007 to 2014. His findings indicated, “Despite being ‘widely recognized to be harmful to patients and their families,’ aggressive care is still administered to the majority (75%) of [these] patients.’ Moreover, the article states, “This included about two-thirds of patients who were admitted to the hospital or the emergency room in the last 30 days.”
While some may question both the definition of advanced cancer and whether age is a state of mind, it might be best to define advanced cancer as occurring in people over the age of 85 that cannot be conservatively managed as an outpatient. Naturally, survival of the fittest is called into question anytime these patients arrive in the ED. The certain reality is that these patients are no longer surviving and are in fact dying. How physicians treat patients at this juncture is to either restore confidence in their being fit for graduation or advocate indignation through their being fit to be tied in an ICU bed.
Muhammad Ali, 74, died two days after being admitted to a local hospital on Friday, June 3. The three-time heavyweight champion had been fighting Parkinson’s disease almost immediately after retiring from boxing 35 years ago. He had been hospitalized several times in the past two years for severe urinary infections.
It is often said of the dearly departed, “He died with dignity.” Can patients who are presumably near the end of life and succumb to dying in the hospital still claim to have passed with dignity? Did Ali have an advance care plan or did he let his guard down?
As previously reported by the Associated Press, “He is being treated by his team of doctors and is in fair condition.” In actuality, he had been placed on a ventilator, underwent dialysis and was in critical condition. Were doctors miscommunicating with his family or just with the public? Moreover, was there a greater misunderstanding of Ali being near the end and how he might have been cared for more properly?
Emergency physician, Kevin Haselhorst, MD and author of Wishes To Die For states, “The end of life is not a medical condition, it’s a spiritual destination. In this regard, the experience of coming home often means being surrounded by loved ones amid a dwelling place of comfort and peace.”
Advance care planning is necessary for anyone above the age of 18. Palliative care resources allow patients to keep their guard up and provide additional coaching strategies for both caregivers and patients battling end-stage illness. Ideally, a palliative care team would have protected Ali from the brutality displayed by this gang of aggressive doctors.
What has been said of Ali was that he stood up for his beliefs – practicing Islam and protesting the Vietnam War. The Quran states . . . and if anyone saved a life, it would be as if he saved the life of all mankind. This type of war against death and dying continues to be propagated by the healthcare industry, yet this stance no longer serves humanity and the greater good.
The iconic image of The Greatest lighting the Olympic flame might ignite and inspire a new perspective for how we honor those afflicted with end-stage illness. The final blow to Ali was an assault on his dignity. Dignity is rarely seen in proclaiming greatness and being treated heroically, but rather through abiding in humility and respecting the process of aging and illness. Haselhorst states, “Society needs both a referendum and the referee of good conscience to end the assault on consummate fighters down for the count.”
Presently, Medicare will pay physicians to have end-of-life conversations with patients long before they frequent hospitals and end life through this means. Dr. Haselhorst offers his Terms of Engagement for End-of-Life Discussions as an introspective exercise to ready individuals with self-determination prior to entering the ring of end-of-life conversations. This PDF download is available at www.kevinhaselhorst.com.