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"...beyond the medical advances, Dr. DeBakey's story is emblematic of the difficulties that often accompany care at the end of life. It is a story of debates over how far to go in treating someone so old, ... and risky decisions that, while still being argued over, clearly saved Dr. DeBakey's life. It is also a story of Dr. DeBakey himself, a strong-willed pioneer who at one point was willing to die, concedes he was at times in denial about how sick he was and is now plowing into life with as much zest and verve as ever. But Dr. DeBakey's rescue almost never happened. He refused to be admitted to a hospital until late January. As his health deteriorated and he became unresponsive in the hospital in early February, his surgical partner of 40 years, Dr. George P. Noon, decided an operation was the only way to save his life. But the hospital's anesthesiologists refused to put Dr. DeBakey to sleep because such an operation had never been performed on someone his age and in his condition. Also, they said Dr. DeBakey had signed a directive that forbade surgery. As the hospital's ethics committee debated in a late-night emergency meeting on the 12th floor of Methodist Hospital, Dr. DeBakey's wife, Katrin, barged in to demand that the operation begin immediately.

Dr. Peter J. Pronovost, medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, travels the country advising hospitals on innovative safety measures.

Excommunication of Phoenix nun, & ejection of St. Joseph's Hospital, for allowing an abortion to save a mother's life; prohibitions of tubal ligations in Texas & Oregon.

by Paul Moses - Newsday - 6/29/2001 DR. FREDERICK SMITH has the usual textbooks on ambulatory care, surgery and prescription drugs in his office. But the shelves also hold D.T.Suzuki's "Essays in Zen Buddhism," a volume of Cardinal John Henry Newman's writings, books on Confucianism and Judaism, the Quran and alarge-type, 69-year-old Bible a patient gave him, so worn that its cover has fallen off. These, too, are tools of Smith's trade. As associate chief of internal medicine at North Shore University Hospital in Manhasset, the gray-bearded, 56-year-old physician has found that religious faith can help his patients,and he's trying to teach that to a generation of up-and-coming doctors. His 2-year-old course, Religion and Medicine, is part of a growing move to sensitize doctors to the role faith plays in their patients' lives. It gives residents at North Shore who've completed medical school but are still receiving some training a chance to learn about their patients' religious traditions....

I refused further radiation and chemotherapy. I lay in my bed and watched the events around me - the distress of my family, the helplessness of my doctors - without anxiety, comfortable that I had made the correct decision. My doctors couldn't override it or persuade me to change my mind, but, luckily, my wife, Diana, could and did. From my mental cocoon in the hospital bed, I could sense Diana at my side. "You're going to finish the treatment," she said softly. I did not have the energy, or perhaps the will, to disagree. She wheeled me down herself to finish my radiation treatments in the basement of the hospital.

... not quality of pt care

Most prestitious hospitals receive billions to train residents, few of whom go into primary care, where society needs them most.

The North Shore-LIJ Health System, with 16 hospitals and more than 300 outpatient centers in Long Island and New York City, is laying the groundwork to be an insurer, as well as a provider of health care.

Startup cost & shortage of palliative MDs.

Actually GOALS for changing medical culture

"Health Law, Ethics, and Human Rights" Hospitals/systems should disclose large-scale adverse events (e.g., non-sterile equip't)

Palliative care program at Montefiore Hospital

Discussion of palliative sedation at end of life (Franklin Hospital Hospice Unit, NSLIJHealth System & Hospice Care Network of L.I.)

A nun at a Catholic hospital in Phoenix has been excommunicated for allowing an abortion to be performed on a woman who doctors say would otherwise have died. Sister Margaret McBride may also be expelled from her order. Now, there's a debate about the church's quick, severe penalty while it waited years to punish pedophile priests.">

So for nursing home residents with advanced dementia, sons and daughters often opt to return the favor - even though the medical consensus is that it's not a favor. Most dementia patients will eventually develop problems with eating and swallowing as the disease progresses, but feeding them through surgically implanted tubes has not been shown to improve their survival, to prevent pneumonia or heal bedsores, or to improve their quality of life. Nevertheless, about a third of nursing home residents with advanced dementia do receive feeding tubes, usually during a hospitalization.

Most people in health care understand and accept the need for clinical hierarchies. The problem is that we aren't usually prepared for them; nor are we given protocols for resolving the inevitable tensions that arise over appropriate care. Doctors and nurses are trained differently, and our sense of priorities can conflict. When that happens, the lack of an established, neutral way of resolving such clashes works to everyone's detriment. This isn't about hurt feelings or bruised egos. Modern health care is complex, highly technical and dangerous, and the lack of flexible, dynamic protocols to facilitate communication along the medical hierarchy can be deadly. Indeed, preventable medical errors kill 100,000 patients a year, or a million people a decade, wrote Rosemary Gordon and Janardan Prasad Singh in their book "Wall of Silence."

Peter B. Bach, M.D., M.A.P.P.: The Debate over Regional Variation in Health Care Spending: "The regional variations in health care spending that are documented by the Dartmouth Atlas of Health Care have been cited by many as a justification, and possible basis, for changes in provider payment rates. ..."