End Of Life Care In America, A Doctor's Diagnosis

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The Ethical Way To Heal American Health Care

TERRY GROSS, host:

This is FRESH AIR. I’m Terry Gross.

Most Americans die in hospitals these days, and often their dying does not go
well. Dr. Robert Martensen makes that observation in his new book, “A Life
Worth Living: A Doctor’s Reflections on Illness in a High-Tech Era.”

His book is about what he describes as some troubling aspects of what’s become
a biomedical industrial complex. If you’ve had to make difficult medical
treatment decisions or have watched friends or relatives die in a hospital,
you’ll recognize the issues he’s addressing.

The book is based on his 25 years of experience as an emergency-room physician
and his work as a bioethicist and his research into the history of medicine.
One chapter is devoted to the death of his father.

Dr. Martensen has also been a professor of the history of medicine at Harvard,
Tulane and the University of Kansas. He’s now at the National Institutes of
Health, where he directs the museum and the office of history.

Dr. Robert Martensen, welcome to FRESH AIR.

As you say in your book, most Americans die in hospitals these days, and often,
their dying does not go well.

You say compared to those in other countries, older Americans dying in
hospitals in America experience an extended and agonizing process. What’s
different about American health care that makes the process of death more drawn
out and agonizing here?

Dr. ROBERT MARTENSEN (Author, “A Life Worth Living: A Doctor’s Reflections on
Illness in a High-Tech Era”): A couple things are different. I think
particularly in hospitals what’s different in American hospitals is that
advanced technologies, aggressive interventions, keep getting applied to
patients and literally applied right up until the body can no longer respond.

And the default in regulation in the United States, is one must keep doing
things unless the patient or the patient’s surrogate tells you in advance not
to do things. That applies from infants to the very old, and it means that when
one dies in a hospital, unless one has spelled things out in advance and the
hospital knows it – there’s often a slippage between indicating it and having
the hospital actually know it, the people in the hospital – things keep
happening.

Patients are put on ventilators. Cardiopulmonary resuscitations happen.
Aggressive interventions with drugs occur. This doesn’t occur much in other
countries, both for policy reasons and for just operational reasons.

GROSS: Well, I want to say I’ve seen this happen with older relatives when they
approach death. I mean that the heart was going, so there was heart surgery.
There was cancer. There was surgery to remove that. And then the kidneys
started to go. There were interventions for that, and an infection, antibiotics
for that.

And, like, every single system seemed to be shutting down, and every system
required an intervention, and it ended in death and, I have to say in a couple
of instances, no real quality of life in between.

Dr. MARTENSEN: People spend their last six, eight weeks, sometimes months, in
this agonizing shuttle between hospital, having things done, skilled nursing
facility. They get tuned up. As soon as they’re tuned up in the hospital,
they’re discharged to skilled nursing, sometimes to home with skilled nurses.

Things deteriorate. They’re back in the hospital. And as you say, yes. One
organ system after another is gradually or precipitously failing, and
specialists are convened, and specialists work on the organ system, and things
keep getting done.

Nobody stands back and says this patient is dying. Nobody says it to the
family. Nobody says it to the patient if the patient is responsive. Things just
keep getting done.

And the result is that, I think, we who are doing these treatments are causing
great suffering. So there are structural problems in the system, and the result
is that the patient who doesn’t want any more aggressive treatment, who just
wants comfort care, can feel very frustrated.

And I’m going through it. I’m in Santa Cruz to spend time with my mom, who’s in
her 91st year and at that point in her life. So it’s very real for me, and I
was with her this morning before coming here to talk with you.

GROSS: Is she dying? Are you saying she’s dying?

Dr. MARTENSEN: I think she will be dying in the next few days to the next two
weeks. She has said – and she was – to give you a little background, my mom was
living on her own until the end of January. She had a woman who comes in to
help her three or four hours a day, drives her around, and my mother stopped
working when she was 85, working in an antique store.

But now my mother has – will say to us, said to me yesterday, I don’t know who
I am. I don’t know who you are. I don’t know where I am. I can’t remember
anything for more than 10 minutes. I do not want this. Why is it so hard to let
go?

GROSS: And did she mean why is it so hard for her to let go or for the staff to
let her go?

Dr. MARTENSEN: For the staff to let her go. Why is it so hard to just not let
me die?

GROSS: Does she have a medical directive that says - that would allow her to
assert her wishes with that?

Dr. MARTENSEN: Yes, she’s had a medical directive for years. She had breast
cancer, fortunately not a very aggressive tumor, in her 60s, had it removed and
has done splendidly, and that’s been her only real medical problem, that and
some arthritis.

And so yes, she had a directive, and everybody at the nursing place knows about
it. Her physician knows about it, and they’re trying to follow it, and I think
hospice care was started a couple weeks ago, and I think my mom is – mostly now
we just hold her hand, and sometimes she’s aware, and sometimes she isn’t.

GROSS: Did you help her or her doctors make any medical decisions?

Dr. MARTENSEN: Yes I did. I was – this happened in February. I was actually up
in the mountains skiing for a couple days, and I got a cell phone call, and it
was from her doctor, saying your mom has a heart block. Should we put in a
pacemaker?

And a couple things happened. My medical side – this is a common problem for
emergency physicians. So it was what does the EKG show? What degree of heart
block? There are degrees, one, two and three. Is there an underlying event? Has
she had a heart attack, which you can often tell by looking at an EKG, an
electrocardiogram, or perhaps does she not have enough, the appropriate amount
of fluid, which also can cause that.

And the issue with her was fluid, but I’ll tell you how it felt, and how it
felt, first I was astonished to get this call because I was up at about 11,000
feet, and it was snowing heavily.

The other side of it was I thought, you know, I’m used to this. I spent 30
years dealing with these kinds of problems, and because in part my mom had been
very clear in her written instructions – I do not want this, I do not want
that. If my mental function does not, you know, a recovery is not likely. And
she’d also given my older brother and me durable power of attorney for health
care.

So we had been very clear with her physicians not to do this. Nonetheless, the
physician being conscientious, called. So there was this knowledge that I had,
but there was also this experience of being her son and this - you need to make
a decision. You need to make a decision.

And my sense was, wow, what do ordinary people, people without medical
training, how do they experience this when they’re presented with it’s your
choice. Should we do this? Should we not do that? Should we do this? Should we
not do that? It’s just got to be absolutely daunting for the families to go
through.

GROSS: Now, he knew that you were a doctor, I assume, but had you not been a
doctor…

Dr. MARTENSEN: Yes, he did.

GROSS: Yeah, do you think that there are things he should have told you that he
didn’t - about her condition, about her dementia, about the likelihood of her
ever returning to a quality of life that she’d consider a life?

Dr. MARTENSEN: Yes. Had he not – had I not been a doctor, he would have
recommended doing the temporary pacemaker and perhaps then a permanent
pacemaker because although he said he agreed with the comfort-care approach my
mother wants, and which she’d authorized, in practice it turns out he really
believes that one should live as long as possible.

My mother is since under the care of another physician with a philosophy more
compatible with her approach, but that particular physician, who was very
attentive, very conscientious, nonetheless for him, if you can do something
that extends physiological function, how one’s body works, you do it, and he
never told me or discussed with any of us, perhaps because he knew I was a doc,
he never went into what this meant.

And so I wondered how he would be. At the time I wondered. Well, fortunately
for mom, I have this medical experience. Had I not, what would, you know –
people would be flying blind. They would be asked to make decisions without
adequate understanding.

GROSS: And you know what, putting in a pacemaker doesn’t sound like a major
intervention. It’s not like coronary bypass surgery or removing a lung or
something like that.

It’s - I think, from the little I know about medicine, it’s a relatively easy
and safe procedure. So it’s easy to feel, like, well why not do that? Why not
take that step?

Dr. MARTENSEN: Particularly for somebody – fortunately my mom’s hearts and
lungs and kidneys had been functioning reasonably well, although nothing is –
you know, there’s always a significant risk in somebody who’s in her 91st year.

But yes, it could be viewed as not quite benign but not major invasive surgery,
and therefore, why shouldn’t we do it? Her heart will function better? But it
would do nothing for her - what matters to my mother - which is her mind.

GROSS: So you told them no?

Dr. MARTENSEN: Absolutely. I said there’s no – first of all, what I said was I
want to know the cause. Number two, have you considered trying some fluids,
modestly, and see if mother’s pulse picks up?

So I wanted a diagnosis, I wanted a modest treatment, a safe treatment, and
then I said let’s talk again. So they called back. They’d given fluids. My
mother’s pulse and blood pressure had recovered. Her EKG, a repeat EKG, didn’t
show a heart attack, neither did the blood measurements of heart muscle
function.

And so it became a kind of moot issue. But initially my response was - wait a
minute. Just slow down. Slow down because I felt like you’re in – you know, a
freight train coming at you.

GROSS: Well, but that’s the thing. If you weren’t a doctor, like if this were
me, and I got that call, I probably would’ve said go ahead, do the pacemaker. I
mean, I wouldn’t have said oh, did you try fluids? Did you do – I mean, how do
I know that?

Dr. MARTENSEN: You don’t want to be second-guessing the…

GROSS: Well, I wouldn’t even know to make that guess. I mean, I’m just – I’m
not a doctor.

Dr. MARTENSEN: Right.

GROSS: Which is exactly your point that if you’re not a doctor, you in an
absolutely impossible situation when you parent is elderly, or a loved one is
elderly, and you have to make these sudden decision of whether to proceed with
something or not.

Dr. MARTENSEN: Because things happen precipitously. Decline happens. An event -
something bad happens, and there’s a treatment for it. So one feels as though,
to use another kind of analogy, you feel as though, although it happens sudden,
and it’s like a bad roller-coaster ride, you know, you’re pushing against this
pressure to have things done.

And one has to be insistent. I mean, we finally asked another physician to take
over. And it happened gracefully, but one has to insist because the American
system is set up to keep doing these things.

Now, the science behind doing them, by the way, is - either doesn’t exist,
meaning there’s a vast array of ignorance about how these treatments work in
very elderly people, people for whom the treatments were never developed for,
never tested on. There’s just a huge amount of ignorance. Nonetheless, they are
offered.

And of course, they are compensated. Talking with somebody about what they wish
the end of their life to be like, I can spend an hour and a half talking with
the patient and a patient’s family. When the patient learns they have a life-
threatening diagnosis or life-limiting diagnosis, we can spend an hour and a
half or two hours together, which is perfectly appropriate. It’s the way to go,
I think, to find out what matters to them - relevant medical history, do a
physical exam, etcetera.

In New York State, Medicaid pays $18 for that service.

GROSS: Wow.

Dr. MARTENSEN: If, on the other hand, I said with the patient, you know, you
have this problem, we think. You know, it looks like it’s a Stage Two
Adenocarcinoma of the lung, and today we’re going to be doing a lot of tests.
Spent 15 minutes with the patient, did tests, maybe did a procedure myself, the
procedure would be well compensated.

But my time to listen, that is not compensated and yet that makes all the
difference in what people experience as they’re navigating this very daunting
set of circumstances.

GROSS: My guest is ER physician, bioethicist and medical historian Dr. Robert
Martensen. His new book is called “A Life Worth Living: A Doctor’s Reflections
on Illness in a High-Tech Era.” We’ll talk more after a break. This is FRESH
AIR.

(Soundbite of music)

GROSS: If you’re just joining us, my guest is Dr. Robert Martensen, and he was
an emergency room physician for many years and is now the director of the
museum and the office of history at the National Institutes of Health in
Washington.

He has a new book that’s part medical history, part medical analysis, part
memoir. It’s called “A Life Worth Living: A Doctor’s Reflections on Illness in
a High-Tech Era.”

We’ve been talking about your mother, who is dying now, and you’re visiting her
on the West Coast, but you live on the East Coast. And you’re going through
what many of us have gone through and what many people will go through, which
is that loved one, who lives thousands or hundreds of miles away and who’s
dying, and you have to decide what your commitment is to stay there versus what
commitments you need to keep in your home - to your family, to your job, to
whatever else you’re committed to.

And I mean, one typical thing that happens is that, you know, you fly out, you
make what you think is going to be that final visit. You make your peace with
the fact that you’re losing this person. You say your goodbyes, you fly back
home - and then the person rallies.

You know? And then you’ll be coming back for a week or two. And then you
wonder, like, should I fly back out, should I wait? And you get into this
bizarre dilemma of what to do. And it’s so expensive to fly out, too. Have you
been in that cycle yet, of not…?

Dr. MARTENSEN: Yes, yes.

GROSS: Can you talk about that a little bit?

Dr. MARTENSEN: Well, this is my fourth trip.

GROSS: Okay, you’re there.

(Soundbite of laughter)

Dr. MARTENSEN: Back and forth to Santa Cruz, California, from Washington, D.C.,
where I live - since late January. So I have been there, and there is –
certainly, there’s a kind of anticipatory grief that goes along with it.

You know, my mother is alive. I saw her, you know, an hour ago. I’m going to be
seeing her after we stop talking today. Will I be out here at the moment she
passes on? I don’t know.

So there’s that. And it’s this business at the very end of life is messy. If my
mother were dying of a disease she had earlier in her life but then was cured,
breast cancer, if she were dying of that, it’s a fairly predictable trajectory,
and I would just be staying here.

Physiologically, she has some other problems that make the actual event or
process that would end her life difficult to predict. So she can rally. She’s
had a couple infections. She has rallied in the sense those problems are not
problems right now, but we treated them because – particularly the first one
because we thought she might recover her mental function, which is what she
really treasures. That’s not going to happen.

So over the last two weeks, my brother and I, with my mother’s prior approval,
have elected hospice care. So now we are not going to be treating infections
and assuring everything that can be done for her comfort, which we were trying
to do earlier.

But your point, yes, this end-of-life scenario, when people are remote
geographically from each other, is just a very strange zone of life both for
the patient and for the child, in my case, or the close person or the
caregiver, because it’s a kind of suspended animation for the patient and for
us.

GROSS: Just another thing about your mother’s condition. Your mother always
made it clear her mind was the most important thing, and she didn’t want to
continue living if she had lost her mind, if she was living with dementia, if
she’d lost her memory.

But you always wonder, at least I do, that’s what you say when you have your
memory. That’s what you say when you’re cognizant, but maybe when you’ve lost
your memory, maybe when you no longer know who you are, there are still some
things that give you pleasure, although in this case, your mother said that
there weren’t.

Your mother said why can’t they just let me go. But just because somebody said
before they were sick that they didn’t want to live if they had dementia
doesn’t mean that they feel the same way with the dementia.

Dr. MARTENSEN: No that’s true, and I have another woman I’ve been close to, a
neighbor whose family I was very close to, who’s also my mother’s age. She’s
91. She’s very demented. She’s been living in assisted living for over a year.

She’s always had a great sense of humor. She’s very jokey, she’s very flirty.
She’s a widow. She can’t remember anything, but she still has the function to
make wisecracks. And she can kind of joke with the nurses, and she has –
there’s a gentleman living down the hall from her. What they like to do is sit
and hold hands.

Now I don’t know – I won’t mention her name on air. I don’t know if she wishes
to stay alive or not, but her daily life, as she says she experiences it – a
daughter lives nearby and sees her every day – is she’s content. And her life
for her and for her family is – you know, has a richness to it, and yet the
level of dementia is about the same.

GROSS: Dr. Robert Martensen will be back in the second half of the show. His
new book is called “A Life Worth Living: A Doctor’s Reflections on Illness in a
High-Tech Era.” I’m Terry Gross, and this is FRESH AIR.

(Soundbite of music)

GROSS: This is FRESH AIR. I’m Terry Gross back with Dr. Robert Martensen,
author of the new book “A Life Worth Living: A Doctor’s Reflection on Illness
in a High-Tech Era.” He was an emergency room physician for 25 years. He is
also a bioethicist and has been a professor of medical history at Harvard,
Tulane, and the University of Kansas. He is currently at the National
Institutes of Health directing the museum and office of history.

There is a chapter in your new book, “A Life Worth Living,” that’s devoted to
your father’s death, and your father had what you would describe as a
relatively good hospital death as opposed to the kind of hospital death that is
just too awful to describe. And your father had a kind of condition where his
lungs couldn’t really pass on oxygen into the blood, so he was having great
deal of difficulty with his breathing and then also the infection spread to his

blood, so he was septic. So you know, you and your family were faced with the
decision of what to do and how to do it.

And you agreed to let your father go. He had a medical directive that said he
didn’t want to be resuscitated. And if he didn’t have the medical directive, he
probably would have been put on a ventilator and that would have led to what
you would describe as the really bad version of the hospital death. Why are you
relieved that he didn’t go the ventilator route?

Dr. MARTENSEN: Because the ventilator, the ventilators were developed to bridge
difficult situations: somebody has a traumatic injury; somebody has an
infection, their lungs are not functioning; somebody is recovering from surgery
and their lungs are not functioning. You put them on a ventilator - the
intention was this is bridging, this will get them over a difficult patch and
allow them to survive. For my dad, who was in his 86th year, who had a
progressive deteriorating lung function, he had been doing pretty well till
three weeks before he died, then things got worse. And to put him on a
ventilator would have just extended that artificial functioning for an
indefinite period of time. And a ventilator - your body can’t tolerate a
ventilator without being heavily sedated, particularly initially. If you have a
- imagine something blocking your airway. Well, the brain reflex is so
primitive and so powerful, you’ll do anything to get it out.

And the way medicine counters that is by initially paralyzing people but then
sedating them and giving them pain meds and so forth. That to my father would
have been anathema, and it also - from my father’s point of view, and I happen
to agree with him - would have been to no purpose, because his – he never would
have gotten off the ventilator. Instead of dying in two days, he might have
died in two weeks or two months later, but he never would have been able to get
off the ventilator because he didn’t have the lung function.

GROSS: And that extended time would have been a time of great pain and anxiety
for him.

Dr. MARTENSEN: Yes. Having catheters in every orifice, needles, drugs so that
he could tolerate the ventilator, and it would have been an artificially
extended existence, but not a life as my father understood life.

GROSS: Then you had to make the morphine decision. Describe what that decision
was.

Dr. MARTENSEN: Well, the decision is: how should one use morphine and opiates
in end-of-life situations? Morphine is useful for helping to relieve a sense of
air hunger. Morphine is obviously very useful for pain. Opiates are the
mainstay of therapy for pain. My dad wasn’t having pain, but he was having air
hunger. He was getting oxygen but he was still hungry for air and becoming
anxious as a result. So to ease that discomfort, his doctor - with my approval
– we, or she, was administering morphine so that he was more at ease.

Now, he was still conscious, he could talk with us. So it allowed all the
family who were there to each spend time one on one with dad and have a chance
to say goodbye. And he was getting morphine, still conscious. We said, you
know, dad - I said, dad, you know, this is - life is slipping away. It’s – I
think it’s your time; I’m going to take the oxygen off. And he said thank you,
and he died two or three minutes later. So the morphine in and of itself
relieved his symptoms. It didn’t - the intention was not to end his life
prematurely. His life would have ended as soon as the oxygen was taken off, but
he would have suffered considerably.

GROSS: Those words, thank you, were probably two of the best words you’d ever
heard, because that’s such a difficult thing to do, to take the oxygen away
knowing he would then only have a couple of minutes left to live.

Dr. MARTENSEN: Yes. I felt gratitude to him for saying that, and an enormous
relief. I also have to say, had I or his physician been more aggressive about
treatment and kept on the ventilator, or had he gotten on the ventilator
somehow and we hadn’t been able to stop it - getting somebody off is harder
than getting somebody on. Had that continued, I would have felt worse. I would
have felt I’ve done something my father absolutely didn’t want.

GROSS: You could have given your father a slightly larger dose of morphine that
would have hastened his death by a few minutes, but you wanted to make sure
there was time for everybody to say their final goodbyes. That’s how you
describe it in the book.

Dr. MARTENSEN: Yes.

GROSS: And then you ask for your family’s forgiveness because there was four or
five minutes of what appeared to be distress on your father’s behalf, but you
wanted to reassure your family that he wasn’t really suffering. It was just the
appearance of suffering, the appearance of – what, choking and…

Dr. MARTENSEN: Well, he had a – it’s gruesome. It’s gruesome to experience,
it’s gruesome to describe. He had a death rattle. And that could have been
suppressed and maybe we should have done that. Sometimes it can be - one can
give a pharmaceutical that may suppress it, is how I should say it. And I’ve
reflected subsequently on that. My father - I wish he had chosen this part of -
after he was gone - part differently, but he did not want a funeral, he did not
want a memorial service. He didn’t – his - he didn’t want any of that. So that
was the last we would be with him, and that happened. And it’s hard to go
through. Particularly when you haven’t witnessed it.

GROSS: What makes you confident that he wasn’t suffering during those last few
minutes?

Dr. MARTENSEN: Because his - there was no pulse, his cardiopulmonary function
had ceased. It was just his - there was no trace on EKG. He was not responsive.
It’s a discharge of the brain stem. The lower part of the brain, the more - the
handles are primitive reflexes.

GROSS: Uh-huh.

Dr. MARTENSEN: It’s a discharge of the brain stem and it – and it happens after
the heart ceases function, can happen.

GROSS: My guest is ER physician, bioethicist and medical historian Dr. Robert
Martensen. His new book is called “A Life Worth Living: A Doctor’s Reflections
on Illness in a High-Tech Era.” We’ll talk more after a break. This is FRESH
AIR.

(Soundbite of music)

GROSS: If you are just joining us, my guest is Dr. Robert Martensen, and he was
an emergency room physician, a professor of medicine who’s taught medical
history. He’s a bioethicist and he is also now the director of the National
Institute of Health’s Office of History and its museum. His new book is called
“A Life Worth Living: A Doctor’s Reflections on Illness in a High-Tech Era.”

Dr. MARTENSEN: Perhaps I should say, Terry, that I do work for the National
Institutes of Health. The views I’m expressing with you are my own and not
necessarily those of the NIH or the U.S. government.

GROSS: In your book “A Life Worth Living” you write about illness in high-tech
era. As a doctor, and as a son, what would you most like to change about how
death is handled in hospitals?

Dr. MARTENSEN: I would like to see - and I’m encouraged because it is starting
to happen - is that hospitals and physicians and nurses in them embrace a model
of palliative care. And palliative care - it’s for people with a whole range of
life-threatening diagnoses, and it’s not about the final two weeks of life or
two days of life. It’s about one when learns one has one of these diagnoses,
one of these problems, a diagnosis where the disease may shorten life, to start
planning from the beginning with the physician, with the physicians a kind of
interactive exchange of forming a treatment plan together, so that it isn’t
just - we can do this, we can do this, and it’s not fully discussed - that time
is used, and this process of consultation between the patient and the patient’s
family and the medical team is a regular part of life.

So they are - everybody is – is kept in the loop. It takes time. I would love
to see hospitals embrace that, particular the multi-specialty academic medical
centers, the kinds of places where I spent most of my medical career. They tend
not to do it. The specialists don’t provide coordinated care. Nobody seems in
charge. The patient just gets one thing done and then another thing done. The
actual discussion happens in short bursts of minutes. Nothing is sustained, and
the result is that people feel things are just done to them.

And they never have a chance to kind of shape what might help them. And many,
many different ways of treating something are possible, and many of the
treatments, particularly for very old patients, were never developed for very
old patients. So how they work in old patients can be very different from how
they work in middle-age patients, the kind of patients who were - the studies
were based on.

GROSS: Now, I want to get back to something we were talking about before, which
is ventilators and how ventilators were made to be a kind of bridge invention,
just tide you over between an event that prevented you from breathing properly
back to a period when you can sustain breathing on your own and be healthy
again, but that they’re often used now at end of life when there is really no
chance of recovery, just prolonging life and making it more uncomfortable. As
you point out in your book, we call ventilators a form of life support, and you
think that that is sometimes an inappropriate word for it. What word would you
prefer?

Dr. MARTENSEN: I think in talking with patients, it’s important to say we have
artificial means that can extend your mother’s bodily functions - to somehow
get into the conversation that this is artificial and it’s about extending
bodily functions the way kidney dialysis can extend kidney function, pacemakers
can preserve heart function for a time, versus saying what is usually said,
what has been said to me with my mom now - if you talk to a family and say,
well, do you want us to continue with life support, do you want us to stop life
support? - I think the way people hear that, and I think it’s perfectly normal,
is you are saying, do you want to let mom or dad die? Or - more darkly – okay,
so you think its okay to kill them. Because that’s how patients hear it.

So this euphemistic language is, first of all, not appropriate to the machines,
and secondly it’s not appropriate to that span of existence that it’s seeking
to describe. These technologies extend organ function. That’s what they do. And
you know, what’s happened now - and this where there’s a definite monetary
factor into it – in California there are 30-35, and growing, kind of chronic
intensive care units, not built on hospital property, built separately.
Medicare will pay for people on chronic ventilators. So these places which are
kind of (unintelligible) concrete buildings by freeways house patients on these
ventilators. And I think for some families this is fine, this is a kind of
medical sanctuary, for others it’s a living tomb. The point that troubles me
the most is that there very seldom is a candid discussion with the family or
the patient - if the patient is alert, usually is not - about this extended
kind of space, twilight zone of existence.

They continue because Medicare pays for them and there is an industry dedicated
to expanding them. In a medical school - a major medical center I won’t name, I
was just there a couple of weeks ago - is entering into a contract to build
one, put it’s name on it. It’s not built near the medical center because that
violates Medicare rules and they’re hoping in time to get a percentage of the
revenue from the contract company that is building this facility. So what
distresses me is at the level of policy we’re not talking about this. Is this
what the government should be doing routinely because unless you say no, no
ventilator, it happens.

GROSS: Does this figure at all into the kind of health reforms that President
Obama is proposing or that you’d like to see him propose?

Dr. MARTENSEN: It figures in a very indirect way. The proposals coming out of
the administration, as I understand them, about effective care are to look at
these kinds of issues. The push back from those who initially oppose the
administration’s health reform efforts are to say - to look at something like
effective care: is this something that actually does what we say does and hope
it does? And so you can look at effective care but you can never consider cost.
So they want the cost issue removed from the effectiveness issue.

But when you look at Medicare overall half the money that we spend in this
country on Medicare is spent on patients in the last six months of their lives.
And if we were providing some kind of wonderful existence, then one could make
the case but as I have written about and as I certainly experienced, and I
gathered you’ve experience and many others, these last six months are not,
they’re often agonizing and very unsatisfying for all concerned. So I think
that’s the Obama administration’s approach.

There are a lot of financial interests who don’t want to have this propensity
to treat and treat and treat - that’s lucrative, subject to close examination
though there’s a kind of battle of lobbyists going on in Washington.

GROSS: You wrote that your father was an agnostic, didn’t believe in afterlife.
You’ve implied that you have a more spiritually oriented side of you than he
did. And I guess I’m wondering how being around so much suffering and death as
a long time emergency room doctor affected you sense of life and spirituality
and – those things are so hard to talk about.

Dr. MARTENSEN: Well, a lot of action in the emergency room - patients get
better. I mean, it’s a very – generally - a very positive place because people
can come in absolute wrecks or threatened, you know, disaster from infection,
from diabetes out of control, from trauma, from all kinds of issues and if the
team’s working right they recover and recover splendidly. So when I think about
the ER I think about that and I do have a sense, yes for myself that one
definitely dies but one doesn’t completely disappear. And I don’t know how that
happens. Somehow it’s out in the atmosphere. Certainly the material is - of our
existence, our bodies - is preserved and the universe conserves material, we
just go into different forms.

So it’s a more a Buddhist sense I suppose that informs me and where I found
more meaning, a kind of existential Buddhism, where I’m not terribly caught up
in a particular form of an afterlife - just this sense that there’s a
continuity in some way and embrace that.

GROSS: Well, I’m glad you mentioned that in the emergency room lots of people
get better because that’s a part…

Dr. MARTENSEN: Yes.

GROSS: …of medical care we didn’t talk about. So…

(Soundbite of laughter)

Dr. MARTENSEN: Right.

GROSS: …thank you for pointing that out. Dr. Martensen we need to let you go
now. I want to thank you so much for talking with us and I’m very sorry that
you’re losing your mother. Thank you for this conversation.

Dr. MARTENSEN: Thank you, Terry. It’s been a very satisfying and helpful
conversation for me.

GROSS: Dr. Robert Martensen is the author of the new book “A Life Worth Living:
A Doctor's Reflections on Illness in a High-Tech Era.” He’s currently the
director of the National Institutes of Health Museum and Office of History.

This is FRESH AIR.
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After 'ER', What's Must-See TV?

TERRY GROSS, host:

Tonight NBC devotes its entire primetime schedule to a send off of “ER,” the
medical drama series that made a star of George Clooney and has been running on
the network since 1994. Our TV critic, David Bianculli, likes the way this
series has been playing out. But he doesn’t have a very positive prognosis for
the future of broadcast network drama series in general.

DAVID BIANCULLI: Here's the odd thing about NBC's treatment of “ER.” The
network is doing everything it can to make tonight's farewell episode a big
event. It wants to cash in on every emotional connection from fans past and
present. It wants to remind us of every award the program has won and how it's
held an honored place on the NBC schedule. From its first season in 1994, “ER”
has occupied Thursday night, the same "Must-See TV" slot formerly occupied by
“LA Law” and before that, by “Hill Street Blues,” the cop show that rewrote all
the rules and ushered in a new golden age of TV drama.

Yet though NBC wants us to remember and care about all that, it seems like NBC
itself couldn't care less. Next week, NBC will premiere a new cop series,
“Southland,” in the coveted Thursday time slot at 10 PM Eastern. But come fall,
“Southland” will either be canceled or transplanted, because NBC's final hour
of primetime, Monday through Friday, is set aside for Jay Leno.

Jay Leno took over “The Tonight Show” two years before “ER” began. And yet,
when Leno says goodbye to “The Tonight Show,” there won't be any trace of the
sort of emotional viewing experience and shared cultural touchstone, as when
Johnny Carson left after 30 years. Different time, different show, different
guy, different culture. And Leno’s not really leaving, just reporting for work
a few hours earlier.

But with “ER,” its departure means something. Every year, there are fewer and
fewer series on broadcast TV whose departures deserve more than a shrug, much
less special attention. But long-running hit shows, over the years, have
gathered several mini-generations of fans. And even those who stopped watching
years ago are eager to return for a reunion at the end. It's a type of TV
closure and when it's done right, it's a nice national ritual. Some finales are
pitch-perfect, like the end of “Newhart,” which smuggled in Suzanne Pleshette
from Bob Newhart's previous sitcom. Some are perfect to some and infuriating to
others like the snow globe autistic daydream ending of “St. Elsewhere” or the
passive-aggressive non-ending of “The Sopranos.”

NBC has been doing it right with “ER.” Most of this season, individual episodes
have wrapped up storylines for the newer characters, while making room for the
return of older ones. George Clooney showed up, unannounced but very expected,
two weeks ago, and it wouldn't be at all surprising to see him tonight as well.
The plot presents a reunion of its own, so the revolving door is wide open. And
to prime all these primetime memories before showing this evening's two-hour
finale, NBC is presenting a one-hour retrospective special. The NBC promo says
it all.

(Soundbite of promo of “ER”)

Unidentified Man #1: Thursday…

Unidentified Man #2: I know of lot us, never actually thought this day would
come.

Unidentified Man #1: The most honored drama in history ends.

Unidentified Group: (Singing) (unintelligible) the way.

Unidentified Man #1: With all your favorites from its 15 years.

Unidentified Woman: You’ve done a great thing here, John.

Unidentified Man #1: The “ER” finale event Thursday at eight, seven central, on
NBC.

BIANCULLI What NBC isn't doing, though, is trying to replace these expensive,
quality departing shows with expensive, quality new ones. The network would
rather shave costs and present reality and talk shows in primetime. And its
broadcast rivals aren't far behind. A few years from now, when NBC presents the
farewell episode of “Deal or No Deal,” will anyone care? And when TV fans a few
years from now order downloads of a full season of their favorite show, how
many of them will opt for Jay Leno?

Unless the promo department can squeeze ratings from a finale, TV history isn't
appreciated very much by TV itself. This week CBS announced the cancellation of
“Guiding Light,” a soap opera that predates television and is more than 70
years old. It's one more genre, like the made-for-TV movie and mini-series,

that broadcast TV seems willing to let slip through its fingers. And even
today, most of the best drama series, from “Dexter” and “Breaking Bad” to “Mad
Men” and “In Treatment,” are produced and presented by cable TV. Broadcast TV
may be good at saying goodbye to its best shows, but it appears to be less and
less capable of replacing them.

GROSS: David Bianculli writes for tvworthwatching.com and teaches television at
Rowan University. You can download Podcasts of our show on our Web site,
freshair.npr.org.
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Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.