Crave

...an excerpt from...
Crave
by Sarah Kane
(1998)

C  She is currently having some kind of nervous breakdown and wishes she'd been born black, male and more attractive.

B  I give myself.

C  Or just more attractive.

B  I give my heart.

C  Or just different.

M  But that's not really giving.

C  Just someone fucking else.

A  Fragile and choking.

C  She ceases to continue with the day to day farce of getting through the next few hours in an attempt to ward off the fact that she doesn't know how to get through the next forty years.

A  I love you still,

B  Against my will.

C  She's talking about herself in the third person because the idea of being who she is, of acknowledging that she is herself, is more than her pride can take.

B  With a fucking vengeance.

C  She's sick to the fucking gills of herself and wishes wishes wishes that something would happen to make life begin.

A  I'm a much nicer person since I had an affair.

C  You can only kill yourself if you're not already dead.

M  Guilt does that.

A  Because now I know that betrayal means nothing.

To be forgotten

...an excerpt from...
The Rings of Saturn
by W.G. Sebald
(1995)

Much as in this continuous process of consuming and being consumed, nothing endures, in Thomas Browne's view.  On every new thing there lies already the shadow of annihilation.  For the history of every individual, of every social order, indeed of the whole world, does not describe an ever-widening, more and more wonderful arc, but rather follows a course which, once the meridian is reached, leads without fail down into the dark.  Knowledge of that descent into the dark, for Browne, is inseparable from his belief in the day of resurrection, when, as in a theatre, the last revolutions are ended and the actors appear once more on stage, to complete and make up the catastrophe of this great piece.  As a doctor, who saw disease growing and raging in bodies, he understood mortality better than the flowering of life.  To him it seems a miracle that we should last so much as a single day.  There is no antidote, he writes, against the opium of time.  The winter sun shows how soon the light fades from the ash, how soon night enfolds us.  Hour upon hour is added to the sum.  Time itself grows old.  Pyramids, arches and obelisks are melting pillars of snow.  Not even those who have found a place amidst the heavenly constellations have perpetuated their names:  Nimrod is lost in Orion, and Osiris in the Dog Star.  Indeed, old families last not three oaks.  To set one's name to a work gives no one a title to be remembered, for who knows how many of the best of men have gone without a trace?  The iniquity of oblivion blindly scatters her poppyseed and when wretchedness falls upon us one summer's day like snow, all we wish for is to be forgotten.

A thumbnail sketch

…an excerpt from…

You Bright and Risen Angels

By William Vollmann

(1987)

About three weeks ago my fiancee, with whom I had been living for almost three years, decided that she did not love me anymore.  This put her in an unenviable strategic position, for I remained stubbornly oblivious to this fact despite her best efforts at delicate suggestion, so at last, no longer able to stomach my endearments (she had always been my Bee; and I had been her Beetle), losing interest in the tedious details of my life (which, like a robin redbreast, I had been all too eager to feed her in our nest, as if she were still my baby bird who was content to eat what I might bring her), and unable to desire me sexually (it had gotten to the point where I had to beg her each Saturday morning for about forty-five minutes until finally she would hitch up her nightgown and spread her legs and close her eyes and lie there motionless), there was nothing for her to do but unveil her pure hard will in a session of evil mercy killing; for it was all too clear that I had no minimum level of self-respect below which I would not debase myself to keep her.  So, one night after she had bought my birthday present, she steeled to shoot her own dog.  It would be unnecessary, she knew, to disregard my tears and nasty groveling entreaties in order to compel me to see that no matter how good I might be henceforth my case was hopeless, that I simply could not have her anymore.  I am told that when a girl gets her ears pierced the poor dumb flesh tries to grow back where it is not wanted; and sometimes she must push needles through the spot several times over the next few days in order to kill it for good, because it will try until it is dead to heal the wound.  So it was here.  I had to be dealt with in one great firm stroke, without unnecessary cruelty, but the knife had to go in and it had to be twisted just as firmly in the wound, because the flesh would not understand.  I remember once when I was working on a ranch my friend Eric was showing me how to kill a pig.  We were smoking all our pigs for sausage.  The previous three had been dispatched; the last had hidden itself behind a pile of straw in its hutch, for pigs are very intelligent animals.  As we exposed it and dragged it outside and onto the bloodstained sand, it began to scream.  We flung it down on its back and Eric bayoneted it through the heart.  It screamed and screamed.  The dark pig-blood spurted.  Eric and I held the dying animal down.  Eric removed the bayonet so that the blood could run freely, and with exquisite gentleness he worked the trembling pig’s back legs, forward and back, forward and back, to pump all the blood out. The pig lay there sweating and shaking and pissing and rolling its eyes.  Eric stroked its head to calm it, just as he might have done with a dairy cow that had been spooked by something.  “All right now,” he said gently but inflexibly into the pig’s ear.  “You just lie there and bleed.”

This, then, was the hard ceremony of cauterization which my fiancée had to conduct.  No doubt she consulted with our mutual friends to find the best way of doing it, just like her best friend Milly had studied all the sex manuals and anatomy charts for weeks before she finally parted with her maidenhead, back when we were all in college; for all this day there was an eerie silence in our (now Bee’s) apartment, the friends evidently warned by Bee to leave the path clear for the operation.  Now, as I returned home from work, like a rapist strapped to a table, wheeled along to his castration, her heart failed her for a moment; and when I got into bed beside her she told me that we would stop being lovers for the time being, and would sleep in separate rooms, but we could still live together and see if we could be friends.  This was somewhat akin to piercing the earlobe once and letting nature takes its course, healing if it might; or to stabbing through almost to the pig’s heart but not quite penetrating it; then sewing the animal up with catgut stitches and debating whether or not to give it antibiotics; or to cutting of only one of the rapist’s testicles.  –I told her that as we had already stopped cooking together or eating together or seeing each other for more than about ten minutes a day I couldn’t se that this would do anything but lower our mutual expectations another notch. –“Well,” asked my Bee, “what’s your alternative?” –The Beetle clicked and fluttered its elytra in nervous grief and burrowed deep beneath the bedclothes, “We could spend more time together,” it hazarded; “we could, Bee, we could’ and we could each give up something else to make time and do more things together,” but Bee buzzed angrily at it and said, “The more things we do together the worse we get along. There is a third alternative,” and now already she was recovering from her vacillation and raising her stinger and having the Beetle roll over and bare its black glossy insect-tummy to her, and brushing alcohol on its thorax where she would carry out sentence and sting; and the Beetle, understanding that is pleas had made an unpleasant impression, lay still and thought back on all the crimes it had committed, such as crawling up into her hive and drinking honey from her combs when she was busy and had worked so hard to make it for herself; and the Beetle said, knowing the answer very well, “What alternative?” and the Bee buzzed like a saw and said, “You know what I mean,” but Beetle said, “No I don’t,” because Beetle did not want to admit that it knew the answer; so Bee hummed and buzzed and said, “We could end this completely,” in a very determined voice; and Beetle said, “Oh,” in a very small voice because it was the first time that Bee had ever said that, and it went to hide at the foot of the bed again, but bee flew up and hovered over it like the Angel of Death and said, “Well, would you rather accept my alternative or break up?”; and the Beetle thought about it and decided what was a little more degradation if that meant that it could keep its Bee; and very rapidly it rubbed its elytra together and said, “I don’t like your alternative, but I want to stay with you and I’ll accept any compromise…” – but looking up into the darkness with its bug-eyes the Beetle could sense that the Bee had no intention of compromise in any form, so it added quickly, “But if that’s what you want I’ll do it because I’ll do anything you want me to do; I love you;” but then the bee settled on the Beetle nonetheless and grasped the proper spot and stung it deeply and slowly and thoroughly, and said, “I don’t think I love you anymore.” That was the first time that she had ever said that.  – “Oh,” said Beetle (the last thing it ever said).  – “I’ve never broken up with anyone before,” Bee hummed, “and I don’t know if I’m doing this right – you can hate me if you want – but I don’t want to live with you anymore.”

The cool sting-venom spread a bottomless numbness as the Beetle turned up its stiffening legs and died, for now I could never be her Beetle again, and I was left with a dry cerebral exhaustion (which I hope that God feels every time that an insect dies).  In the meantime the sad little corpse twitched and struggled for another interval, just as a crocodile can bite for up to an hour after death; for there were still a few biomechanical standby command centers functioning trying to make the Beetle survive the massive shock trauma and nervous failure (though Bee, I must say, had stung firmly and well, advised both by her instincts and the example of other bees, and remained with her stinger inside the Beetle for some moments to make sure that she had done the job, just as a trapper will rock on his heels upon a coyote’s throat for a quarter-hour after the animal’s eyes have bulged out and its tongue has turned blue and it has gone limp; just as, according to the dictates of quaint American marriage manuals, a husband trying to impregnate his wife will leave his limp penis inside her for quite a while so as not to make it any harder for his sperm to swim up through their mutal slime; reason dictates that long after a fleshly process has been accomplished to apparent satisfaction it is best to practice overkill.)  And in fact Beetle made thrashing movements for some days, so much did it love its Bee and so little did it want to die.  When Bee was out in the subsequent days I missed her as if she, not Beetle, were dead, for my Bee would never come back to me now; and when she entered the apartment at night my mouth dried up so that I was unable to say a word to her, and my heart pounded with fear of her, a sort of sharp green fear – I had to look at her and hear her in the other room and know that she was conscious of me as a problem solved in all but disposal; and now she shut the door to her room (we exchanged few further words after that night) and began to study her Polish.  She was a very young girl; she was not yet nineteen.  I had known that someday she would send me away from her.  It was so terrible being in the apartment when she was in the bedroom. – She was very short and stout and walked with a slight limp.  There was a metal plate in her ankle; she had broken the bone years ago and had always been too busy to have her plate extracted.  I could recognize her step in the evenings as she came down the hall to our number.  I would usually be curled on my side on the floor, sobbing picturesquely into the rug.  When I heard her I would run silently to my chair in the corner of the living room, almost mad with misery and terror.  The key turned in the lock.  I stared down at my toes, grinding my teeth and holding my breath.  I would not have her looking at me full on; I was sideways to the doorway.  I would not expose my back to her, either; I could best take her presence in the side, the shoulders, the neck. She came in quickly, face turned away from me, and marched into the bedroom.  The door closed behind her.  I heard her sighing and grumbling as she took off her little daypack, got out her books and set to work.  She would be in there until five or six the next morning; then she’d go out, off to her classes and friends, and be gone all day.  The mattress where I now slept was against the wall right by the door.  When she went out, she stepped over my face. – I never dared to ask quite why it was that she didn’t love me anymore: Had I been mean to her?  Did I smell bad? – Sometimes I could not bear it and stuck my head in the oven and turned on the gas, but here I was a bungler just like poor Electric Emily, and all that happened was that I got a terrible headache and felt dizzy and had to go to the bathroom to vomit.*

But this still lay in the future, for now the problem was to get through the night in the double bed (which Bee and I had bought on Haight Street) with Beetle’s smooth rounded body still rocking side to side with faint comical motions like a scientific balance finally coming to equilibrium, and locking its legs in its death-agony all through me; and with Bee lying beside me tense and uncomfortable yet proud, I think, of what she had done.  This American girl must have seen (as she waited out the hour of midnight) the night-noon horizons of future frontiers, the sun burning down on the salt licks and desert barrens, her cooking-pot over her shoulder and behind her a dead stranger at the water hole; time to push on while she could (but actually this trope is ill-suited to her because she hated to walk anywhere; we had fights about this; she was plump and sedentary like a sweet caterpillar, but there was this ruthlessness in her still; she was also going to get rid of her snakes when they got too big.  Perhaps I think of her as a bold pioneer making tracks away from me not only because she, like myself, was a citizen of our great Republic, but also because before I went to Afghanistan in 1982 she had taken me to see Lawrence of Arabia and held my hand; and it was great, it was keen, it was really marv; especially the part where Lawrence had to go back in the desert sun to rescue one of the Arabs in the caravan that was going to storm Aqaba. – “Aqaba, Aqaba!” cried Lawrence madly; in his own memoirs he does not mention whether he did anything of the kind, but all accounts agree that he had to stop worrying about Aqaba for a minute because a man had fallen off a camel in the night and Lawrence was going to turn around and save him even though they said it was impossible because the sun would kill him and must have already killed the other guy anyhow (that was why they rode by night); and now the sun began to rise and shrivel things up as if it were the Emperor of the blue globes, and the sand started smoking, but Lawrence rode into the sunrise just the same, and the Arabs were furious with him because he would die and thereby louse up the Aqaba campaign, that son of Iblis, but he didn’t die then; that was the remarkable thing; he rode back through the white-hot dunes and found the man crawling along in the sand, already close to dead, and lifted him up onto his camel and hauled him back to camp.  – “Wawrence!” cried the two servant-boys who waited for him on the hill at camp, hoping while the other Arabs slept brutishly, needing the stimulus of a white man to lead them on to victory against the Turk. – Yes, here came old Lawrence, a real man was he; they all gave him water and celebrated madly.  Later Lawrence had to shoot he same fellow he rescued, for the sake of harmony.  – Only the shooting part is described in his memoirs; the desert rescue is, I think, a contrivance, much like our own notion of rescuing our Iranian hostages some years ago, though we failed miserably there, by God; but the point of all this is that Bee was off to Aqaba!  Or maybe she was reading proudly along, moving from “A” to “A” in the great desert of knowledge; now she and her caravan of books were already as far west as Provo, Utah, pursued by beetles and snakes and Gila monsters, but onward, onward she went with her retinue; and now she was in Bishop, California; now the wagon train came down through the palms of Sacramento, closer to the fine new smell, the smell of the Pacific, of an undergraduate degree, a teaching assistantship; yes, here was Aqaba all right; those bloody stupid Turks had set their guns facing the sea because they didn’t have the imagination to realize that somebody had the guts to do it the hard way, crossing the desert dunes to fall on them from behind, as I would have if it would have done any good; oh, I would have kissed her ass a million times; anything, anything.) – She could not sleep that night; I could not sleep.  Although it was impossible to see her in the darkness I could sense the rigidity of her body next to me, and when she shifted her position slightly or coughed then I knew that she was still awake and was lying listening to my movements, until finally I could not stand it and asked her to please sleep on the mattress in the other room.  She would not go at first, I don’t know why—did she feel regretful about the necessity of getting up now and leaving me? Was she satisfied where she was?—but after another hour had passed and we were still both lying there hearing each other breathe she took her blankets out wordlessly and did not come back. 

The next day was Saturday and I woke early, feeling under the weather.  She was dialing her friends, informing them in a low buzz that all was well; “I did it; Beetle and I broke up last night.  Now we just have to work out the”—she gave the following words a droll emphasis—“gory details.” — The little corpse spasmed, gorily.  It had been Aqaba’s last defender.  And Lawrence went wading in the sea, inhaling the cool spray of freedom. –Over my cereal she presented me with an itemized bill for rent and food and her share of certain common possessions, which I could not read for tears and agreed to every term of for the sake of harmony.  All the time I knew that her friends had done it, that her friends had tricked my Bee…This was the only explanation.  – An hour later Milly and Arthur came by, and Milly, who had always despised me, was extremely polite and spoke to me more than she had in months and asked how I had slept and looked me full in the face with great satisfaction. 

When they left, Bee stepped outside with them and they talked out of my hearing for perhaps forty-six minutes according to my watch, then she came back and told me that Arthur wanted to have a little chat with me that evening, and got her keys and fluttered away with other friends to spread the new; and as soon as the door was closed I stuck my fist in my mouth so that no one would hear and screamed and screamed with my mouth open like a grub’s; then it was time to gash myself half-heartedly with Bee’s steak knives a few times and maybe hit my head with a lightweight hammer just for the hell of it, then back to the gas oven to be saved, then off to the broom closet for a mop to clean up my vomit.  Now here came Bee again, ignoring a smell of gas when was so clearly a textbook example of the Call for Help, rushing instead to the phone to dial: --“Oh, Diana told you? –Great; yes, Milly knows, she had a lot of good advise beforehand and was very very supportive; oh, I feel fine, thank you, very relieved it went so well; no, that’s very nice of you to say but I’m sure I must have been horrible to him too at times; why, that’s so funny; Arlova promised last week to help me with that; that’s really neat; no, I’m just reading; really, I do feel fine; it was much easier than I thought and when you told me…” – Here she sunk the receiver into her neck and chest and bent her head and whispered something into it and cocked her head and listened for a minute and laughed.  – “Oh, no, I made it really clear, and now all we have to settle is”—giggle—“the gory details” – I kept abreast of the politics of the situation as best I could, learning from indirect reports that Milly blamed me entirely for forcing Bee to initiate the break-up (Milly was a meta-feminist at Stanford), and Arlova had always thought I exerted a weird and repressive influence on Bee’s entire environment, that Diana felt that it was important to hold my assets until I paid what I owed of the rent; and that Pavel and Richard were fighting over who could ask Bee out first.  Arthur contented himself with saying that he was disappointed in me for letting this happen, and Seth got me drunk.  Meanwhile the dead Beetle was rapidly being effaced from Bee’s life and Crystalline Hive, for I was now moving out my effects, the piles of boxes shrinking day by day, I feeling a certain emotional squeeze because the slower I went the longer I would be in proximity to her, which was unbearable since even when she was out I was in constant fear that she might come back and I would have to say something to her or look at her or answer a question; but he faster I went the more irrevocably I cooperated in my own liquidation.  In the end I chose the latter option, because Beetle had always been obedient to its Bee in scheduling matters and it seemed that she wanted me out, so I wrote a note saying I’d do anything, anything if she’d take me back (but couldn’t bear to read any response so instructed her never to answer), moved my last suitcase out, returned the apartment keys, mailed her a check for everything I owed her plus ten dollars to go to movies on, and settled into a resignation which I did not dare to examine too closely.

Of course at night I dreamed that I made amends for whatever it was I had done wrong, and came to her on my knees, and she hugged me and let me come back to her, and I woke up exhausted but happy, not knowing where I was (for I was now living with Seth and Arthur), and then I looked around me and realized that it was “only” a dream, just as when I was a child I used to dream of finding treasure or being given presents, and would wake up in the morning convinced that I could still feel something in my hand but it was melting fast like fairy ice and by the time I opened my hand there was never anything there.  Or I would dream that Bee let me fuck her one last time to say good riddance, and she spread her legs wide for me but I could feel her revulsion, and I mounted her and entered her deeply and panted and snorted like a bull mounting a piece of rawhide stretched on a frame, which the insemination agent has rubbed against the backside of a cow in heat—and how we laugh to see him going at it and ejaculating on a damned sawhorse for Christ’s sake, so we can use his semen just like we use the rest of him; and she lay there under me holding her breath as we did it, stiff with disgust, and when I was almost through she closed her legs tightly to trap me and called for all her friends and they came rushing out of the closet and seized me and pulled me off and threw me on my back and spread my legs and shoved Bee’s nightgown up against my nose and mouth so that I could feel the cotton soft against my face and smell the honey-sell of my Bee and be soothed and pacified and tricked like an animal, and Bee held one of my ankles and Milly stepped up with a razor and put her hand on the inside of my thigh and traced the place with her forefinger and Richard nodded and Milly cut my femoral artery while they held me firmly against the spongy mattress, and Bee said, “He’s bleeding now; you can let go of him,” and they all got up and stood round me to see if another cut would be needed, and while they waited Milly worked up a big gob and spat in my face…

* Carbon monoxide injures through tissue hypoxia.  Hemoglobin’s affinity for it is 218 times greater than that for oxygen, so it must really love it, just like Beetle loved its Bee.  Blood levels of less than 10% carboxyhemoglobin produce few symptoms.  As we move up the evolutionary scale to 10-30, headaches, nausea and mild dysfunctions of the central nervous system appear (for you are just beginning to damage yourself now), decreasing visual acuity and impaired cognitive beeping and clicking being among the most common indications.  More advanced psychotics prefer to aim for 30-40, which yields a harvest of severe headaches, dyspnea on exertion, dizziness, real nausea, not this kid stuff, vomiting, dim vision and, if you achieve your goal, ataxia and possible collapse.  The professional proceeds to levels in excess of 50, which state induces tachypnea, convulsions, coma and death through profound shock and respiratory and cardiac failure.  – While we’re on the subject of suicide, I should mention that in our great Republic males commit that deed three times as often as females, but call suicide prevention centers only a third as frequently.  – As this book goes to press, I find myself anxious to keep it up to date, so I must add a relevant fact from one of the Cyanide Society’s publications, only recently available to the lay reader: namely, that gas ovens throughout this nation have been reformatted to make lethality a more distant possibility.  There is some new additive in the gas which restores corpses to life.  This explains why chickens and hamburgers broiled in the gas oven always taste good; they are brought back to themselves, as it were, and then killed fresh, backed alive; but I am losing the moral, which is that nothing will stop a real man; so if necessary stick your head in the oven and turn on the gas and light the pilot.  It will feel much like a high fever.  

How Doctors Die

http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus/

by Ken Murray

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.

Taking ownership of one's society

In light of the popular protests arising across the Arab world and now the US...

 ...an excerpt from...
Ulysses
by James Joyce
(1922)

 --You suspect, Stephen retorted with a sort of a half laugh, that I may be important because I belong to the faubourg Saint Patrice called Ireland for short.
 --I would go a step farther, Mr Bloom insinuated.
 --But I suspect, Stephen interrupted, that Ireland must be important because it belongs to me.