A long piece today in the NYT on end of life issues, specifically the questions that surround whether or not to establish "do not resuscitate" (DNR) orders for terminally ill patients. 

    These are difficult issues, with which I have had some experience.  There are no clear criteria for determining how far to push medical care or when to stop and accept palliation.  But I think we need to be more open, in general, to accepting death when it is near.  The article is helpful in pointing out the distorted view of "heroic" measures that people might get from TV:

Many doctors believe that their medical judgment about whether CPR will
be effective in a given patient’s case, and their knowledge of the
havoc it can wreak on a dying body, should prevail. But a patient’s
representative, who is often a relative, may believe that every medical
option should be exercised and that a miracle could be just a chest
compression away. And patients’ families, spurred on by TV medical
dramas, often mistakenly believe that CPR is almost always effective —
a notion emphatically disproved by studies.

…

The widespread misunderstanding about CPR itself can make a family’s
agony worse. The technique, which has been an accepted medical
procedure for about 40 years, can be successful in patients who have a
sudden, unexpected heart attack or severe respiratory distress. But it
was not intended to be used routinely for very sick patients, for whom
cardiac arrest is expected. Some studies show that the long-term
survival for hospitalized patients given CPR is about 15 percent; some
find even smaller percentages. But according to a 1996 article in The New England Journal of Medicine, the long-term survival rate on TV medical dramas for patients given CPR was 67 percent.

    This is important information.  CPR does not work most of the time.  Of course, we should know how the cited studies define "long-term."  It might be true that a week or two or a month more life is really quite valuable to some.  But we need to puncture the dominant myth that we can revive just about anyone.  We can’t.  Indeed, when you factor in the broken ribs that an aggressive CPR assault can inflict on an elderly body, an attempted resuscitation could leave a person with more pain, rather than less.

     This is not to say that doctors are always right.  They have a certain perspective, which must be part of the deliberations, but family members must also be centrally involved.  What is needed is both an understanding of the medical possibilities and a sense of the person in his or her social context.  At the family end of things there has to be, at some point, an acceptance that a life has been fully lived and further medical intervention will not make that life better.

      Another point that emerges from the story is that law, which demands clear and precise definitions consistently applied, is not a good medium for working out agonizing end of life issues:

“The black and white of the law has significant limitations in the
emotional gray area of decision making around serious illness and
dying,” said William H. Colby, a lawyer who represented the family of
Nancy Cruzan, a patient in a vegetative state whose parents won the
right to refuse medical treatment for her.

  We don’t have to agree with all of the implications of the Cruzan case to see the wisdom of Colby’s point.  These are not each decisions and they cannot be dictated by ideology or legalisms.

     Rather, we must anticipate facing these kinds of quandaries and cultivate in ourselves a sensibility that weighs the impulse to save a life against the necessity of accepting the end of a life.  Chuang Tzu can help us toward that understanding:

Birth and death, living and dead, failure and success, poverty and wealth, honor and dishonor, slander and praise, hunger and thirst, hot and cold – such are the transformations of this world, the movements of its inevitable nature.  They keep vanishing into one another before our very eyes, day in and day out, but we’ll never calibrate what drives them.  So how can they steal our serenity…?  If you let them move together, at ease and serene, you’ll never lose your joy.  And if you do this without pause, day in and day out, you’ll invest all things with spring.  Then, mingling it all together, you’ll bring seasons alive in the mind.

     Maybe that is how we should think about end of life questions…