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Through the Valley of Shadows: Living Wills, Intensive Care, and Making Medicine Human

Through the Valley of Shadows: Living Wills, Intensive Care, and Making Medicine Human

by Samuel Morris Brown
Through the Valley of Shadows: Living Wills, Intensive Care, and Making Medicine Human

Through the Valley of Shadows: Living Wills, Intensive Care, and Making Medicine Human

by Samuel Morris Brown


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Hospital intensive care units have changed when and how we die—and not always for the better.

The ICU is a new world, one in which once-fatal diseases can be cured and medical treatments greatly enhance our chances of full recovery. But, paradoxically, these places of physical healing can exact a terrible toll, and by focusing on technology rather than humanity, they too often rob the dying of their dignity. By some accounts, the expensive medical treatments provided in ICUs also threaten to bankrupt the nation.

In an attempt to give patients a voice in the ICU when they might not otherwise have one, the living will was introduced in 1969, in response to several notorious cases. These documents were meant to keep physicians from ignoring patients' and families' wishes in stressful situations. Unfortunately, despite their aspirations, living wills contain static statements about hypothetical preferences that rarely apply in practice. And they created a process that isn't faithful to who we are as human beings. Further confusing difficult and painful situations, living wills leave patients with the impression that actual communication with their physicians has taken place, when in fact their deepest desires and values remain unaddressed.

In this provocative and empathetic book, medical researcher and ICU physician Samuel Morris Brown uses stories from his clinical practice to outline a new way of thinking about life-threatening illness. Brown's approach acknowledges the conflicting emotions we have when talking about the possibility of death and proposes strategies by which patients, their families, and medical practitioners can better address human needs before, during, and after serious illness.

Arguing that any solution to the problems of the inhumanity of intensive care must take advantage of new research on the ways human beings process information and make choices, Brown imagines a truly humane ICU. His manifesto for reform advocates wholeness and healing for people facing life-threatening illness.

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Product Details

ISBN-13: 9780199392957
Publisher: Oxford University Press
Publication date: 04/29/2016
Pages: 288
Product dimensions: 5.80(w) x 8.30(h) x 1.20(d)

About the Author

Samuel Morris Brown is Assistant Professor of Pulmonary and Critical Care Medicine and Medical Ethics and Humanities, University of Utah School of Medicine and founder and director of the Center for Humanizing Critical Care at Intermountain Medical Center. A practicing intensive care physician, researcher and award-winning historian of ideas, Dr. Brown writes at the intersections of medicine, ethics, and culture.

Table of Contents

Table of Contents



Chapter 1. A Culture in Crisis
Historical Death Culture and the Dying of Death
Life Support and the Miracles of Resuscitation
The Rise of Intensive Care and "Life Support"
Life in the 1960s

Chapter 2. The Rise of the Living Will
The Findings of the Court
Disclosurism and a Focus on Procedures
Improving enforcement
Futility, Financial Disaster, and Obligations to Society
Expanding horizons

Chapter 3: Empirical and Ethical Problems with Living Wills
Conceptual Problems with Living Wills
Pig Iron under Water: Living Wills Don't Apply in Real Life
Paradoxical Threats to Autonomy
"If I'm ever like that, let me die": Disability Stigma
The Limits of Prediction Make Living Wills Difficult to Use
Problems of race
Living Wills Can Backfire
Empirical evidence that Living Wills Don't Work

Chapter 4. Living Wills Don't Make Decisions; Human Beings Do
Thinking like a Human Being
What your Brain Doesn't Know Might Kill You
Affective forecasting and psychological adaptation
Things that Go Bump in the Night
Moral Distress
Moral Hazards
Choosing to See

Chapter 5. The Barbaric Life of the ICU
Barbarism and Brutality
The Experience of the Ventilator
Tubes and more tubes
The Brain under Siege
Terrible Communication
We Don't Always Know What We Want
Deforming Death in the Rush to Rescue

Chapter 6. Life after the ICU
A Few Visionary Researchers
The Post-Intensive Care Syndrome
Is It All Worth It?
The Tension between Outcomes Research and Advance Directives

Chapter 7. Reform: The Current State of the Art
Eliciting Values and Wishes
Registration Drives for Advance Directives in Wisconsin
Multimedia Persuasion
Tailoring Advance Care Planning
Decision Aids
Choice Architecture
The Science of Communication
The Conversation Project
Redesigning the ICU

Chapter 8. Healing the Intensive Care Unit
Let Families In
Fixing Code Status
Hope for the Best, Prepare for the Worst
Wrapping Up
Recognize the Crossroads
Create a Support Community
Create Space for Facilitated Farewells
Change the Framing to Manage Clinicians' Moral Distress
Changing Culture outside Medicine
Not Left Unsaid
Authentic Personalization
A Possible Map: Five Approaches to the ICU
Approach 1: Do Everything
Approach 2: Be Aggressive Only if I Have a Reasonable Chance of Recovery
Approach 3: Only Admit Me to the ICU if I Have an Excellent Chance of Recovery
Approach 4: Don't Admit Me to the ICU
Approach 5: Don't Admit Me to a Hospital; Focus Only on My Comfort
Epilogue. What Should We Do in the Meanwhile?

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