In recent years, doubtless because of the anxious disquiet of so many who have witnessed experiences of their friends and families, books examining “end-of-life issues” have become so numerous as almost to constitute a little genre of their own. At first glance, Dr. Martensen’s book appears to fall neatly within this category. The emergency physician and medical historian recounts numerous memorable patient stories, discusses technology overuse at end of life and the ambiguities of "medical futility" when most doctors have seen the occasional almost-miraculous recovery, and says he wants the book to assist those with “difficult choices.” Martensen is perceptive and balanced about the terrors and disruptions of serious chronic illness, and its shifting, confusing territory, and I think the book is of real potential use – as he wishes – to those facing advanced illness.
Martensen does not confine his reflections to one end of life. His chapter on sick children is imbued with great respect for them and their situation. With both children and very old people, the triangulated nature of interactions with the families can present many problems. Martensen wonders whether we are wronging minors by allowing parents to make exclusive decisions on treating them, telling a haunting story of a girl who underwent many brutal procedures before her death from cancer, including amputations of her legs, hips and lower pelvis.
Another valuable chapter dealt with the factors that can make life for people with serious limitations either rewarding or hellish. He contrasts the reasonably good life led by a mentally limited individual he knows with good family support and enough connections to obtain a part-time job with the horrible conditions of many folk he regularly sees who come into his ER in distress. Martensen is quietly outraged:
When I decided to become a doctor in the 1970s, I never expected to practice in an America where the dire has become an everyday experience for so many…For the past thirty years, however, life has not gotten better for our most vulnerable. Through Democratic and Republican administrations alike, compassion has been scarce, despite political and commercial expressions to the contrary. Though our health care approaches squander billions on extravagant treatment regimes that end up accomplishing little, as a society we refuse to adopt the small, even tiny, adjustments that could easily reduce the clawing uncertainties that now degrade millions.
Martensen talks about the jolting contrast of seeing a diabetic die in his emergency department as a result of having to scrimp on his expensive insulin, right before attending a luncheon where a university chancellor triumphantly announced the legislatively-permitted transformation of his hospital to an “entrepreneurial private-public partnership” that would expand to add new, lucrative, heart and stroke centers, while the hospital would be permitted to cease functioning as a public hospital and state funding for indigent care at the hospital would be phased out.
Martensen, who at the time was serving as the hospital’s “chief ethics officer,” tartly reflects that ethics committees are never consulted about these critical big issues. If administrators actually cared about ethical issues and not just about window-dressing, he reflects, they would “include [an ethicist] to opine on large-scale change, just as they do a score of lawyers.”
Martensen is troubled, too, when he is urged (perhaps too early, in his mind) to press grieving parents for organ transplants that will be financially beneficial for the hospital.
Though he's acutely aware of the bigger picture, Martensen doesn't let that interfere with attending to the details of what we all need to try and do within a system we cannot control to have the best outcomes possible for ourselves, for family, and for patients. He is hopeful and humane about the quest for meaning and dignity in difficult circumstances.
Martensen covers such wide territory that the book (like this review) can be a bit disjointed, even though everything truly relates to his title and central theme. But that's a minor flaw. This short, engaging, readable book packs an enormous punch, and I heartily recommend it.