Introduction

November 10, 2010

hands

How far would you go to sustain the life of someone you love, or your own? When the moment comes, and you're confronted with the prospect of "pulling the plug," do you know how you'll respond?

In Facing Death, FRONTLINE gains extraordinary access to The Mount Sinai Medical Center, one of New York's biggest hospitals, to take a closer measure of today's complicated end-of-life decisions. In this intimate, groundbreaking film, doctors, patients and families speak with remarkable candor about the increasingly difficult choices people are making at the end of life: when to remove a breathing tube in the ICU; when to continue treatment for patients with aggressive blood cancers; when to perform a surgery; and when to call for hospice.

"What modern medicine is capable of doing is what 20 years ago was considered science fiction," Dr. David Muller, dean of medical education at Mount Sinai, tells FRONTLINE. "You can keep their lungs breathing and keep their heart beating and keep their blood pressure up and keep their blood flowing. ... That suspended animation [can go] on forever. [So] the decisions at the end of life have become much more complicated for everyone involved."

In this powerful look at the reality of today's medicalized death, FRONTLINE producers Miri Navasky and Karen O'Connor (The Undertaking, Living Old, The New Asylums) introduce us to Albert Alberti, a 53-year-old father of three young children who's hoping to receive a third bone marrow transplant in his fight against leukemia. Bone marrow transplants have the potential to cure diseases that are otherwise incurable, but they are also among the most drastic treatments in oncology. The treatment itself can kill the patient. "He's got to take every step possible," says Deborah, Alberti's wife. "It's tough, but, you know, why give up? What's that going to do?"

"Some physicians can keep giving treatment, and some find it unacceptable, and that, I think, is where the art of science and medicine mix," says Dr. Keren Osman of Mount Sinai's Bone Marrow Transplant Unit. "The lines are blurred, and they're also different for different physicians. Sometimes there are patients for whom ... I wish we'd stopped earlier because I think they suffered unnecessarily. ... Sometimes there are forces outside of the patient and myself that are the patient's family, other physicians. Sorting that out can be very, very tricky in those moments."

John Moloney, a 57-year-old corrections officer, was diagnosed two years ago with multiple myeloma. He has tried every available treatment, including two bone marrow transplants. Now he wants to continue chemotherapy, even though the chance of its working is minuscule. "Bomb me," he tells his wife. "I'd rather be like that than dead."

"It's hard to watch. John was 6 foot 3, 250 pounds. He's like, 150 pounds now," says his wife, Debbie Moloney. "And I told John: `No more cancer treatment, no more chemo. I can't see you be any more debilitated.' But then you talk and you say, `OK, let's try something mild,' because doing nothing -- it's scary to do nothing, because ... I don't want him to die. So ... you want to do something."

Decisions about how aggressively to treat a patient can be complicated for doctors as well. "It's very difficult for me to say to a patient, `I don't think you have any treatment opportunity.' I never said that to any patient, never," Dr. Celia Grosskreutz of Mount Sinai's Bone Marrow Transplant Unit tells FRONTLINE. "I can't humanly say that to a patient. I always say, `Well, we can do this or the other,' even if it's in a palliative way. But I offer. I always say there is something to do."

FRONTLINE also meets Marthe Laureville, who is 85 years old and has dementia. She has been intubated for two weeks, and now her daughters, Nadege, a nurse, and Sherley, a physician, have to decide whether to keep her on a ventilator. "I myself would not want to put Mom through a trach[eotomy]. ... I'm not sure, at this point, what the benefit is of that," says Nadege. "Will that prolong the life that she has right now, for one month or two months?" But Mrs. Laureville's other daughter, Sherley, disagrees: "I don't want to be the one to say [do not resuscitate] and to be responsible for her death before her time. ... I [will] not stop her from breathing. ... I will maintain her until the last minute."

"There are clinical situations where the odds are so overwhelming that someone can['t] survive the hospitalization in a condition that they would find acceptable, then using this technology doesn't make sense," says Dr. Judith Nelson, an ICU doctor at Mount Sinai. "And yet, in my clinical experience, for almost everybody involved, it feels much more difficult to stop something that's already been started." But, according to Dr. Nelson: "Nobody wants to die. And at the same time, nobody wants to die badly. And that is my job. My job is to try to prevent people from dying if there's a possible way to do it that will preserve a quality of life that's acceptable to them, but if they can't go on, to try to make the death a good death."

In the face of death, many patients will do almost anything to live, but new questions are being raised about whether we can afford the growing cost of end-of-life care. "There's a tremendous pressure now to reduce care to numbers as though there's an algorithm for every decision," says Dr. Jerome Groopman, professor of medicine at Harvard University. "When you look at Medicare data on expenditures at end-of-life and what is very glibly termed "waste," 30 percent of all care is waste. That's the new mantra. It's very hard to know what that means. And it's very hard to bring that out of Washington and into a hospital and at the bedside, with a single individual facing death."

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posted november 10, 2010

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