Abstract
In this scholarly volume, Helen Chapple provides a richly layered account of how American hospitals marginalize dying patients and those who care for them. While rooted in an ethnographic study of staff in two quite different hospitals, her analysis embraces insights into the roles of economics, bioethics, the hospice and palliative care movement, and iconic American cultural beliefs. This volume would be rewarding reading for any student of American health care, including hospital administrators and board members as well as clinicians and change agents frustrated by the epidemic of over‐treatment of hospitalized patients at the end of life.
Some of our physician colleagues attribute the persistence of rescue‐oriented care entirely to physician greed and hospital bean counters. This seems a gross over‐simplification and Dr. Chapple would agree. She describes in detail how the Ideology of Rescue is deeply rooted in moral values and buttressed by entrenched power. For example, she points out that the care routinely lavished upon seriously injured trauma patients is probably the most equitable allocation of health care resources to be found in our system due to its immediacy and unquestioned high priority, far outdistancing the fairness of distribution in prevention, rehabilitation, or the management of chronic disease. Further, acknowledging the work of Baudrillard and Good, she writes, “Should the victim be rescued alive, then the hospital becomes the site of this moral drama (of the heroic fight against death) … To overcome adversity with technology and intensity defeats the reminders of human vulnerability. Such is the impetus behind the valorization of rescue and its infrastructure” (p. 83). Far deeper and more entrenched than mere financial gain, but aligned with it, is our fear of death and our pretense that death is optional.
The more technology is deployed and the more time is compressed, the more heroic the enterprise and the more “legitimized” the patient. Dr. Chapple describes “the Ritual of Intensification” in which seriously ill patients are afforded more and more high‐tech intervention until hemodynamic stabilization is achieved or the patient dies. The power of this Ritual of Intensification is seen in the way it can suspend the routine institutional pressure for timely “throughput,” that is, moving the case along in a fashion that both fits the rescue mission and bolsters the bottom line. Indeed, time, often a key variable in clinical ethics, is a recurring theme in Chapple's analyses.
According to Dr. Chapple, there is an outcome worse than death from the hospital's perspective. That occurs when a patient emerges from the Ritual of Intensification neither recovered nor dead and is labeled as “Dying.” Such a patient is simultaneously devalued socially and is a rebuke to the dominant ideology of the hospital culture. Such an outcome can be more offensive to the orderliness of hospital process, the moral comfort of the staff, and the hospital's financial health than the “failure” of a death occurring during an all‐out rescue effort.
Given all the ways that hospitals have hidden, obscured, and ignored death, there are no rituals for dying and often no place and no adequate staffing for the dying. When there is a place, as when the hospital designates a few beds as hospice beds, this setting does function to decrease the moral distress of the hospital staff. The assignment of the patient to hospice or “comfort only” care signals his or her ineligibility for rescue. The relief of staff is reflected in frequently recorded statements such as, “At least, she's not suffering any more.” These expressions testify both to the speakers' compassion and to their allegiance to the Ideology of Rescue. They may not see that the dying situation has possibilities for making meaning, or that the rescue atmosphere in the hospital may unconsciously motivate them to speed the dying process.
The book ends with proposals for making hospitals better places for dying. Dr. Chapple boldly suggests a fundamentally different remedy than that offered by many change agents in the palliative care field who advise emphasizing how well palliative care takes dying patients out of the ambiguous, embarrassing, and expensive “Dying‐in‐our hospital” category. She argues that this approach preserves the hospital's devotion to the Ideology of Rescue and its marginalization of the Dying. Instead, she proposes an approach of deliberately bearing witness that enhances the status of the dying and enlarges the hospital's mission. While we think that some of the more successful palliative care ventures have managed to work both sides of this street without compromising integrity, her proposals reflect important insights from her anthropological vantage point and include several creative suggestions for specific, programmatic goals.
This book is loaded with serious, intellectually strenuous material, making some popular books on dying in America seem downright breezy by contrast. Because Dr. Chapple is a good writer and her volume is well organized, the book is dense only in the best sense. Most importantly, clearly told patients' stories and direct quotations from interviews with those who cared for them keeps the analysis grounded in hospital realities.