Ira Byock, MD is Director of Palliative Medicine at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire and a Professor of Anesthesiology and Community & Family Medicine at Dartmouth Medical School.
Dr. Byock has authored numerous articles on the ethics and practice of hospice, palliative and end-of-life care. His first book, Dying Well, (1997) has become a standard in the field. His most recent book, The Four Things That Matter Most, (2004) is used as a counseling tool widely by palliative care and hospice programs, as well as within pastoral care.
Dr. Byock has been a consistent advocate for the voice and rights of dying patients and their families. He has been the recipient of the National Hospice Organization’s Person of the Year (1995), the National Coalition of Cancer Survivorship’s Natalie Davis Spingarn Writers Award (2000), the American College of CHEST Physicians Roger Bone Memorial Lecture Award (2003) and the Outstanding Colleague Award (2008) of the National Association of Catholic Chaplains.
Question: What are the downsides of dying in a hospital?
Ira Byock: Well, the medical model that, I began to talk about this problem-based model is really restricted, it’s very powerful and it helps us, but it only takes us so far. The fundamental nature of dying is not medical, it’s personal. And so dying cannot be encompassed by a set of medical problems, and a set of diagnosis and treatments. So while we can remain disease focused for as long as it makes sense, we also have to attend to the personal aspects of dying. People, you lose and dying in the hospital many times is you lose that personal time. Your space is not your own, people walk in and out, you don’t have this privacy or intimacy with family.
Beyond that though we – staying within that medical model, everybody who walks in your room or interacts with you or talking to you about medical problems, they will continue to conscript your attentions to the lab test and the scans and the next treatments and the drugs and your vital signs and all of that, instead of attending to the personal.
They actually conscript your time and energy for the medical. The best end of life care that I know of through modeled by hospice programs and the best palliative care programs still does all the medical stuff, but its subordinated to the personal, its – in hospice care we make appointments to see you and your family not the other way around, we’re coming to your home, we are explicitly acknowledging the importance of interactions of your privacy and intimacy.
And beyond that we’re even offering some help, some guidance that maybe of value to you in this area of human interaction, I would call life completion and life closure, which again in a problem-based medical model doesn’t even exist, it’s not there. Quality of life and quality of life completion really exists in a developmental model that really honors the breadth of human life for the person and family but not in a problem-based model. So even the very best of problem-based medicine, and including attention to symptoms and the like, tends not to see those personal experiences of completing one’s affairs, physical and legal and project-related affairs but also they are personal affairs, they are relationships, they are explorations of their own meaning and significance of their own life. Their relationship to something larger than themselves, that stuff that’s not abstract for people who know that, that their life is measured in weeks or days, it’s very tangible.
Recorded on: March 21, 2008