Death and Dying
Speakers: Rev. Charles Meyer (click here for biography)
Soap Summit 4

Transcript of Proceedings
October 9, 1999

SONNY FOX: Charles Meyer is Vice President of Operations for Saint David's Medical Center in Austin, Texas. He's also on the boards of a lot of other groups including a hospice, and he deals with long term illness and death. He has written extensively, spoken nationally about it, and travelled all over the world. He's written two books, Surviving Death, A Practical Guide For Caring and Dying and Bereaved, and his newest edition, his newest book is, A Good Death Challenges Choices and Care Options. He has also written a number of mystery books and other books. My favorite is The Gospel According To Bubba. Now Chuck in the last paragraph of your CV, there's a line here which really has us puzzled. It says Chuck Myers is a mystery writer cleverly disguised as an Episcopal priest. Chuck is an Episcopal priest. It says you spent 10 years in a New York prison and a Texas jail.

REV. CHARLES MEYER: Working.

SONNY FOX: Working. Aha. In one man then, we have quite a remarkable assortment of talents, the Reverend Chuck Myers.

REV. CHARLES MEYER: I am from Austin, Texas, as you've heard. The live music capital of the universe, where country and western singers have all turned 45, and have recently discovered death. So we're getting songs like "We're Only Here for a Little While ". Clint Black's excellent song by the way, "No Time To Kill" and the one called, "You Finally Brought Me Flowers ", and the theme song of the Texas State Funeral Directors Association, "Prop Me Up Beside The Jukebox If l Die ". My all time favorite is kind of a combination country and soap song, it's called, "When The Hair On Her Chest Ain't Mine".

In the short time that I have, I'd like to very quickly set the scene for you on some of the major trends in health care today. Then I want to talk about how, in fact we die, as opposed to how we usually die on television. I want to raise some issues about pain that Robert began with a little bit ago, and talk a little bit about spirituality. All this in the next 25 minutes, so it'll be like the Federal Express man.

Let me go to the first slide. Walter Cronkite said just as the Holy Roman Empire was neither holy, roman, or an empire, so our health care system is neither healthy, caring, nor a system. But we are beginning to see some major changes, or shifts in what we do. A physician friend of mine says, "Always remember shift happens." The first shift is from optional to obligatory. We are the last western industrialized nation on earth. The only one, other than South Africa, that doesn't provide universal access to health care.

We've got to figure out how to do this. This is just a national disgrace for a whole host of reasons. I mean, we currently have 44 million uninsured Americans. Even in December '98, the AMA declared itself the national champion of universal access. Six of the largest physicians specialty groups have gotten on board, along with the American Hospital Association, Catholic Health Care Association, all in moving towards some sort of appropriate health care for all Americans.

Very interesting ethical issues this will raise. Kellogg did a survey earlier this year, and they found that 60 percent of Americans believe the government should subsidize health coverage for those who can't pay out of pocket. 80 percent of the people responded that we definitely, at the very least, should be doing this for children. This is just sensible health care economics. We know that for every one dollar we spend on prenatal care, we save three in the intensive care nursery, when that person comes to the ER with absolutely no care.

Well some of our patients currently view their hospital stay as this: "Calm down this equipment is for our paperwork. You, we just hook up to the cash machine". My favorite is "They'll cover your rear diagnostic test over there". Or this one, "We'll need you unconscious for the operation. Would you prefer sodium pentathol or a peak at your bill?"

Well, I was talking to a group of intensive care nursery nurses last week, talking about this whole issue of the uninsured. I said, the way this plays out is that the woman doesn't have health insurance so she gets no prenatal care. People who are uninsured wait longer to come in for health care. When they do come in, they come in to use the emergency room as primary care. We know from studies that people who are uninsured and come to emergency rooms get fewer tests, fewer treatments, die in larger numbers, and have sicker babies that spend months in our intensive care nursery. So, it really is in our own best interest to move toward this system. And we are.

We're seeing, even as of a couple days ago, this being discussed in Congress. Well, the most far-reaching change is away from the technology imperative. This is the most radical change in 50 years. For 50 years we have practiced medicine, delivered health care under the technological imperative. I want to urge the past tense here because every medical show that I see on TV is 20 years out of date where this issue is involved. They're still projecting and image of medicine, and image of health care based on the technological imperative.

What we used to think was, if you came to my ER you need a vent. I had a vent. I had to put you on a vent. I thought it was medically, legally, morally, ethically required to use the technology. It was imperative. Well, now, as we're seeing two things happen. One, the aging of the population, a whole interesting group of aging statistics we talk about, there's 60 thousand Americans 100 years old or older. The fastest growing age group is 85 and over. They're all ahead of you out on the expressway out there. All you see is two little white gloves on the steering wheel of a Buick.

So we're seeing the aging of the population combined with outcome studies. We are for the first time, what a shock, measuring, the outcomes of what we're doing. And we're seeing that the use of the technology results in at least a worse death, and at worst a bad death compared to what would happen if we allowed a natural death.

For instance outcome studies. They did an outcome study in ICU, looked at CPR and ICU. They determined at the end of that study that they probably shouldn't be doing CPR and ICU, on anybody over age 70 with cancer sepsis GI-Renal failure. Why? Survival of the discharge rate, zero. They all die. Well that's an interesting statistic to have if it's your mother or father who is in the intensive care unit. Now the problem here is not that we're bad practitioners, or that we mean ill, the problem here is this giant learning curve. We've done this for 50 years. It's like turn that ship around in the middle of the ocean. Well, you are part of the turn-around process. You can project this, and teach people what in fact the truth is about these issues, and help us to turn that ship around for their own good.

Now again, we have to be careful that we don't rush into anything. This guy says I'm gonna take a nap, watch my plugs, will you? We're seeing a shift from paternalism to collaborative decision making. The days of paternalistic medicine are over. Where the doctor comes in and says, as Robert said, this is what you've got, I know it, and you better have it. The baby boomers are coming into the system. It's us. These people didn't exactly worship authority in the '60s. So the same people who took over the Dean's office in 1969 are taking over the doctor's office in 1999, with the same sign: "Hell No We Won't Go". Except it's a lot worse. In the '60s we just thought we knew everything. Now we know we know everything. We know because we're older and we have clicked our mouse. We have downloaded volumes of information about our little disease with which we're coming into your office saying, "Okay, so why don't you know this?"

Well, in addition to putting pressure on physicians, the boomers are also putting out cartoons like, "There's a boomer service station, on the left is Rogaine, on the right is Prozac, back behind it's Viagra." You know what happens if you take Rogaine and Viagra? You get Don King's hair. Or this one: "See, the problem with doing things to prolong your life is that all the extra years come at the end when you're old." Well, there are lots of plot possibilities here. Connecting the needs of the boomers with the needs of the elders. What if it was reversed? What if the boomer had the terminal illness and the elder needed the money for long term care? All kinds of interesting conflicts.

That kind of sets the health care stage. And to launch into the next area I would like you to think about - you don't have to write these down or raise your hand - but think about two things that would have to happen for you personally to have a good death. What would have to happen personally. Let me tell you what I have found around the country. The big four. It doesn't matter who the group is. It doesn't matter where they are. It doesn't matter what their ages are. I talked to University of Texas students, I talked to elderly people in nursing homes. I get the same answers. It's fascinating.

Quick, painless, at home with family around. Those are the big four. Well, that's very interesting because if you look at where in fact we do death, we find 85 percent of the deaths in this country occur in hospitals, long term care settings. Fifteen percent of that 85 percent in ICU. So what that means is you and I stand not only an 85 percent chance that our death will be managed, directed and decisional. It's real hard to wake up dead in a hospital. You can do it but you have to be real sneaky. Take those little leads off your chest. Put a little out-to-death sign on the door. There's an 85 percent chance your death will be in an acute care medical facility, 15 percent chance that you and I will die after they do things to us, that if we did them out here on the sidewalk, it would be a felony.

So this is what we're trying to turn around. This is what the Last Acts effort on Robert Wood Johnson is working at addressing. I tell every audience I talk to that part of the problem is that patients and families I deal with are out there watching shows like Chicago Hope, ER, Rescue 911. ER is working on this, they had their first show the other night where they're trying to address some of these issues. Make 'em a little different because Robert Wood Johnson has talked with them about how accurately to portray this. I get people making end of life treatment decisions by what they see in Chicago Hope and ER. You know what the success rate is for CPR in Chicago Hope? 96 percent. That's pretty good, 96 percent. I wanna go to Chicago Hope. You know what it is on Rescue 911? It's 100 percent. Nobody ever dies on that show. Well, those are fascinating educational messages.

It's no surprise to me that I get family members holding the gun to our heads and the doctor's head, keep mama at full code. Why? Because they'll rip off the ventilator and bicycle home. I saw it last night on Chicago Hope. Or you want someone never to die? Hit 911. Interesting educational messages! Remember that every episode you write is educating the American public about what they should expect when they go to a health care setting. What they are obligated to do when their loved one is dying.

The most emotional part for me is what they should feel guilty about for the rest of their lives if they don't do. It's often reinforcing the technological imperative. If you take one thing out of here today, take this. What you say is what they see. I show the same slide to physicians, to nurses, to chaplains, to case managers, social workers, volunteers. The way we describe at the bedside what's going on in that room is what the family sees when they go in. Even more powerfully for you, the way you portray this on the screen is what the family is going to see when they go in that room. What you say is what they see. The problem is our biomedical technology has out-paced our vocabulary to talk about it. We don't have good language for this stuff yet. So we continue to use old language and old metaphors to describe new technology. And not only does it not work, it doesn't fit. It gives false, inaccurate, misleading information to people trying to make very difficult decisions. Which is why I never use the emotionally loaded terms 'life support' anymore. Don't talk about life support. It's presumptuous to talk about what life is for you. How do I know this machine is supporting your life? When we call it life support we're using a capital L here. The family hears capital L Life. And you have now labeled this Life even though the family is thinking boy, you know, this is not the quality of life to which my father would want to be kept going. This is not the quality of life for him.

I ask families if your dad could come out of the coma for five seconds, sit up in the bed, look you in the eye and say do this, what would he say for you to do? How would he give you instructions? We were talking about this last night. The Surviving Death book talks about how to be with dying people. I've got a couple copies of those books if you want them. I always tell people be careful what you say around dying people. I mean they can usually hear. I mean I've had people come out of surgery and ask the doctor to repeat the punch line to the joke they missed as he was grabbing their gall bladder. I actually had somebody come out of a coma, I was in a room one time, and a person came out of a coma, looked at a family member and said you're out of the will. Make a good plot right there. I've heard every word you said.

So don't talk about life support. Talk about artificial interventions. I talk about medical treatments, all of which can be withdrawn. It is not true that once you start something you can't stop it. If we believed that, we would never start anything if you could never turn it off.

Likewise I never use the emotion-loaded terms food and water. It is not, please, it is not a feeding tube unless you think you can get an enchilada down that sucker. You think it's food? You eat it. A little surprise for you at lunch today. Does it come from my food service department? No. Does it come from dietary? No. It comes from the pharmacy. And the problem is when you and I label this feeding tube or food we are responsible for calling up in the memories of that family's decades of rich emotional associations with nurture. We say feeding tube, the family hears nurture, care, love, attention. And if you think they can remove a feeding tube, if they think it's nurturing their loved one, you've got another think coming. We need to tell the truth. We have an ethical obligation to truth telling.

This is artificial nutrition, artificial hydration being force-pumped by a machine into the body to keep the body functioning, I didn't say alive. We need to educate people about what happens when you withdraw it, because they don't know. They're watching TV. Let me suggest to you, this is not food. This is not food. And when people think it is they're reluctant to withdraw it because the next thing they think is they'll starve to death. I hear this all the time. I hear this from physicians. Physician wrote this in the chart DO NOT FEED HIM. Get out, what is this? What? You went to like Sears Roebuck Medical School? Starve to death? Another major myth of health care. Nobody starves to death. Problem is that the last national repository of information about how in fact we die is in the brains of your parents and some of your grandparents. Because pre-1950 over 50 percent of deaths occurred at home. We have forgotten how we die. We have medicalized death, and forgotten what our parents and grandparents knew. Pre-1950 over 50 percent of deaths occurred at home. Why? We didn't have ICU, didn't have intensive care nurseries, didn't have cardiac monitors, didn't have pegs, artificial nutrition tubes. We didn't have ventilators. We had iron lungs for polio patients. You know who ran the ambulance services in Texas? The funeral homes. Is this a conflict of interest? Slow down. Let's see, do we take him to the ER or do we pay off the boat?

So our parents and grandparents knew what to do. They kept people at home. Little cold cloth on their head, in their bed, kept patting on them, loving on them until they died. If they were Episcopalian, had a little shot of whiskey on the way out.

We are kinder to death row inmates in my state than we are people up in my ICU trying to die. Now old Billy Bob, before he gets up on the table to get the lethal injection down in Huntsville, right before he dies what do we say? We say, "Billy Bob what do you want to eat?" He said, "Man, I want Shiner Bock, the national beer of Texas. I want a Shiner Bock and a steak." We said, "Give that man two he's gonna be dead in the morning." The guy up in my ICU says, "I'd like a little shot of Jack Daniels." We say, "God no, it might kill you."

So our parents and grandparents knew how we die. Okay. So how do we die? Well, when you withdraw nutrition and hydration, you have to withdraw both of them. Just withdraw nutrition and maintain hydration you are forcing the body to starve to death. You have to withdraw both of them. We start to dehydrate. We become asystemic. As we dehydrate and throw off fluids, waste products that are built-up in our system create a natural analgesic effect. Endorphins are released in the brain. We become sleepy, comatose, and die in about two weeks. If there is any pain or discomfort with that, that's why God made vitamin M, morphine.

We can fix it. And we should. I have an ethical obligation to quell pain. We also need to educate people about what happens when you maintain nutrition and hydration in a patient with a terminal condition. Because again, technological imperative, language, people think they have to. We need to at least make sure they're educated both ways so they can make this choice. This is what happens. This is a natural death.

In fact, there are some places that are moving away from DNR, which is the Do Not Resuscitate. You know, we terrify family members with "let's make your mother a no code", yeah. We terrify them with Do Not Resuscitate. Sounds like maybe implicitly you're not doing something you should be doing. So at our hospital, we're working on changing this DNR to AND, Allow Natural Death. Very different emotional message there. So what happens if you maintain nutrition and hydration in the patient with a terminal condition. You're pumping nutrition and fluids in this body trying to become asystemic so you have to catheterize them, suction them... that's comfy. As fluids build up in their tissues it becomes very painful. You have to increase narcotic medication. So you may actually snow them before you would have to. You get enough artificial nutrition on board, you can create intractable diarrhea, or you can wake people up so they fully appreciate their suffering and death. And we do it. We do it not because we're bad people. Learning curve here. Turn that boat around. The other interesting difference is between effect and benefit. In medicine and nursing and health care, most of what we do is having some effect on the patient's body or organ system or lab numbers.

The question in a patient with a terminal condition, that's irrelevant. It's not, can you make them pee, clear their kidneys, clear their lungs. The question is does that benefit them in any way that the patient would define benefit for his or her definition of his or her quality of life? Quality of life. Now the ethical thing to remember here, it's very important. I get a call about once every two weeks. Just got a call on Tuesday. Same situation. Family has a loved one with end-stage Alzheimer's, or some sort of dementia. They're in a nursing home. They may be on a peg, an artificial nutrition tube. They have not known anybody, recognized anybody for maybe six to eight months. They get pneumonia, what do you do? Well, if you're the physician, hey, this is not a problem. We start IV antibiotics. Get those sulfur drugs out - boy, we'll fix this. We can cure the pneumonia. That's true. The ethical question to ask here is that by medically intervening for cure, are we restoring this patient to the previously acceptable quality of life for this patient? Or are we not? If we're not, then you have to ask why are you treating the pneumonia for cure? Why aren't you treating it for comfort? Comfort.

Pneumonia used to be called... anybody know? The Old Man's Friend. That's right. Actually, politically correct is the Old Person's Friend. It's the Old Man's Friend. We don't know what the old women died of, probably taking care of the old man. So you have to die of something. Now we have people languishing in nursing homes with whatever disease, and still we're using the technological imperative, language issues, feeling like we have to.

I want to suggest to you that the ethical question is are we restoring them to where they want to be, or is it time to call in hospice? You almost never see hospice portrayed in daytime TV or at night. You never see home deaths, people dying at home, calling in a hospice to allow a natural death at home. Question is when do we cross the line from sustaining life, which is what we ought to be doing, to prolonging dying which we ought not to be doing? We'll feel horribly guilty if we don't. Lots of guilt issues. We need to be telling families too, what the cause of death is when you withdraw nutrition and hydration. What the cause of death is when you remove a vent.

I get family members that feel horribly guilty. My God, I've killed Dad. Because the doctor comes out and says so, do you want me to turn off your father's ventilator? And they think great, so on the death certificate it's going to say "died because family turned the vent off". No. We need to be telling it, '"died of pulmonary failure". That's what he had before he started the vent. That's the cause of death. We're going to get out of the way and allow a natural death.

Another important issue is pain and suffering Americans think this is one word. Problem here is pain and suffering. We have to quell pain and suffering, when in fact they are two words and can be dealt with very differently. We' re pretty abysmal at pain management in this country. Robert Wood Johnson has pointed that out with the support study that was mentioned.

The American Society of Anesthesiologists recently reported that more than 47 percent of all patients recovering from surgery in this country, about 12 million people, do not receive adequate pain control. About 40 percent of all cancer patients die in under-relieved or unrelieved pain. Well, in terms of terminal care I would urge you to look up the Last Acts web-site. It is excellent. It has data from the SUPPORT study - Study To Understand Prognosis and Preferences For Outcomes And Risks of Treatment. I always think they must have spent about six months working on the acronym.

What they found was that Americans die alone, isolated in intensive care, unconscious, on ventilators. If they're conscious, over 50 percent spend the last three days of their existence in moderate to severe pain. Treatment withdrawal preferences are unknown or undiscussed. Families are financially devastated. Little attention is given to spiritual needs. Let me suggest to you that it's counter-intuitive to do this. The way we treat our dying patients in this country, our loved ones, is counter-intuitive. It's neither in our intuitive nature, or as someone recently said, not in our genetic code to treat irreversibly ill and dying people the way we do. So why do we do it? Well, we think we have to. We think we've always done it this way, technological imperative, language issues. We do it because families demand it, partly because all of the stuff keeps being reinforced for them in the media and on television.

And they want to, people are trying to do the right thing here. What we need to do is educate them about what their options are. This is not academic to me. I deal with people everyday making very tough end-of-life treatment decisions. It would also affect our whole death care. If we were half way decent at really good pain management, the issue of assistance in dying would diminish. I chair our Ethics Committee at the hospital, another great area for drama. Should we do this? Should we not? How do we decide?

All these issues will force us to look at the kinds of silly religious things we say to dying patients and their families making end-of-life treatment decisions as well, many of which are reinforced in the media. For instance, "You don't die until your number comes up." That makes God the clerk at the deli section of your local grocery store. "Sorry, you must be in excruciating pain for 85 more numbers. Get to the end of the line, and we'll get to you." In fact, my experience is that people often choose their time of death. It's often around birthdays, holidays, anniversaries, special days for that couple or family, so it's very important to let them know who's coming in, and treat them as though they can hear you. Don't ask them to do cute little tricks. Talk about this and surviving. Don't ask them to squeeze your hand, blink an eye, or wiggle a toe. Come through the flaming hoop, Mother, we'll feel much better knowing you're in there. They can't do that, but they very often can hear and know what day it is and what time it is.

So, they need to know. The grandbaby will be there at three. They'll die at four. Mother-in-law will be here at noon, they'll die at eleven. People need to have that kind of God's will. This covers everything from birth defects to hemorrhoids. Fascinating how many people think God has enough time to worry about where you sit, but people would rather believe this than believe either in personal responsibility for illness or the capricious nature of disease. Capricious because any time you say this, people start thinking of the 25 things they did to deserve dying, or being sick, or being in excruciating pain. I was just reviewing a book on the way up here, and I got to tell the guy, I cannot endorse this because they keep talking about trying to figure out the meaning. Well, the meaning of this is, you have cancer. That's the meaning of it, and you're going to die from this.

Now, you think God gave this cancer for a reason. I had a lady tell me one time that God had given her the cancer, inflicted her with the disease. She was really in a lot pain, to bring her daughter to Jesus. That is just so convoluted and absurd, but a very common thing we hear, along with there's a reason for everything. A really good little book, if you haven't seen it, is called The Will of God by Leslie Weatherhead. It was written back in the '40s. It talks about the wills, plural, of God. Where there's life, there's hope. Yet another lie.

Where there's life, there's often excruciating pain, hopelessness. I was walking down a hall talking to a guy dying of brain cancer at one time. He said, you know, he said, "It's okay with me if I live, and it's okay with me if I die, because either place, I'm loved." Now, that's hope not optimism. He was not optimistic, and he knew that there were things worse than death, and there would come a time for him when death was better than what was going to be going on with him physically. It's hope because it's death, embracing and transcending rather than death-rejecting. Interesting man.

Well, what to do about all this? Remember that death is a form of healing. Death is a form of healing, and if we treated death as a form of healing, we would treat our terminally ill patients vastly differently than we do at the present time. Death and healing as not opposites. I hear this all the time because I've lived in the gold buckle of the Bible Belt, and it's fascinating to me when you see TV preachers. They assume that healing is always physiological change, and that's fascinating.

That's a prejudice. The leg got longer, or the blood flow went away, or the cancer vanished or whatever. You probably didn't know, that Oral Roberts put out 33 1/3 album a number of years ago. It didn't sell, the little hole in the center kept healing over. Lots of things can be healed. Memories can be healed. Dreams can be healed. Angers, guilt, resentments of a lifetime can be healed all in the course of dying so that healing and death, I would argue, are not opposites, but death, in fact, is a form of healing.

In Texas, we have a really stupid law for nursing homes. If a nursing patient by regulation loses one pound - one pound - the director of that nursing home can be cited. That's absurd, because the other thing we've forgotten about how we die is, that's how we start to die. We quit eating. There was a study done of people over the age of 85 in nursing homes. One week they were wheelie walkers. They were just zipping around and eating and drinking. Everything was fine. The next week, they said, "Well, you know, I'm just not as hungry as I was", and they quit eating and drinking. It's like a little computer chip in their head went, "Time to go. We're out of here." And what happens? Azotemia begins to kick in. But what do we do about that? Technical imperative, language. You try doing that in a nursing home in my state, they're going to drag you off to my emergency room and peg you, put you on an artificial nutrition tube unless one of us is standing at the door trying to re-route this.

So, what is medically and legally right, may not be ethically right. The most important thing, finally, you can do about this issue is to examine your own death. How many people here have a Living Will? Mainly this section. How about a Medical Power of Attorney? How many of you have made any or paid for your funeral arrangements? Right, two of us are really going to die and meet you at the bar when this is over to discuss this.

Robert, you probably won't like this. I have a copy of your Living Will here that I picked up on the way over. Hope you don't mind if I share it with them. Here's Bob's Living Will: "If I ever get to the point where I'm no longer able to make decisions for myself, I hereby instruct my next of kin to place me on a beach in Martinique and feed me rum punch until I expire from natural causes." Jot that down.

I always ask church groups, now how many people want to go to Heaven? Everybody raises his or her hand. How many people want to die? Whole connection shot right by you. Everybody wants to go to Heaven, nobody wants to die to get there. It's like Woody Allen says, "I don't care if I die, I just don't want to be there when it happens." He won't have to worry, he'll be in a court in New York. Well, no matter what you do, last time I checked, the death rate's 100 percent. One out of one dies. That would be an interesting thing to tell people, too.

My favorite quote, actually, is from Redd Foxx. He said, "All those health food freaks are going to feel real stupid 20 years from now, lying in the hospital dying of nothing." It is extremely important to at least look at advanced directives, or talk with whoever it is that's going to be making your health care decisions, when, not if, when you end up in somebody's emergency room. There are two reasons. One, it's personal. It allows us to know what to do with you when you come in, and it could be in the next 15 minutes, you end up in somebody's ER, or you get a phone call in the next 15 minutes, it's your loved one over there.

You know what their quality of life standards are. You want what they're willing to have withdrawn or live with or without. You know when to change the goal and then to comfort, to comfort and allow a natural death, if not, why not? Second is one that will effect your writing. I'm a writer, I write murder mysteries. It will effect your writing as it effects those of us at the bedside dealing with patients. A friend of mine did a study in Austin, and was teaching a course in Death and Dying. I always wondered how you pass a course in Death and Dying? There's another A.

Anyway, Larry taught this course. He was going to bring in this lady who was going to die, not in front of the class, but later, and he pre-tested the class asking them to get at the comfort level dealing with their own death. Did they have Living Wills, blah, blah, blah? Did they talk to anybody? He collected that data. The lady came in, talked about dying and coping. She left.

He post-tested the class asking them to evaluate how well they thought she was coping and correlated the results. Lo and behold, the students for whom it was very difficult to talk about their own deaths, saw the lady as coping very poorly. The students for whom it's okay to talk about their own death, saw the lady as coping very well, same lady. One of the things that tells is, you want to write well about this? Please, when you get out of here today, have this conversation with your person. It will change not only what you say, but how you write.

Well, finally, Winston Churchill said, "Americans can always be counted upon to do the right thing, but only after they have exhausted all of the other possibilities." I want to suggest to you, every plot you write has an ethical component in addition to an incredibly influential educational and instructional component. We no longer have the luxury of exhausting all of the other possibilities. We have to write accurately about how we die in language and images that are understandable and realistic and filled with really great, incredible dramas at the bedside and at hospitals and at home.

If you're in an extremely influential position because, again, what you say is what they see. You might say, what you write is what they, how they, frame that when they walk into the situation. If we do not hold high ethical values of truth telling, both in our language and our description of outcomes, if we are not aggressive portrayers of accurate end of life decision making and death and dying dramas, then we will allow others, and they will be legislators and insurance companies, to set these standards for us, and ultimately, to make these decisions for us.

And their idea of a good death might look like a generic one, or we may all end up where we are thwarted in our attempt to have a good death for our loved ones and ultimately, for ourselves. Thanks very much for having me here.