TIME health

Why Your Doctor Probably Has a “Do Not Resuscitate” Order

Doctors know that aggressive end of life care can be a waste of money—and painful. Yet that's exactly what happens when Americans die

The greatest success of the American medical system is also its greatest failure. Thanks to amazing advances in biomedicine, doctors can keep you living long after you would have passed away in earlier years. Today a 65-year-old man can expect to live past age 82, and a 65-year-old woman can expect to live even longer. But those extra years can come at a terrible cost. Millions of Americans spend the last few years of their lives in and out of hospitals, racking up huge medical bills. A quarter of the total Medicare budget is spent on the last year of recipients’ lives, with 40% of that money going to their final 30 days. Worse than those billions, though, is the physical and psychological pain that accompanies aggressive end-of-life treatment. Intubations, dialysis, feeding tubes, invasive tests—for far too many Americans, the last phase of life is spent in a hospital intensive care unit, hooked up to machines.

It’s a terrible fate, as doctors only know too well. That’s why it shouldn’t be surprising that researchers in a new study in the journal PLOS ONE found that 88.3% of doctors surveyed reported that they would choose to forgo this kind of treatment if they were dying of a terminal illness. Yet even though they know how painful and futile those treatments are for dying patients—and would refuse them if the situations were reversed—doctors still find themselves carrying out those procedures on their own patients. “Physicians know it’s not the right thing to do, but we find ourselves participating in treatment that causes pain and suffering for our patient,” says Dr. VJ Periyakoil, the director of the Stanford Palliative Care Education and Training Program and the lead author of the paper. “Families are traumatized and there is a huge financial cost to the individual and the nation.”

Doctors aren’t alone. Periyakoil notes that surveys have found that more than 80% of patients say they wish to avoid frequent hospitalizations and high-intensity care at the end of their lives. So why then are so many Americans dying in exactly opposite the fashion that they and their doctors desire? Blame the same medical technology that has helped Americans live longer than ever before. Hospitals and doctors are reimbursed for carrying out procedures, whatever the end result. “The default of the medical system is to doing all possible technological care,” says Periyakoil. “It simply doesn’t make it easy to do the right thing.”

Medical schools bear some of the blame as well. Periyakoil notes that students are taught to extend their patients’ lives if at all possible, but they’re not taught how to speak to their patients and families about the reality of end-of-life care. That’s especially important because elderly, terminally ill patients are rarely in a position where they are capable of expressing their wishes, which too often leaves the decision up to the closest family members. And it’s hardly surprising that, faced with the possibility of losing a loved one, family members opt for whatever care is needed, no matter the financial or human cost. Periyakoil herself has spoken with the family of a terminally ill patient and gently suggested withdrawing extreme treatment, only to have the family push back. “We can present the options, but ultimately I have to defer to them,” she says.

Periyakoil says she published the study in part to show ordinary people what their doctors actually thought about intensive end of life care, with the hope that they would reconsider the need to extend the lives of their loved ones at all cost. This is fraught territory—just look at the hysteria over the so-called “death panels” during the initial Obamacare debates in 2009. But these conversations must be had, on the national level and the personal one. It’s projected that 26.1% of the U.S. population will be 65 or older by 2030, up from 12.8% now, and if intensive care remains the norm, costs will continue to balloon, while the elderly and the terminally ill will continue to suffer—as will their doctors standing witness to that pain.

“My goal is to prolong life—not prolong the dying process,” says Periyakoil. “We have to fix this.”

TIME Books

A Guide to Maya Angelou’s Most Beloved Books

Maya Angelou Signs Copies of "Maya Angelou: Letter to My Daughter" - October 30, 2008
Poet and Author Maya Angelou signs copies of "Maya Angelou: Letter to My Daughter" at Barnes & Noble in Union Square on October 30, 2008 in New York City. Jemal Countess--WireImage

The prolific poet and author passed away on May 28, 2014 at the age of 86. A look back at her most prominent works

Maya Angelou, who died Wednesday at the age of 86, was known for many things throughout her life: her wisdom, her acting, her indefatigable civil rights activism. But more than anything else, Angelou was famous for her writing. Both a prolific poet and memorist, Angelou penned more than two dozens books and collections throughout her life (including two cookbooks).

Despite the scale of her oeuvre, much of her work deals with reoccuring themes: love, heartbreak, family, race and feminism. Her books were critically-acclaimed and adored by many readers; here are some of the most notable works.

I Know Why the Caged Bird Sings (1969)

The first of seven autobiographical works, I Know Why the Caged Bird Sings is Angelou’s most famous and critically acclaimed book. The story spans much of her childhood, following young Maya and her older brother as they bounce from their parents’ home to their grandmother’s and back again. Throughout the memoir, Angelou struggles not only with feelings of chronic displacement but also her experiences with racism, molestation and rape. Nominated for the National Book Award and named one of the All-TIME Best 100 Non-Fiction works (by this writer), Caged Bird was a revolutionary account of what it meant to be young, female and black in America.

Just Give Me a Cool Drink of Water ‘fore I Diiie (1971)

Angelou’s first collected work of poetry, Just Give was written largely before her first memoir was published, with many of the poems originating as song lyrics. (Angelou worked as a nightclub singer in her twenties.) The book is divided into two sections: Where Love Is a Scream of Anguish features poems about love, while Just Before the World Ends features poems about surviving as an African-American in a white society. The collection became a best-seller and was nominated for the Pulitzer Prize in 1972.

The Heart of a Woman (1981)

For her fourth memoir, Angelou recounts her life from the years 1957 to 1962, where she leaves California with her son, Guy, to move to New York. She finds herself amongst other black artists and writers, reading her work at the Harlem Writers Guild, and taking part in the civil rights movement. She also recounts falling in love with a South African freedom fighter, which led her to travel to London and Cairo, though ultimately the memoir isn’t about relationships — it’s about “a voyage into the self.” The book was praised by critics and — 16 years after it was first published — Oprah Winfrey selected Heart as an Oprah’s Book Club selection, which put it on the best-sellers list.

Wouldn’t Take Nothing for My Journey Now (1993)

The first of three essay collections, Wouldn’t Take Nothing is a collection of autobiographical pieces and homilies that Angelou was reportedly encouraged to write by her friend Oprah Winfrey. Together with her second collection of essays, Even the Stars Look Lonesome, which was published four years later, the essay collections were dubbed “Angelou’s wisdom books” in the New Yorker by Hilton Als.

Mom & Me & Mom (2013)

What would become Angelou’s final book was both her seventh memoir and the only work where she focuses on her relationship with her mother. Mom recounts much of the material found in Angelou’s earlier memoirs, but hones in on her mother’s role in the events of her life. Chronicling her mother’s abandonment of Angelou as a young child, the memoir also covers their reunion and reconciliation. The book ends with the death of her mother, along with Angelou’s final words to her: “You were a terrible mother of small children, but there has never been anyone greater than you as a mother of a young adult.”

TIME Companies

What Dog Owners Need to Know About China’s Pet Jerky Treats

Worried about your dog? Here are the warning signs

With more than 1,000 canine deaths reported in connection with Chinese jerky treats and Petco’s decision to withdraw all pet treats made in China from shelves by the end of 2014, pet owners may have reason to worry — especially if they’ve been feeding their dogs or cats imported foods.

TIME’s Bryan Walsh explains which symptoms pet owners should watch out for and why pet food regulations may be difficult to improve.


These Are The 5 Most Lethal States for Pedestrians

Fueled By Consumer Spending, Economy Grew At 3.2 Percent In 1st Quarter
A woman with shopping bags traverses a crosswalk near Columbus Circle April 30, 2010 in New York, New York. Chris Hondros—Getty Images

Read this, Floridians

A new study warns of a nationwide “epidemic” of pedestrian fatalities concentrated in states that aren’t exactly known for their bustling crosswalks.

Researchers at the National Complete Streets Coalition crunched the numbers on 47,025 pedestrian deaths over the last 10 years—a number that exceeds deaths from natural disasters sixteen times over, the study notes.

States with dense urban populations and heavy concentrations of walkers, including Washington D.C., New York and Massachusetts, skewed on the safe side of the study’s “Pedestrian Danger Index,” a measure of deaths relative to the number of people walking the streets.

The real danger zones are down south in the car-centric urban tracts of Florida, Alabama and Louisiana. In short, these states weren’t made for walking.

Source: National Complete Streets Coalition

Orlando, Florida topped the list of most hazardous cities with 583 pedestrian deaths and a danger index four times above the national average. Tampa, Jacksonville and Miami came in 2nd, 3rd and 4th respectively among the most dangerous cities.

The study also found that elderly pedestrians accounted for one in five fatalities, suggesting that Florida’s urban planners should neither be singled out for blame nor let off the hook. And perhaps they should pay a visit to these 5 pedestrian-friendly states:

Florida and 5 States
Source: National Complete Streets Coalition

The study’s authors advocated for reductions in speed limits and clearer delimitations between car lanes, bike lanes and crosswalks to combat an “epidemic” of pedestrian deaths, averaging 5,000 a year.

“Not only is that number simply too high,” said Roger Millar, Director of the National Complete Streets Coalition, “but these deaths are easily prevented through policy, design, and practice.”


New Access To Experimental Drugs For Terminally Ill Patients

The Right to Try act in Colorado will help very sick people get access to some drugs before they're approved by FDA

Very sick people in Colorado have new options as of this past weekend. A state law passed on Saturday gives terminally ill patients the ability to seek experimental treatments that have yet to be approved by the U.S. Food and Drug Administration. And with FDA approval averaging 11 to 14 years for a new drug, skipping the wait could mean a lot for someone who has only months to live.

The “Right to Try Act”—the very first to pass in the U.S.—was signed into law by Colorado’s governor after passing the state legislature unanimously. Similar bills are coming up for approval in Arizona, Louisiana, and Missouri. Each bill would allow patients, in partnership with their physicians, to request experimental medications that are still being tested.

“This is such a paradigm shift for how we approach terminally ill patients’ access to medication in this country,” says Lucy Caldwell, communications director for the conservative public policy and advocacy organization Goldwater Institute, which is behind the current bills.

More from Prevention: Alternatives For The Top 10 Prescribed Medications

Nationwide, people with a terminal illness for which available treatments aren’t working can seek a Compassionate Use Exemption to be included in a clinical trial of a drug or procedure that might help them. Of the 550 requests the FDA received for such exceptions during the 2013 fiscal year, all were approved. “The FDA is strongly supportive of the appropriate use of expanded access,” says Sandy Walsh, a spokesperson for the agency. But many complain that the process is long and mired in paperwork. The new law would allow terminally ill Colorado patients to request treatments without any special exemptions or enrollment in a trial.

Critics of the legislation note that the FDA approval process exists to protect patients from harm, and that true “miracle” drugs are few and far between. Colorado patients will have access to drugs that have passed “Phase 1″—known as the safety phase—of clinical trials. The treatments need not have passed subsequent tests to show whether they are effective or safe in a larger population.

More from Prevention: 20 Ways To Lower Your Cancer Risk

Some 30% of drugs that begin the approval process pass the first phase of clinical trials (which usually include a very small numbers of patients—often between 20 and 80). But only 8% ultimately win approval, and far fewer are truly lifesaving. Some critics worry that opening up unapproved drugs for use will undermine the standards and safeguards the government has put in place to keep patients from needless suffering.

“The FDA has not taken a position on any particular ‘Right to Try’ bill,” says Walsh. “However, the agency is concerned with any efforts that would be inconsistent with its Congressionally mandated authority to protect the public from therapies that are not safe and effective.”

In Colorado, drug companies are under no obligation to provide the drugs, and patients may have to pay for them out of pocket.

“We don’t know what the level of efficacy is going to be—that’s where they’re rolling the dice,” Caldwell says of people who might request experimental drugs. But she notes that for terminally ill patients, side effects might be of little concern: “There’s a side effect that’s certain if I don’t take this drug,” she says. “And that’s death.”

More from Prevention: Measles Vaccine Cures Woman Of Cancer

The article was written by Katherine Harmon Courage and originally appeared on Prevention.com



TIME remembrance

H.R. Giger, Creator Of The Perfect Movie Monster, Dead at 74

H. R. Giger
Visual artist H. R. Giger taking off face mask. Dana Frank—Time & Life Pictures/Getty Images

The Swiss artist created the designs for the hissing, acid-blooded xenomorph in Ridley Scott's haunting "Alien"

Swiss artist H.R. Giger, who haunted movie goers by creating Ridley Scott’s Alien, died Monday at the age of 74. A representative from his museum told the Associated Pressthat he died from injuries sustained from a fall.

Giger was born in Chur, Switzerland in 1940 and became famous for creating nightmarish landscapes and surreal creatures in Hollywood science fiction films. The sculptor, artist, and set designer began working in movies in 1975 on Alejandro Jodorowsky’s uncompleted Dune remake, but came to prominence with the creation of the nightmarish creature in Alien (1979).Ridley Scott was inspired by Giger’s book Necronomicon and hired the artist to work on the film. He later went on to work on films including Poltergeist II and Species.

Here Giger is with his alien progeny:

He won an Academy Award for Best Achievement for Visual Effects for Alien and was named into the Science Fiction and Fantasy hall of Fame in 2013:


Giger’s work lived beyond the screen:

Switzerland Obit Giger
Swiss artist H.R. Giger poses with two of his works at the art museum in Chur, Switzerland. AP

He even created monstrous microphone stands for the band Korn:

Korn Perform in Manchester
Korn in Manchester, England. Shirlaine Forrest—Getty Images

Details on survivors and funeral arrangements haven’t yet been released.


TIME relationships

Who Knew? Husbands Can Be Nagged to Death

Frederic Cirou—Getty Images/PhotoAlto

Danish research suggests a demanding spouse and whiny kids can send a person to an early grave--and that men are more vulnerable than women

A new study suggests that being needled by or arguing a lot with spouses, neighbors or relatives can shorten a person’s life. And that men, particularly those who are unemployed, are especially susceptible.

The research, published online in published online in the Journal of Epidemiology & Community Health, asked almost 10,000 Danish men and women aged 36 to 52 about their daily social interactions. The researchers were pretty nosy, asking participants two main questions: “In your everyday life, do you experience that any of the following people demand too much of you or seriously worry you?’ and “In your everyday life, do you experience conflicts with any of the following people?” participants could choose friends, neighbors, partners, extended family or children.

Nine percent of the participants reported always or often experiencing demands or worries from their partner, 10% from children, 6% from family and 2% from friends. And 6% always or often experienced conflicts with their partner, 6% with their children, 2% with their family and 1% with friends.

In the course of the 11 years that the Danes were followed, 4% of the women and 6% of the men died, mostly of cancer, but also of the usual life-ending maladies: heart disease, liver disease from drinking, or accidents and suicide. And even after taking into account such factors as gender, marital status, long term conditions, depressive symptoms, available emotional support, and social class (defined by job title), the researchers determined that those who were frequently worried by or had demands placed on them by partners and/or children had a 50%-100% higher risk of early mortality than those who lived more peaceable lives.

“In this study, we found that men were especially vulnerable to frequent worries/demands from their partner, contradicting earlier findings suggesting that women were more vulnerable to stressful social relations,” write the authors, Rikke Lund, Ulla Christensen, Charlotte Juul Nilsson, Margit Kriegbaum, and Naja Hulvej Rod, all of the University of Copenhagen, Denmark.

They added that their findings were in line with other studies that found that men respond to stress with higher levels of cortisol, which may louse up their health. Only demanding spouses and children seemed to have this life-threatening effect on people. Annoying neighbors and in-laws, not so much.

Frequent arguments also led to a greater likelihood of dropping early from the mortal coil, but the data suggested that conflict was an equal opportunity grim reaper: both men and women were affected the same and it didn’t much matter who the arguments were with.

Because those who were both unemployed and involved in the most arguments had the highest risk of premature death, the researchers acknowledged that some of these effects could be attributed to differential vulnerability, that is, that people with fewer resources are less able to deal with stresses than more wealthy people can.

They recommend that social services providers teach skills in handling worries and demands as well as conflict management within couples and families.

TIME health

The Medieval Black Death Made You Healthier—If You Survived

Plague killed millions in Europe
The Black Death killed as much as half of Europe's population Photo by Science & Society Picture Library/SSPL/Getty Images

The plague was horrific, could hit without warning and killed tens of millions in 14th century Europe. But paradoxically, the population that survived ended up better off, with higher wages, cleaner living conditions and healthier food

Game of Thrones doesn’t tell you the half of it. Life during the medieval ages was nasty, brutish and short. That was especially true during what became known as the Black Death. The widespread outbreak of plague struck between 1347 and 1351, killing tens of millions of people, resulting in the loss of 30 to 50% of the region’s population. The disease itself was horrific. “In men and women alive,” wrote the Italian poet Giovanni Boccaccio, “at the beginning of the malady, certain swellings, either on the groin or under the armpits…waxed to the bigness of a common apple, others to the size of an egg, some more and some less, and these the vulgar named plague-boils.” And it seemed to strike indiscriminately and without warning. People could be healthy in the morning and dead by evening.

The upside, if you can call it that, is that the plaque left in its wake populations that were healthier and more robust than people who existed before the plague struck, according to a new study published today in PLOS ONE. “The Black Death was a selective killer,” says Sharon DeWitte, a biological anthropologist at the University of South Carolina and the author of the paper. “And after the Black Death ended, there was actually an improvement in the standard of living.” The plague was natural selection in action.

In a way, that’s a marker of how brutal the medieval era was. It took a serial killer of a plague to actually bring about an improvement in living conditions. If that sounds counterintuitive, think about how life might have changed after half of Europe’s population died off. Suddenly there was a dramatic drop in the number of able-bodied adults available to do work, which meant survivors could charge more for their labor. At the same time, fewer people meant a decreased demand for foods, goods and housing—and as a result, the prices for all three dropped. By the late 15th century, real wages were three times higher than they were at the beginning of the 14th century, before the plague struck. Diets improved as employers were forced to raise wages and offer extra food and clothing to attract workers. As a result, the money spent per capita on food in the wake of the Black Death actually increased. “People were able to eat more meat and high-quality bread, which in turn would have improved health,” says DeWitte.

But the clearest evidence that people were healthier after the Black Death than they were before it comes in the bodies themselves. DeWitte looked at skeletal samples taken from medieval cemeteries in London both before the plague and after it. She found that post-Black Death samples had a higher proportion of older adults, and that morality risks were generally lower in the post-Black Death population than before the epidemic. In other words, if you were strong and lucky enough to survive one of the deadliest epidemics in human history, you were probably strong enough to live to a relatively ripe old age. And since the Black Death was so widespread, that was true for the surviving population as a whole.

Earlier studies looking at historical documents like diaries, letters and wills from the time period had shown conflicting results, but that kind of data only covers the very small part of the population that was literate, male and relatively well off. The advantage of DeWitte’s grave-combing bioarchaeological research methods is that they encompass a much more representative swath of the medieval population. “This provides information about the people who are missing from historical documents, including women and children,” says DeWitte. Not everyone in medieval London left a will behind—but everyone left a corpse.

So for survivors, life after the Black Death would have been at least a little less nasty, brutish and short than life before it. But that doesn’t mean the survivors were really the lucky ones. The Black Death was a period of unremitting horror and terror, the likes of which we can’t imagine. No one knew how the disease spread, or how to treat it. Popular but gruesome methods like blood-letting or boil-lancing would have been counterproductive at best, assuming victims could find anyone to treat them. Doctors abandoned their patients for fear of infection, and priests even refused to give last rites to the dying—an appalling dereliction given medieval fears of eternal damnation. Even animals like sheep, cows and pigs fell victim to the disease. “The people who survived the Black Death would have lost everyone they knew,” says DeWitte. “They’re the people I feel sorry for.” If the Black Death really was natural selection at work, it was the cruelest form imaginable.


Jail Where Inmate ‘Baked to Death’ Had Known Heating Problem

Hot Cell Death
Alma Murdough and her daughter Cheryl Warner hold a photo of Murdough's son, Jerome Murdough, at her home in the Queens borough of New York, March 12, 2014. Jason DeCrow—AP

Jerome Murdough, an inmate at Rikers Island, was found in a pool of blood and vomit in an overheated cell one day after employees prepared multiple requests to fix the heating problem

Jail authorities knew of an heating problem and requested repairs one day before a mentally-ill inmate died in an overheated cell, though the repairs were delayed because of a long weekend.

According to the Associated Press, two repair requests prepared on Friday, Feb. 14 weren’t received until the following Tuesday because the maintenance department does not process work orders on weekends and because that Monday, President’s Day, was a federal holiday.

Jerome Murdough, a 56-year-old former Marine, was arrested one week before his death for trespassing onto a Harlem public housing project while seeking warm shelter from a cold night. Four hours after his body was found in a pool of blood and vomit in a Rikers Island jail cell, his internal temperature was 103 degrees.

A spokesperson did return the AP’s request for comment.

In March, one of four anonymous jail officials interviewed by AP said that Murdough “basically baked to death,” though the medical examiner’s office have not yet determined an official cause of death.

The interviewed officials said Murdough was on anti-seizure and anti-psychotic medication, which may have made the inmates especially vulnerable to heat, and that he did not open a vent in his cell to cool down, as others in the jail did.


TIME Oklahoma

Inside Oklahoma’s Botched Execution

After he'd been declared unconscious, Oklahoma inmate Clayton Lockett twitched and gasped and said "something's wrong," before dying of a heart attack. The disorderly execution reignited the debate on states' ability to administer lethal injections that meet the U.S. constitutional laws

This week, Oklahoma death row inmate Clayton Lockett died following a 43-minute long execution gone awry. Exactly what happened during 25 of those 43 minutes is known only to the prison officials inside the execution chamber, as Lockett’s attorneys were told to leave the viewing room.

While authorities have released a timeline of his execution, many questions remain unanswered on exactly what went wrong in Lockett’s execution, the latest in a series of lethal injection executions that have not gone as planned. The United Nations human rights office in Geneva said on Friday that the process to which Clayton Lockett was subjected may have amounted to “cruel, inhuman and degrading treatment” under international human rights law, and may have violated the US constitution.

Lockett’s case has fueled a renewed debate around the use of lethal injection in the United States — since a number of executions have gone awry after states began experimenting with different drug combinations.

Watch TIME’s Josh Sanburn in the video above talk about what we know — and what we don’t know — about Lockett’s execution, and what that says about the state of the death penalty carried out by lethal injection in the United States.





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