Reflections on death and dying.

Americans simultaneously worry about dying and about being tethered to machines that keep them alive beyond a point when life has any meaning. People living with terminal illness often feel isolated from life around them and a burden on those they love; they feel uncertain that their deaths will be relatively free of pain and suffering and that their dignity will be compromised as little as possible. These failings can be remedied. Traditional hospice care and integrating palliative care into the general medical setting are important, but they cannot alone occasion a better dying. The medical community must re-imagine dying and reflect about ways to transform image into reality in practice and in training colleagues and successors. Physicians and others know how to provide care and even improve living when cure is unlikely; the harder task is to respect such care as profoundly as curing. The exigencies of modern medicine, where time is a budgetable commodity, makes caring well for dying patients difficult. Medicine cannot have hegemony over dying and cannot singularly offer people a better death, but it cannot absent itself either. The almost single-minded focus on decision making that has infused conversations about dying and death may divert attention from the attentiveness and loving relationships that are as vital as life's end as at its beginning. Medicine has "colonized" death: It has transformed it into a place where progress in staving it off may appear to be unlimited, and thus it encourages forgetting that death is part of the human condition. The task before medicine, and academic medicine in particular, is to transform death back into a human scale. With all that is available to delay death--but not to make it optional--the most important task is to recover humbleness before an awesome moment and be with the patient, one human being to another, knowing that dying is not always open to solutions.