Hospital intensive care units have changed when and how we die--and not always for the better.The ICU is a new world, one in which once-fatal diseases can be cured and medical treatments greatly enhance our chances of full recovery. But, paradoxically, these places of physical healing can exact a terrible toll, and by focusing on technology rather than humanity, they too often rob the dying of their dignity. By some accounts, the expensive medical treatments provided in ICUs also threaten to bankrupt the nation.In an attempt to give patients a voice in the ICU when they might not otherwise have one, the living will was introduced in 1969, in response to several notorious cases. These documents were meant to keep physicians from ignoring patients' and families' wishes in stressful situations. Unfortunately, despite their aspirations, living wills contain static statements about hypothetical preferences that rarely apply in practice. And they created a process that isn't faithful to who we are as human beings. Further confusing difficult and painful situations, living wills leave patients with the impression that actual communication with their physicians has taken place, when in fact their deepest desires and values remain unaddressed.In this provocative and empathetic book, medical researcher and ICU physician Samuel Morris Brown uses stories from his clinical practice to outline a new way of thinking about life-threatening illness. Brown's approach acknowledges the conflicting emotions we have when talking about the possibility of death and proposes strategies by which patients, their families, and medical practitioners can better address human needs before, during, and after serious illness.Arguing that any solution to the problems of the inhumanity of intensive care must take advantage of new research on the ways human beings process information and make choices, Brown imagines a truly humane ICU. His manifesto for reform advocates wholeness and healing for people facing life-threatening illness.

Table of ContentsAcknowledgmentsIntroductionSECTION ONE: PASTChapter 1. A Culture in CrisisHistorical Death Culture and the Dying of DeathLife Support and the Miracles of ResuscitationThe Rise of Intensive Care and "Life Support"Life in the 1960sChapter 2. The Rise of the Living WillThe Findings of the CourtLegislationDisclosurism and a Focus on ProceduresImproving enforcementFutility, Financial Disaster, and Obligations to SocietyExpanding horizonsChapter 3: Empirical and Ethical Problems with Living WillsConceptual Problems with Living WillsPig Iron under Water: Living Wills Don't Apply in Real LifeParadoxical Threats to Autonomy"If I'm ever like that, let me die": Disability StigmaThe Limits of Prediction Make Living Wills Difficult to UseProblems of raceLiving Wills Can BackfireEmpirical evidence that Living Wills Don't WorkSECTION TWO: PRESENTChapter 4. Living Wills Don't Make Decisions; Human Beings DoThinking like a Human BeingWhat your Brain Doesn't Know Might Kill YouAffective forecasting and psychological adaptationThings that Go Bump in the NightMoral DistressMoral HazardsChoosing to SeeChapter 5. The Barbaric Life of the ICUBarbarism and BrutalityThe Experience of the VentilatorImmobilizationTubes and more tubesThe Brain under SiegeTerrible CommunicationWe Don't Always Know What We WantDeforming Death in the Rush to RescueChapter 6. Life after the ICUA Few Visionary ResearchersThe Post-Intensive Care SyndromeBodiesMusclesLungsBrainsPsychesIs It All Worth It?The Tension between Outcomes Research and Advance DirectivesSECTION THREE: FUTUREChapter 7. Reform: The Current State of the ArtEliciting Values and WishesRegistration Drives for Advance Directives in WisconsinMultimedia PersuasionTailoring Advance Care PlanningDecision AidsChoice ArchitectureThe Science of CommunicationThe Conversation ProjectRedesigning the ICUChapter 8. Healing the Intensive Care UnitLet Families InFixing Code StatusHope for the Best, Prepare for the WorstWrapping UpRecognize the CrossroadsCreate a Support CommunityCreate Space for Facilitated FarewellsChange the Framing to Manage Clinicians' Moral DistressChanging Culture outside MedicineNot Left UnsaidAuthentic PersonalizationA Possible Map: Five Approaches to the ICUApproach 1: Do EverythingApproach 2: Be Aggressive Only if I Have a Reasonable Chance of RecoveryApproach 3: Only Admit Me to the ICU if I Have an Excellent Chance of RecoveryApproach 4: Don't Admit Me to the ICUApproach 5: Don't Admit Me to a Hospital; Focus Only on My ComfortEpilogue. What Should We Do in the Meanwhile?