End Of Life Care In America, A Doctor's Diagnosis Author, doctor and bioethicist Robert Martensen has treated an estimated 75,000 patients in the emergency room and the ICU. In his new book, A Life Worth Living Martensen presents case studies that illustrate the problems and complexities of American health care system
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End Of Life Care In America, A Doctor's Diagnosis

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End Of Life Care In America, A Doctor's Diagnosis

End Of Life Care In America, A Doctor's Diagnosis

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This is FRESH AIR. I'm Terry Gross.

Most Americans die in hospitals these days, and often their dying does not go well. Dr. Robert Martensen makes that observation in his new book, "A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era."

His book is about what he describes as some troubling aspects of what's become a biomedical industrial complex. If you've had to make difficult medical treatment decisions or have watched friends or relatives die in a hospital, you'll recognize the issues he's addressing.

The book is based on his 25 years of experience as an emergency-room physician and his work as a bioethicist and his research into the history of medicine. One chapter is devoted to the death of his father.

Dr. Martensen has also been a professor of the history of medicine at Harvard, Tulane and the University of Kansas. He's now at the National Institutes of Health, where he directs the museum and the office of history.

Dr. Robert Martensen, welcome to FRESH AIR.

As you say in your book, most Americans die in hospitals these days, and often, their dying does not go well.

You say compared to those in other countries, older Americans dying in hospitals in America experience an extended and agonizing process. What's different about American health care that makes the process of death more drawn out and agonizing here?

Dr. ROBERT MARTENSEN (Author, "A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era"): A couple things are different. I think particularly in hospitals what's different in American hospitals is that advanced technologies, aggressive interventions, keep getting applied to patients and literally applied right up until the body can no longer respond.

And the default in regulation in the United States, is one must keep doing things unless the patient or the patient's surrogate tells you in advance not to do things. That applies from infants to the very old, and it means that when one dies in a hospital, unless one has spelled things out in advance and the hospital knows it - there's often a slippage between indicating it and having the hospital actually know it, the people in the hospital - things keep happening.

Patients are put on ventilators. Cardiopulmonary resuscitations happen. Aggressive interventions with drugs occur. This doesn't occur much in other countries, both for policy reasons and for just operational reasons.

GROSS: Well, I want to say I've seen this happen with older relatives when they approach death. I mean that the heart was going, so there was heart surgery. There was cancer. There was surgery to remove that. And then the kidneys started to go. There were interventions for that, and an infection, antibiotics for that.

And, like, every single system seemed to be shutting down, and every system required an intervention, and it ended in death and, I have to say in a couple of instances, no real quality of life in between.

Dr. MARTENSEN: People spend their last six, eight weeks, sometimes months, in this agonizing shuttle between hospital, having things done, skilled nursing facility. They get tuned up. As soon as they're tuned up in the hospital, they're discharged to skilled nursing, sometimes to home with skilled nurses.

Things deteriorate. They're back in the hospital. And as you say, yes. One organ system after another is gradually or precipitously failing, and specialists are convened, and specialists work on the organ system, and things keep getting done.

Nobody stands back and says this patient is dying. Nobody says it to the family. Nobody says it to the patient if the patient is responsive. Things just keep getting done.

And the result is that, I think, we who are doing these treatments are causing great suffering. So there are structural problems in the system, and the result is that the patient who doesn't want any more aggressive treatment, who just wants comfort care, can feel very frustrated.

And I'm going through it. I'm in Santa Cruz to spend time with my mom, who's in her 91st year and at that point in her life. So it's very real for me, and I was with her this morning before coming here to talk with you.

GROSS: Is she dying? Are you saying she's dying?

Dr. MARTENSEN: I think she will be dying in the next few days to the next two weeks. She has said - and she was - to give you a little background, my mom was living on her own until the end of January. She had a woman who comes in to help her three or four hours a day, drives her around, and my mother stopped working when she was 85, working in an antique store.

But now my mother has - will say to us, said to me yesterday, I don't know who I am. I don't know who you are. I don't know where I am. I can't remember anything for more than 10 minutes. I do not want this. Why is it so hard to let go?

GROSS: And did she mean why is it so hard for her to let go or for the staff to let her go?

Dr. MARTENSEN: For the staff to let her go. Why is it so hard to just not let me die?

GROSS: Does she have a medical directive that says - that would allow her to assert her wishes with that?

Dr. MARTENSEN: Yes, she's had a medical directive for years. She had breast cancer, fortunately not a very aggressive tumor, in her 60s, had it removed and has done splendidly, and that's been her only real medical problem, that and some arthritis.

And so yes, she had a directive, and everybody at the nursing place knows about it. Her physician knows about it, and they're trying to follow it, and I think hospice care was started a couple weeks ago, and I think my mom is - mostly now we just hold her hand, and sometimes she's aware, and sometimes she isn't.

GROSS: Did you help her or her doctors make any medical decisions?

Dr. MARTENSEN: Yes I did. I was - this happened in February. I was actually up in the mountains skiing for a couple days, and I got a cell phone call, and it was from her doctor, saying your mom has a heart block. Should we put in a pacemaker?

And a couple things happened. My medical side - this is a common problem for emergency physicians. So it was what does the EKG show? What degree of heart block? There are degrees, one, two and three. Is there an underlying event? Has she had a heart attack, which you can often tell by looking at an EKG, an electrocardiogram, or perhaps does she not have enough, the appropriate amount of fluid, which also can cause that.

And the issue with her was fluid, but I'll tell you how it felt, and how it felt, first I was astonished to get this call because I was up at about 11,000 feet, and it was snowing heavily.

The other side of it was I thought, you know, I'm used to this. I spent 30 years dealing with these kinds of problems, and because in part my mom had been very clear in her written instructions - I do not want this, I do not want that. If my mental function does not, you know, a recovery is not likely. And she'd also given my older brother and me durable power of attorney for health care.

So we had been very clear with her physicians not to do this. Nonetheless, the physician being conscientious, called. So there was this knowledge that I had, but there was also this experience of being her son and this - you need to make a decision. You need to make a decision.

And my sense was, wow, what do ordinary people, people without medical training, how do they experience this when they're presented with it's your choice. Should we do this? Should we not do that? Should we do this? Should we not do that? It's just got to be absolutely daunting for the families to go through.

GROSS: Now, he knew that you were a doctor, I assume, but had you not been a doctor…

Dr. MARTENSEN: Yes, he did.

GROSS: Yeah, do you think that there are things he should have told you that he didn't - about her condition, about her dementia, about the likelihood of her ever returning to a quality of life that she'd consider a life?

Dr. MARTENSEN: Yes. Had he not - had I not been a doctor, he would have recommended doing the temporary pacemaker and perhaps then a permanent pacemaker because although he said he agreed with the comfort-care approach my mother wants, and which she'd authorized, in practice it turns out he really believes that one should live as long as possible.

My mother is since under the care of another physician with a philosophy more compatible with her approach, but that particular physician, who was very attentive, very conscientious, nonetheless for him, if you can do something that extends physiological function, how one's body works, you do it, and he never told me or discussed with any of us, perhaps because he knew I was a doc, he never went into what this meant.

And so I wondered how he would be. At the time I wondered. Well, fortunately for mom, I have this medical experience. Had I not, what would, you know - people would be flying blind. They would be asked to make decisions without adequate understanding.

GROSS: And you know what, putting in a pacemaker doesn't sound like a major intervention. It's not like coronary bypass surgery or removing a lung or something like that.

It's - I think, from the little I know about medicine, it's a relatively easy and safe procedure. So it's easy to feel, like, well why not do that? Why not take that step?

Dr. MARTENSEN: Particularly for somebody - fortunately my mom's hearts and lungs and kidneys had been functioning reasonably well, although nothing is - you know, there's always a significant risk in somebody who's in her 91st year.

But yes, it could be viewed as not quite benign but not major invasive surgery, and therefore, why shouldn't we do it? Her heart will function better? But it would do nothing for her - what matters to my mother - which is her mind.

GROSS: So you told them no?

Dr. MARTENSEN: Absolutely. I said there's no - first of all, what I said was I want to know the cause. Number two, have you considered trying some fluids, modestly, and see if mother's pulse picks up?

So I wanted a diagnosis, I wanted a modest treatment, a safe treatment, and then I said let's talk again. So they called back. They'd given fluids. My mother's pulse and blood pressure had recovered. Her EKG, a repeat EKG, didn't show a heart attack, neither did the blood measurements of heart muscle function.

And so it became a kind of moot issue. But initially my response was - wait a minute. Just slow down. Slow down because I felt like you're in - you know, a freight train coming at you.

GROSS: Well, but that's the thing. If you weren't a doctor, like if this were me, and I got that call, I probably would've said go ahead, do the pacemaker. I mean, I wouldn't have said oh, did you try fluids? Did you do - I mean, how do I know that?

Dr. MARTENSEN: You don't want to be second-guessing the…

GROSS: Well, I wouldn't even know to make that guess. I mean, I'm just - I'm not a doctor.


GROSS: Which is exactly your point that if you're not a doctor, you in an absolutely impossible situation when you parent is elderly, or a loved one is elderly, and you have to make these sudden decision of whether to proceed with something or not.

Dr. MARTENSEN: Because things happen precipitously. Decline happens. An event -something bad happens, and there's a treatment for it. So one feels as though, to use another kind of analogy, you feel as though, although it happens sudden, and it's like a bad roller-coaster ride, you know, you're pushing against this pressure to have things done.

And one has to be insistent. I mean, we finally asked another physician to take over. And it happened gracefully, but one has to insist because the American system is set up to keep doing these things.

Now, the science behind doing them, by the way, is - either doesn't exist, meaning there's a vast array of ignorance about how these treatments work in very elderly people, people for whom the treatments were never developed for, never tested on. There's just a huge amount of ignorance. Nonetheless, they are offered.

And of course, they are compensated. Talking with somebody about what they wish the end of their life to be like, I can spend an hour and a half talking with the patient and a patient's family. When the patient learns they have a life-threatening diagnosis or life-limiting diagnosis, we can spend an hour and a half or two hours together, which is perfectly appropriate. It's the way to go, I think, to find out what matters to them - relevant medical history, do a physical exam, etcetera.

In New York State, Medicaid pays $18 for that service.


Dr. MARTENSEN: If, on the other hand, I said with the patient, you know, you have this problem, we think. You know, it looks like it's a Stage Two Adenocarcinoma of the lung, and today we're going to be doing a lot of tests. Spent 15 minutes with the patient, did tests, maybe did a procedure myself, the procedure would be well compensated.

But my time to listen, that is not compensated and yet that makes all the difference in what people experience as they're navigating this very daunting set of circumstances.

GROSS: My guest is ER physician, bioethicist and medical historian Dr. Robert Martensen. His new book is called "A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era." We'll talk more after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: If you're just joining us, my guest is Dr. Robert Martensen, and he was an emergency room physician for many years and is now the director of the museum and the office of history at the National Institutes of Health in Washington.

He has a new book that's part medical history, part medical analysis, part memoir. It's called "A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era."

We've been talking about your mother, who is dying now, and you're visiting her on the West Coast, but you live on the East Coast. And you're going through what many of us have gone through and what many people will go through, which is that loved one, who lives thousands or hundreds of miles away and who's dying, and you have to decide what your commitment is to stay there versus what commitments you need to keep in your home - to your family, to your job, to whatever else you're committed to.

And I mean, one typical thing that happens is that, you know, you fly out, you make what you think is going to be that final visit. You make your peace with the fact that you're losing this person. You say your goodbyes, you fly back home - and then the person rallies.

You know? And then you'll be coming back for a week or two. And then you wonder, like, should I fly back out, should I wait? And you get into this bizarre dilemma of what to do. And it's so expensive to fly out, too. Have you been in that cycle yet, of not…?

Dr. MARTENSEN: Yes, yes.

GROSS: Can you talk about that a little bit?

Dr. MARTENSEN: Well, this is my fourth trip.

GROSS: Okay, you're there.

(Soundbite of laughter)

Dr. MARTENSEN: Back and forth to Santa Cruz, California, from Washington, D.C., where I live - since late January. So I have been there, and there is - certainly, there's a kind of anticipatory grief that goes along with it.

You know, my mother is alive. I saw her, you know, an hour ago. I'm going to be seeing her after we stop talking today. Will I be out here at the moment she passes on? I don't know.

So there's that. And it's this business at the very end of life is messy. If my mother were dying of a disease she had earlier in her life but then was cured, breast cancer, if she were dying of that, it's a fairly predictable trajectory, and I would just be staying here.

Physiologically, she has some other problems that make the actual event or process that would end her life difficult to predict. So she can rally. She's had a couple infections. She has rallied in the sense those problems are not problems right now, but we treated them because - particularly the first one because we thought she might recover her mental function, which is what she really treasures. That's not going to happen.

So over the last two weeks, my brother and I, with my mother's prior approval, have elected hospice care. So now we are not going to be treating infections and assuring everything that can be done for her comfort, which we were trying to do earlier.

But your point, yes, this end-of-life scenario, when people are remote geographically from each other, is just a very strange zone of life both for the patient and for the child, in my case, or the close person or the caregiver, because it's a kind of suspended animation for the patient and for us.

GROSS: Just another thing about your mother's condition. Your mother always made it clear her mind was the most important thing, and she didn't want to continue living if she had lost her mind, if she was living with dementia, if she'd lost her memory.

But you always wonder, at least I do, that's what you say when you have your memory. That's what you say when you're cognizant, but maybe when you've lost your memory, maybe when you no longer know who you are, there are still some things that give you pleasure, although in this case, your mother said that there weren't.

Your mother said why can't they just let me go. But just because somebody said before they were sick that they didn't want to live if they had dementia doesn't mean that they feel the same way with the dementia.

Dr. MARTENSEN: No that's true, and I have another woman I've been close to, a neighbor whose family I was very close to, who's also my mother's age. She's 91. She's very demented. She's been living in assisted living for over a year.

She's always had a great sense of humor. She's very jokey, she's very flirty. She's a widow. She can't remember anything, but she still has the function to make wisecracks. And she can kind of joke with the nurses, and she has - there's a gentleman living down the hall from her. What they like to do is sit and hold hands.

Now I don't know - I won't mention her name on air. I don't know if she wishes to stay alive or not, but her daily life, as she says she experiences it - a daughter lives nearby and sees her every day - is she's content. And her life for her and for her family is - you know, has a richness to it, and yet the level of dementia is about the same.

GROSS: Dr. Robert Martensen will be back in the second half of the show. His new book is called "A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era." I'm Terry Gross, and this is FRESH AIR.

(Soundbite of music)

GROSS: This is FRESH AIR. I'm Terry Gross back with Dr. Robert Martensen, author of the new book "A Life Worth Living: A Doctor's Reflection on Illness in a High-Tech Era." He was an emergency room physician for 25 years. He is also a bioethicist and has been a professor of medical history at Harvard, Tulane, and the University of Kansas. He is currently at the National Institutes of Health directing the museum and office of history.

There is a chapter in your new book, "A Life Worth Living," that's devoted to your father's death, and your father had what you would describe as a relatively good hospital death as opposed to the kind of hospital death that is just too awful to describe. And your father had a kind of condition where his lungs couldn't really pass on oxygen into the blood, so he was having great deal of difficulty with his breathing and then also the infection spread to his blood, so he was septic. So you know, you and your family were faced with the decision of what to do and how to do it.

And you agreed to let your father go. He had a medical directive that said he didn't want to be resuscitated. And if he didn't have the medical directive, he probably would have been put on a ventilator and that would have led to what you would describe as the really bad version of the hospital death. Why are you relieved that he didn't go the ventilator route?

Dr. MARTENSEN: Because the ventilator, the ventilators were developed to bridge difficult situations: somebody has a traumatic injury; somebody has an infection, their lungs are not functioning; somebody is recovering from surgery and their lungs are not functioning. You put them on a ventilator - the intention was this is bridging, this will get them over a difficult patch and allow them to survive. For my dad, who was in his 86th year, who had a progressive deteriorating lung function, he had been doing pretty well till three weeks before he died, then things got worse. And to put him on a ventilator would have just extended that artificial functioning for an indefinite period of time. And a ventilator - your body can't tolerate a ventilator without being heavily sedated, particularly initially. If you have a - imagine something blocking your airway. Well, the brain reflex is so primitive and so powerful, you'll do anything to get it out.

And the way medicine counters that is by initially paralyzing people but then sedating them and giving them pain meds and so forth. That to my father would have been anathema, and it also - from my father's point of view, and I happen to agree with him - would have been to no purpose, because his - he never would have gotten off the ventilator. Instead of dying in two days, he might have died in two weeks or two months later, but he never would have been able to get off the ventilator because he didn't have the lung function.

GROSS: And that extended time would have been a time of great pain and anxiety for him.

Dr. MARTENSEN: Yes. Having catheters in every orifice, needles, drugs so that he could tolerate the ventilator, and it would have been an artificially extended existence, but not a life as my father understood life.

GROSS: Then you had to make the morphine decision. Describe what that decision was.

Dr. MARTENSEN: Well, the decision is: how should one use morphine and opiates in end-of-life situations? Morphine is useful for helping to relieve a sense of air hunger. Morphine is obviously very useful for pain. Opiates are the mainstay of therapy for pain. My dad wasn't having pain, but he was having air hunger. He was getting oxygen but he was still hungry for air and becoming anxious as a result. So to ease that discomfort, his doctor - with my approval - we, or she, was administering morphine so that he was more at ease.

Now, he was still conscious, he could talk with us. So it allowed all the family who were there to each spend time one on one with dad and have a chance to say goodbye. And he was getting morphine, still conscious. We said, you know, dad - I said, dad, you know, this is - life is slipping away. It's - I think it's your time; I'm going to take the oxygen off. And he said thank you, and he died two or three minutes later. So the morphine in and of itself relieved his symptoms. It didn't - the intention was not to end his life prematurely. His life would have ended as soon as the oxygen was taken off, but he would have suffered considerably.

GROSS: Those words, thank you, were probably two of the best words you'd ever heard, because that's such a difficult thing to do, to take the oxygen away knowing he would then only have a couple of minutes left to live.

Dr. MARTENSEN: Yes. I felt gratitude to him for saying that, and an enormous relief. I also have to say, had I or his physician been more aggressive about treatment and kept on the ventilator, or had he gotten on the ventilator somehow and we hadn't been able to stop it - getting somebody off is harder than getting somebody on. Had that continued, I would have felt worse. I would have felt I've done something my father absolutely didn't want.

GROSS: You could have given your father a slightly larger dose of morphine that would have hastened his death by a few minutes, but you wanted to make sure there was time for everybody to say their final goodbyes. That's how you describe it in the book.


GROSS: And then you ask for your family's forgiveness because there was four or five minutes of what appeared to be distress on your father's behalf, but you wanted to reassure your family that he wasn't really suffering. It was just the appearance of suffering, the appearance of - what, choking and…

Dr. MARTENSEN: Well, he had a - it's gruesome. It's gruesome to experience, it's gruesome to describe. He had a death rattle. And that could have been suppressed and maybe we should have done that. Sometimes it can be - one can give a pharmaceutical that may suppress it, is how I should say it. And I've reflected subsequently on that. My father - I wish he had chosen this part of -after he was gone - part differently, but he did not want a funeral, he did not want a memorial service. He didn't - his - he didn't want any of that. So that was the last we would be with him, and that happened. And it's hard to go through. Particularly when you haven't witnessed it.

GROSS: What makes you confident that he wasn't suffering during those last few minutes?

Dr. MARTENSEN: Because his - there was no pulse, his cardiopulmonary function had ceased. It was just his - there was no trace on EKG. He was not responsive. It's a discharge of the brain stem. The lower part of the brain, the more - the handles are primitive reflexes.

GROSS: Uh-huh.

Dr. MARTENSEN: It's a discharge of the brain stem and it - and it happens after the heart ceases function, can happen.

GROSS: My guest is ER physician, bioethicist and medical historian Dr. Robert Martensen. His new book is called "A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era." We'll talk more after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: If you are just joining us, my guest is Dr. Robert Martensen, and he was an emergency room physician, a professor of medicine who's taught medical history. He's a bioethicist and he is also now the director of the National Institute of Health's Office of History and its museum. His new book is called "A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era."

Dr. MARTENSEN: Perhaps I should say, Terry, that I do work for the National Institutes of Health. The views I'm expressing with you are my own and not necessarily those of the NIH or the U.S. government.

GROSS: In your book "A Life Worth Living" you write about illness in high-tech era. As a doctor, and as a son, what would you most like to change about how death is handled in hospitals?

Dr. MARTENSEN: I would like to see - and I'm encouraged because it is starting to happen - is that hospitals and physicians and nurses in them embrace a model of palliative care. And palliative care - it's for people with a whole range of life-threatening diagnoses, and it's not about the final two weeks of life or two days of life. It's about one when learns one has one of these diagnoses, one of these problems, a diagnosis where the disease may shorten life, to start planning from the beginning with the physician, with the physicians a kind of interactive exchange of forming a treatment plan together, so that it isn't just - we can do this, we can do this, and it's not fully discussed - that time is used, and this process of consultation between the patient and the patient's family and the medical team is a regular part of life.

So they are - everybody is - is kept in the loop. It takes time. I would love to see hospitals embrace that, particular the multi-specialty academic medical centers, the kinds of places where I spent most of my medical career. They tend not to do it. The specialists don't provide coordinated care. Nobody seems in charge. The patient just gets one thing done and then another thing done. The actual discussion happens in short bursts of minutes. Nothing is sustained, and the result is that people feel things are just done to them.

And they never have a chance to kind of shape what might help them. And many, many different ways of treating something are possible, and many of the treatments, particularly for very old patients, were never developed for very old patients. So how they work in old patients can be very different from how they work in middle-age patients, the kind of patients who were - the studies were based on.

GROSS: Now, I want to get back to something we were talking about before, which is ventilators and how ventilators were made to be a kind of bridge invention, just tide you over between an event that prevented you from breathing properly back to a period when you can sustain breathing on your own and be healthy again, but that they're often used now at end of life when there is really no chance of recovery, just prolonging life and making it more uncomfortable. As you point out in your book, we call ventilators a form of life support, and you think that that is sometimes an inappropriate word for it. What word would you prefer?

Dr. MARTENSEN: I think in talking with patients, it's important to say we have artificial means that can extend your mother's bodily functions - to somehow get into the conversation that this is artificial and it's about extending bodily functions the way kidney dialysis can extend kidney function, pacemakers can preserve heart function for a time, versus saying what is usually said, what has been said to me with my mom now - if you talk to a family and say, well, do you want us to continue with life support, do you want us to stop life support? - I think the way people hear that, and I think it's perfectly normal, is you are saying, do you want to let mom or dad die? Or - more darkly - okay, so you think its okay to kill them. Because that's how patients hear it.

So this euphemistic language is, first of all, not appropriate to the machines, and secondly it's not appropriate to that span of existence that it's seeking to describe. These technologies extend organ function. That's what they do. And you know, what's happened now - and this where there's a definite monetary factor into it - in California there are 30-35, and growing, kind of chronic intensive care units, not built on hospital property, built separately. Medicare will pay for people on chronic ventilators. So these places which are kind of (unintelligible) concrete buildings by freeways house patients on these ventilators. And I think for some families this is fine, this is a kind of medical sanctuary, for others it's a living tomb. The point that troubles me the most is that there very seldom is a candid discussion with the family or the patient - if the patient is alert, usually is not - about this extended kind of space, twilight zone of existence.

They continue because Medicare pays for them and there is an industry dedicated to expanding them. In a medical school - a major medical center I won't name, I was just there a couple of weeks ago - is entering into a contract to build one, put it's name on it. It's not built near the medical center because that violates Medicare rules and they're hoping in time to get a percentage of the revenue from the contract company that is building this facility. So what distresses me is at the level of policy we're not talking about this. Is this what the government should be doing routinely because unless you say no, no ventilator, it happens.

GROSS: Does this figure at all into the kind of health reforms that President Obama is proposing or that you'd like to see him propose?

Dr. MARTENSEN: It figures in a very indirect way. The proposals coming out of the administration, as I understand them, about effective care are to look at these kinds of issues. The push back from those who initially oppose the administration's health reform efforts are to say - to look at something like effective care: is this something that actually does what we say does and hope it does? And so you can look at effective care but you can never consider cost. So they want the cost issue removed from the effectiveness issue.

But when you look at Medicare overall half the money that we spend in this country on Medicare is spent on patients in the last six months of their lives. And if we were providing some kind of wonderful existence, then one could make the case but as I have written about and as I certainly experienced, and I gathered you've experience and many others, these last six months are not, they're often agonizing and very unsatisfying for all concerned. So I think that's the Obama administration's approach.

There are a lot of financial interests who don't want to have this propensity to treat and treat and treat - that's lucrative, subject to close examination though there's a kind of battle of lobbyists going on in Washington.

GROSS: You wrote that your father was an agnostic, didn't believe in afterlife. You've implied that you have a more spiritually oriented side of you than he did. And I guess I'm wondering how being around so much suffering and death as a long time emergency room doctor affected you sense of life and spirituality and - those things are so hard to talk about.

Dr. MARTENSEN: Well, a lot of action in the emergency room - patients get better. I mean, it's a very - generally - a very positive place because people can come in absolute wrecks or threatened, you know, disaster from infection, from diabetes out of control, from trauma, from all kinds of issues and if the team's working right they recover and recover splendidly. So when I think about the ER I think about that and I do have a sense, yes for myself that one definitely dies but one doesn't completely disappear. And I don't know how that happens. Somehow it's out in the atmosphere. Certainly the material is - of our existence, our bodies - is preserved and the universe conserves material, we just go into different forms.

So it's a more a Buddhist sense I suppose that informs me and where I found more meaning, a kind of existential Buddhism, where I'm not terribly caught up in a particular form of an afterlife - just this sense that there's a continuity in some way and embrace that.

GROSS: Well, I'm glad you mentioned that in the emergency room lots of people get better because that's a part…


GROSS: …of medical care we didn't talk about. So…

(Soundbite of laughter)


GROSS: …thank you for pointing that out. Dr. Martensen we need to let you go now. I want to thank you so much for talking with us and I'm very sorry that you're losing your mother. Thank you for this conversation.

Dr. MARTENSEN: Thank you, Terry. It's been a very satisfying and helpful conversation for me.

GROSS: Dr. Robert Martensen is the author of the new book "A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era." He's currently the director of the National Institutes of Health Museum and Office of History.

This is FRESH AIR.

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