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Lessons in Dying Well

eating but picked at her food to please the nursing home staff. Mostly, she wanted to be left alone. "Why is it so hard to die?" she asked.

Her son, Dr. Dennis McCullough, an associate professor of community and family medicine at Dartmouth, had both a personal and a professional interest in the answer to that question. After practicing family medicine for several years, he had combined his interests in community-based medicine and geriatric medicine as the medical director of Kendal at Hanover, a life-care community in Dartmouth Medical School's backyard.

As a result, McCullough understood that nursing homes are assessed by how long they keep their residents alive, and that hismother no longer wanted to live. So he moved her to a residential hospice facility, where she was permitted to follow her own changing rhythms. Rather than be woken and urged to eat regular meals, she was allowed to sleep for 24 hours at a time if she wanted to and was provided with coffee and toast when that's what she requested. For about five weeks, Bertha McCullough woke once a day for a couple of hours, enjoyed her snack, talked about her dreams, planned her funeral, and told stories in exquisite detail. "She was very connected while awake," Dennis McCullough recalls. And then she died.

During the last years of his mother's life, McCullough suffered some health problems of his own. Forced to give up clinical practice, he embarked on studying, and writing about, the many complex issues surrounding elder care. He is now committed to educating the public on the subject. "People over 80 are intense users of health resources," he says. "Why not focus on better care, with early intervention, so little ailments are stopped before they become health crises?"

McCullough is one of many medical professionals who have come to recognize that this country's current health-care system swings between inflicting on the elderly too little care (not

Dennis McCullough's mother was allowed to sleep for 24 hours at a time if she wanted to and was provided with coffee and toast when that's what she requested.

spending enough time listening and not stepping in early because of cost constraints) and too much care (recommending invasive diagnostic tests and treatments that may be inadvisable for someone who is frail or battling multiple ailments). It's a system, he and others have concluded, that is expensive, inefficient, and not particularly humane. "Care is what matters," McCullough says, "not intervention."

As part of his campaign to raise awareness about end-of-life care, McCullough has written a book titled My Mother, Your Mother. The book describes a concept he calls "slow medicine"—a "compassionate approach to caring for your aging loved ones." He suggests relying more on community and common sense and less on hurried decision-making, hospitalization, and invasive procedures. "I'm trying to help families understand what their options are," McCullough says. The approach—and the term he uses to describe it, borrowed

from the "slow food" movement—seem to be resonating with both elderly patients and their families.

McCullough hopes that slow medicine will continue to spread. He's helping a group of DMS faculty members—headed by Dr. Stephen Bartels, a geriatric psychiatrist—launch a wide-ranging effort to improve care for the elderly throughout northern New England. He'd like to see a process for recognizing hospitals that deliver community-based care for the elderly—care that accounts for psychological as well as physical health. And he'd love to see Dartmouth-Hitchcock accredited as the nation's first Slow Medicine Hospital.

Open to the individual process

Just how hard it can be to negotiate the end-of-life process is illustrated by the fact that two additional physicians agreed to be interviewed for this article but then decided, on reflection, that they preferred not to make public the "minute particulars" of their personal stories.

But one of them—whom we'll call Dr. John Jones—was willing to share the lessons he learned when a parent facing metastatic cancer proved adamantly opposed to hospice care. Jones was initially surprised by the reaction. But a later conversation made himrealize that some people prefer not to share with non-family something as intimate as their thoughts about dying.

Jones has since then come to believe that people nearing the end of life need a guide who knows them and listens to them but doesn't push ideas on them. He realizes now that helping his patients get the care they want sometimes means addressing a detailed list of ailments, but it sometimes means just helping them attain a general sense of well-being. The experience, Jones explains, "taught me to bemore open to the individual process—that it was all right for a patient to choose not to deal with death, not to confront it head on.

"I learned," he concludes, "that 'my way or the highway' didn't work."

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Deborah Luskin is a freelance writer, a commentator for Vermont Public Radio, and a visiting scholar for the Vermont Humanities Council. She wrote a feature for Dartmouth Medicine's Fall 2007 issue on the financial and regulatory pressures that impelled her husband—Dr. Timothy Shafer, a 1981 DMS graduate who is a family physician—to close his own practice and go to work for a hospital in southern Vermont. We are very grateful to the faculty members she interviewed for the loan of the family photos used here.

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