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lines for the first time in the organization’shistory.At the state level, a new Pennsylvanialaw covering decision-making proceduresfor terminally ill patients took effect thisFebruary. Incidentally, that was just daysbefore Governor Ed Rendell’s administrationreleased a 40-page report of recommendationsfor improving end-of-life care. The document’s160 recommendations aim to improveresearch, outreach, advance-directives policy,healthcare-fi nance structures, professionaleducation, sensitivity to the needs of specialpopulations, and palliative care standards—especially in acute-care hospitals, where mostPennsylvanians die.On February 9, scholars from around theworld gathered on Pitt’s campus for a seminaron end-of-life issues, hosted by Pitt’s CulturalStudies Program and School of Medicine.The springboard for the discussion was TheContemporary Deathbed, a book by emergency-medicinespecialist and cultural historianJohn Tercier of the University of California,San Francisco. The bookfocused on the iconicimage of death in themedia—the heroic CPRattempt that often takesplace after a patient’s lastbreath. Tercier questionswhy CPR has been so central to resuscitativeprocedures across a gamut of cases, eventhough it has been proven effective onlywhen administered immediately after certaintypes of cardiac arrest. “For a number of yearsnow,” he writes, “medical personnel, whilepumping on the chests of the dying, havebeen asking themselves, ‘Why are we beatinga dead horse?’”Perhaps the question now is: How do westop?It’s not news that few Americans want toend their time on earth in a hospital, withintensive—not to mention expensive—lifesustainingtreatment. Yet that’s exactly whatmost get. In the last three decades, 27 percentof the total Medicare budget has been spenton treatment during Americans’ last year oflife and, of that, about 40 percent in the lastmonth.Given that so many doctors are uncomfortableeven asking patients about theirwishes, it’s not surprising that the contemporarydeathbed still has more than a few bugs.For all our dollars spent and efforts made, andall our talk of living wills and other advancedirectives, we’re often still missing the mark.Where do we fall short of providing thegood death, and what can we do to improve?Barnato and others at Pitt are starting toanswer these questions.Pitt’s Bob Arnold, a former presidentof the American Academy of Hospice andPalliative Medicine, says the good death hasremained elusive for a variety of reasons. Toname a few: Patients and families don’t knowto expect good palliative care, healthcareproviders haven’t traditionally been trainedto provide it, and health care in this countryis financed with an emphasis on acute ratherthan chronic illness.To address these issues, Family Hospiceand Palliative Care—one of the first hospiceprograms in Pennsylvania—and Pitt’shealth sciences schools jointly established theInstitute to Enhance Palliative Care in 2003.The institute educates healthcare providersabout palliative care, raises public awarenessabout palliative care availability, advancespublic policy supporting better care for seriouslyill patients, and conducts research intobest practices.“Twenty or 30 years ago there wouldhave been no one looking at this stuff,” saysArnold. “Now there’s a whole group of juniorinvestigators and researchers at Pitt whoare all really interested in focusing on theseissues.”David Barnard, who directs the Institute toEnhance Palliative Care and palliative care educationat Pitt’s Center for Bioethics and HealthLaw, says one of the bigger problems with thecontemporary deathbed is the way prognosis isoften communicated. Studies show that doctorstend to paint a brighter picture to patientsand their families than the doctors themselvesperceive—either consciously because they’reuncomfortable or unconsciously because thebetter doctors know their patients, the morelikely they are to be overly optimistic in theirpredictions. This leads to problems once apatient really starts to decline.As a member of the UPMC EthicsCommittee, Barnard has seen it countlesstimes: The patient has multisystem failureand has been on a ventilator for two weeks.The doctor calls and says, “The family doesn’tget it.” Barnard explains: “Too much timeis spent deciding which treatments to do,rather than getting to know the patients andwhat they want. The important question theyshould be asking patients is: ‘What characteristicsof life make it worth living?’”In 2001 and 2005, Barnard securedfour-year National Cancer Institute (NCI)grants—totaling about $1.75 million—toincorporate new palliative care offerings intothe curriculum. Palliative care training is nowavailable at all levels of instruction, fromclassroom to residency to fellowship.In one course, Barnard pairs first-year studentswith patients with life-threatening illnesses.They spend time together throughout thesemester. Medical student Yohko Shinozawa(Class of ’08), who took the class two yearsago, was assigned Mike Kolansky (not hisreal name), a bearded, tattoo-clad motorcycleenthusiast in his 60s. Kolansky had undergonea liver transplant, and, as a result of his immunosuppressantmedications, his kidneys began“Medical personnel, while pumping on the chests of the dying,have been asking themselves, ‘Why are we beating a dead horse?’”failing 10 years after the surgery.Each Saturday, Shinozawa sat with him forone hour of his 12-hour weekly dialysis regimenat the VA hospital.To Shinozawa’s surprise, the two didn’tdiscuss his illness much. “He was laid-back,always joking around,” she says. “He was veryfocused on living and making the most of hislife.” Since her semester in Barnard’s class,she has volunteered regularly for the palliativecare program.The institute also offers a two-year palliativecare fellowship that combines researchwith clinical care. First-year fellow ElizabethWeinstein (MD ’02, Res ’05) notes that whilemany palliative care fellowship programs arerun through oncology or geriatrics divisions,Pitt’s is part of the Division of GeneralInternal Medicine. “One of the things I loveabout Pitt is that we see such a broad rangeof patients.”Weinstein says that a feather in the program’scap is Arnold himself. “A couple ofweeks ago we were at a national meeting.Everyone was grabbing for five minutes ofBob Arnold’s time. ... But he always down-22 PITTMED