Many Blessings

[Jo6]

I know it is so very hard taking care of our LO's, but some where in there are blessings to be found.

MIL is still slowly going down that hill. Oh how I wish I could help her. Mr. Jo has gone to feed her today. I say feed, but it is the only nurishment she has.
Fluids, but she always takes it all.The process has to be very slow and making sure she swallows all of the sip before going on. She will strangle so easy. I'm gratefull she can still take in the fluids, but she is making sounds way down deep in her throat that does not sound good.
I've heard this before and it makes me sad to know what will come next.
I hope all of you had a good day, as much as possible. We have so many blessings and I am thankful for them all.
Jennifer, I hope things are getting easier for you. I am worried about YOUR health. Please take care and don't forget your limitations.

Joy, Tootsie and all others that come here, also those that "lurk" I wish for a better day for you all.
my love, jo

[rumpled]

Ah Jo... so sorry that you are on this slope as well.
I hope your day went well.
Peace to all.
Jen

[Jo6]

Jennifer. Yes it sounds like our MIL's are getting ready to move on. We love them, but we don't want them to hurt or any body hurting them.

How is your MIL? I think of all of you a lot. It's kind of like a family, but one that is happy with each other.

take care, Jo

[rumpled]

Sorry it has taken me so long to reply. I have been a bit under the weather. She is here and there. One day responsive, the next not. The worst is seeing my FIL get his hopes up on the days she is responsive and then get knocked back like it is unexpected when she is not... he is just not facing this well at all.
I saw your post on the blood work and will follow that. The hospice nurse and some articles I read also indicated that the BP will just get lower and lower and while they will eat, they will not absorb nutrition, which is why feeding tubes do not work (even though they are pushed - I just read an article in the paper on Sunday). It was also good to read that dehydration is not a painful way to go. They just do not explain enough to the families, try to many heroic measures and then end up not really helping.

[Jo6]

Hi Jennifer. Yes, at this point things change, then they will change again. Ups and down. I never know how things really are.

Mr. jo talked with Hospice today. I don't have a clue what was said, if and when they will start helping with her care, any thing at all. It was evident he didn't want to talk to me about it.

That's ok. I have been there, I know how hard it is, especially when it is MOM. I am here if he does want to talk. I don't ask questions anymore. He just gets upset. I told his sis to let me know if there is anything I need to know concerning him. I know nothing more to do.

I go when I can. I stay as long as I can manage. Yes, I have been down this road several times , but it does not make it any easier.

Jen, I thought what you posted was very interesting . I agree that they never tell the family, or at least the one that is speaking for her now that she can't . Hubby appears to be holding it all inside and that is not good. I just hope he is talking with someone.

You know, the part about the feeding tube, I'm wondering why they push so hard for that. they were going to put one in MIL when she broke her hip and had a stroke the next day. Her condition as well as a copy of her records from NH should have known this wasn't the thing to do.

Hubby had to tell them again, no feeding tube. If you find any thing else that wou;d at least help the family please post. the Hospice thing today, it surely has taken it's toll on him, yet another heart breaking thing to take care of.

How are you feeling, Jennifer? you mentioned you had been under the weather. I hope you are feeling better. thanks for posting, Jo

[rumpled]

A troubling abundance of care
Despite efforts, state's sick don't live longer
Sunday, December 02, 2007
BY CAROL ANN CAMPBELL
Star-Ledger Staff
During the last two months of life, Dorothy Glas endured so many blood tests her thin arms turned black and blue. The 85-year-old woman submitted to probes of her abdomen. Radiologists scanned her brain, kidneys, thyroid and heart. A psychiatrist screened her for depression.

"My mother told him, 'Of course I'm depressed! I'm dying. How can you be happy?'" said her daughter, Meredith Snedeker of Hamilton Square.

Glas withered to 80 pounds from an intestinal infection and, after a fall, entered the hospital in July for the final time, complaining of dizziness and a cut foot. The medicine revved up and doctors at Robert Wood Johnson University Hospital Hamilton ordered a flurry of tests: X-rays, CT scans, echocardiograms and scopes of her digestive tract.

Kidney specialists examined her. So did gastroenterologists, infectious disease specialists, neurologists, internists and a cardiologist, according to a 22-page Medicare summary. Her daughter said she felt helpless as the tests and consultations snowballed. Glas, a former nurse suffering from several serious chronic ailments, including heart disease, slowly sank into the kind of high-tech death she always feared, even though a living will spelled out her wishes and she spoke up to oppose many of the tests.

"Blood gasses. EEGs. EKGs. The closer she got to death the more tests they did," the daughter said. Then, after an apparent stroke, the elderly woman stopped eating and a physician suggested that what Dorothy Glas really needed was a feeding tube.

"I was in disbelief," Snedeker said.

Dying in New Jersey is unlike dying anywhere else in the country -- it is hard and expensive. The sick and elderly get more tests, see more doctors and endure more procedures than patients in any other state.

Yet they do not live any longer or suffer any less.

Interviews with families, physicians, ethicists and health care experts, as well as several new studies, create a picture of dying in New Jersey that resembles a runaway train.

"New Jersey is literally off the charts in nearly every measure," said Elliott Fisher, director of the Dartmouth Center for Healthcare Research and Reform in Lebanon, N.H., and a professor at Dartmouth Medical School. "Yet high-intensity practices are not associated with better care. Evidence suggests the quality of care is worse."

Fisher also directs the Dartmouth Atlas of Health Care, an exhaustive study released last year that examined nearly 5 million deaths of chronically ill Medicare patients from 2000 to 2003. The Atlas looked at everything from the percentage of deaths in the ICU to the number of specialists patients visit at the end of life. It found that reducing unnecessary medical care would save the nation's taxpayers $40 billion over four years while improving the quality of health care.

The Atlas quantified what many in New Jersey have long believed: Sick and elderly patients get too much care at the end of their lives.

In New Jersey, for instance, chronically ill Medicare patients spend an average of $39,809 during the last two years of life, the highest in the nation. In contrast, residents of Idaho, the lowest state, spend less than $24,000, while the national average was $29,199.

The Atlas found that these New Jersey patients will log 25 visits with specialists in the last six months of life -- about double the national average and the highest in the nation. As a result, families have described disjointed care that pushes loved ones from imaging tests to EKGs to endoscopes with no one taking charge of the patient's overall care, or giving the family the candid truth as death nears.

Other studies add to the picture. A Brown University study found that nursing home residents in New Jersey are more likely to be hospitalized than similar patients in most other states.

Meanwhile, a 2006 study underwritten by Horizon Blue Cross Blue Shield of New Jersey and the Robert Wood Johnson Foundation called New Jersey among the most "resource intensive" states in the nation. But the study -- the New Jersey Health Care Almanac -- found no corresponding improvement in the quality of care.

The studies have jolted some in the state's medical establishment and prompted calls for a fundamental change in how chronically ill people die in New Jersey.

"The data confirm what we have been saying all along," said physician Susan Bauman, director of Palliative Care Services at Hunterdon Medical Center in Raritan Township. "We need to change. This is not just a feeling that we've had."

For years, Bauman and others in the fields of hospice and palliative care -- a specialty to control pain and symptoms -- have protested futile tests and interventions for dying patients. They have worked to make sure the wishes of patients are followed.

"With all the resources we have in New Jersey there is a tendency to use them," said the Rev. Joseph Kukura, a priest and president of the Catholic Heathcare Partnership of New Jersey, which represents 15 hospitals in the state.

"We ought to step back and say, 'What are we trying to achieve with all these tests and treatments?'"

Palliative care physicians find their philosophy often clashes with unrealistic expectations of families and the can-do attitude of physicians trained to save lives.

"We have to stop offering interventions that are medically inappropriate or futile," said Jeanne Kerwin, ethics and palliative care coordinator at Overlook Hospital in Summit.

"But it's easier and less risky to offer everything and just say to the family, 'It's your choice.' That's a terrible burden for families," she said.

[rumpled]

A DAUGHTER'S ANGER


Even now, as she sits in her kitchen three months after her mother's death, Snedeker, a loan assistant at a bank, gets angry.

"The last time my mother was in the hospital she said, 'I'm not coming home. This is it,'" Snedeker said. "She kept saying, 'I don't want these tests. I don't want all this.' But they kept giving her tests."

She says doctors insisted her mother needed a feeding tube.

"The doctor said to me, 'You have to understand. Your mother has stopped eating.' Finally I said, 'No tubes. You stop this or I get an attorney involved.' I said, 'My mother's dying. She's had enough.' My mother had a living will. I had power of attorney."

A nurse finally suggested she call hospice.

Officials at Robert Wood Johnson University Hospital Hamilton declined to speak about the Glas case, although Snedeker signed forms to give the hospital permission to comment.

However, Janice Stout, a hospital executive, said nurses, case managers, social workers and the hospital chaplain work with physicians to provide medical and emotional support for patients and families.

"If ever there is a conflict in terms of what the patient is asking for and what the doctor is recommending, we have a process to address that," she said, adding that the hospital will arrange meetings with all the specialists "when we see a need to do that."

Social workers also will call in outside agencies, such as hospice, when needed, Stout said.

"The nurses look to make sure the patient and family have the information and services they need," she said.

Glas went into a hospice program on July 15 and died two days later.

Her daughter said she regrets having little time to just sit and be with her mother, hold her hand, brush her hair and read books to her.

Then she looks again at the Medicare summary of charges and notices a $150 test -- in Medicare shorthand she cannot decipher -- dated July 15.

"What test did she need 48 hours before she died?"


ABUNDANCE OF CARE


Why do dying patients in New Jersey receive so much medical care?

Some experts say the state simply has too many hospital beds. In 2000, New Jersey had above the national rate of hospital beds per 100,000 residents, according to the National Center for Health Workforce Analysis.

Like empty closets, hospital beds tend to get filled.

Others point to the high use of specialists in the state.

The Dartmouth Atlas found that chronically ill Medicare patients in New Jersey get the highest proportion of their care from specialists, as opposed to primary care doctors, at the end of life -- second only to Washington, D.C.

"The cardiologist looks at the heart," said Bauman, the palliative care expert. "The nephrologist looks at the kidney. The neurologist looks at the brain. Sometimes you need someone to step back and see the forest. Is the goal to keep the heart ticking as long as possible? Or maybe the goal for a frail, elderly person is to go home and see their grandchildren."

Others point to a costly culture of physician practice in New Jersey. The state's outgoing health commissioner, Fred Jacobs, said New Jersey physicians collaborate too much, rely on multiple consultations and keep patients in the hospital too long.

"I hear doctors say to me, 'But my patients are more demanding. They are sicker than most patients. They need more consults.' I say to them, 'There are 49 states and the District of Columbia that can do the same job with less and they do it better. You can't convince me that your patients are so unique.'"

Jacobs urges hospital administrators to make sure physicians follow accepted guidelines when treating chronically ill patients or risk losing their privileges.

High use of care in New Jersey does not just affect patients at the end of life.

"Doctors in New Jersey admit an above average number of patients to hospitals. And they tend to prescribe significantly more care," said Jon Glaudemans, a senior vice president with Avalere Health LLC, a consulting firm that created the New Jersey Health Care Almanac.

It found once patients are in a New Jersey hospital, they tend to stay longer than patients in other states. The average hospital stay in New Jersey is 4.8 days, compared with the national average of 4.3 days, according to the New Jersey Hospital Association. The gap among Medicare patients is even higher: 6.2 days in New Jersey versus the national average of 5.5 days.

The stakes are high for hospitals, which often lose money when patients stay longer than Medicare or private insurance will cover. Half of the state's 79 acute care hospitals now operate in the red. Patients lingering in the ICU costs hospitals money and forces other acute patients to stay in emergency departments.

Experts say physicians need more training to start candid conversations about death. Aline Holmes, senior vice president for clinical affairs at the New Jersey Hospital Association, said more hospitals need palliative care teams, or end-of-life ethicists, to help physicians and families navigate the painful discussions.

"Nobody wants to die in the ICU with IV lines and tubes and only seeing their family every hour for five minutes," she said.

Others suggest that patients and families in New Jersey may, in fact, be different from patients in, say, Idaho.

"Yes, maybe we are over-doctored here," said Howard Kaplan, a Teaneck attorney specializing in elder law. "But the technology is available right here. We're at the top of the medical world. What was heroic in 1995 is routine now. People want to live. Maybe it's different if you live in Osh Kosh," he said. He said he has dealt with angry families who believe physicians did not do enough.

One of the state's leading physicians said doctors want to be part of the solution. Richard Scott, an orthopedic surgeon and president of the New Jersey Medical Society, said patients, especially those in nursing homes, need living wills.

"If a nursing home patient is brought to the hospital and there is no directive, maybe no family close by, we are compelled to pretty much do everything," Scott said. "And we have thousands of people in nursing homes without directives."

He said physicians are working with hospitals to make changes, but added that New Jersey physicians practice in a "climate of fear" because of the state's medical malpractice laws.

"No emergency room physician ever wants to be in court defending why he didn't order the CT scan for the patient with a headache who turns out to have a stroke the next day," he said.

[rumpled]

'I WANT TO GO HOME'


Dori Patrick knows what it is like to deal with all kinds of specialists. She still struggles with guilt that, in the end, she failed her mother -- "and she was a mother who always sacrificed for us."

Vivian DelGreco, a longtime crossing guard in New Milford, was diagnosed with cervical cancer in May 2005, and her doctors at Englewood Hospital and Medical Center prescribed radiation.

But after the powerful treatments, the 76-year-old mother never walked again, Patrick said. In and out of a nursing home and the hospital, she died four months after the diagnosis.

"She had a primary physician. An oncologist. A gastro-intestinal guy. A radiologist. An internist," Patrick said. "We just got bits and pieces of information. I think they knew how bad she was, but they didn't tell us."

A spokeswoman for the hospital, citing privacy laws, declined to comment.

Patrick said the family would have made better decisions if they understood the potential side effects of treatment and the severity of their mother's illness.

"Every time I went to see her she was getting a test," Patrick said. "I'm sure she was mortified. The last lucid thing she said to me was, "I want to go home.' We would have found a way to take her home if we understood she was not going to recover."

Patrick said her mother had a "Do Not Resuscitate" order, but on the day she died the daughter walked into the hospital room and saw her mother with a bag on her face and a tube down her throat.

"I think they were working on her for 15 minutes. They asked me, 'Should we continue?' I said, "No. No more.' They stopped immediately. I know my mother would not want to come back as a vegetable," Patrick said.

In the end, Patrick believes she failed her mother.

"She had no quality of life in those last four months."


THE HARDEST DECISION


Unnecessary tests and interventions often continue because difficult discussions about death never take place.

"If you keep using resources, you can keep yourself from facing the fact that life is coming to an end," Kukura, the Catholic ethicist, said. "Some families think that to show love they must do everything possible without asking if everything is appropriate."

Kerwin, the end-of-life expert at Overlook Hospital, found that families forced to make difficult decisions about ventilators, feeding tubes and other interventions often felt torn and guilt-ridden months, even years, later. "Doctors are afraid to be wrong," Kerwin said. "So we dump too much on the family."

She said for some patients, tests and procedures do not lengthen life but merely prolong the dying process.

"Let's say a 92-year-old has a massive stroke," Kerwin said. "The family calls 911. She can't breathe, so they put her on a ventilator."

"Then she can't eat. So she gets a feeding tube. After two weeks she does not look like she will recover. You have this train moving, but there's no conductor," she said.

The use of feeding tubes can be one of the most controversial end-of-life decisions. Twenty-six percent of New Jersey nursing home residents with cognitive impairment -- such as dementia or Alzheimer's disease -- are on feeding tubes, compared with the national average of 21 percent, according to Joan Teno, a researcher at Brown University. She said feeding tubes do not help severe dementia patients live longer or feel better, and families often are not given all the facts to make informed decisions about feeding tubes.

"The worst thing you can do for someone actively dying is to partially hydrate and partially feed them," Teno said. She said fluid can accumulate in the patient's lungs, suffocating them -- "a hard dying experience." Patients often cannot fully digest the contents of the feeding tube, causing intestinal distress.

"If you let someone die of dehydration, they will go into renal failure," she said. "These people slip away quietly and peacefully."


A HUSBAND'S DECISION


End-of-life decisions seldom are simple and, more often, force families to choose between two painful outcomes.

Ask Milton Beveridge.

On a recent afternoon, he leaned forward to kiss the woman he married 62 years ago.

He shook her shoulder.

"C'mon. Wake up a little."

Barbara Beveridge, curled in her nursing home bed, eventually opened her eyes. She could not speak, walk, eat, drink or communicate. Alzheimer's disease had taken her mind. Beveridge believes she may no longer recognize him.

"Hey Barbara. Hi."

She exhibited a bright, though brief, grin. Then her eyes closed again.

Beveridge points to the medical intervention that still tears at him. A bottle with nutritional supplement empties into a tube that stretches to his wife's stomach. He approved the insertion of the gastro-intestinal tube in April, when his wife had trouble swallowing. She'd become dehydrated.

Both he and his wife signed living wills that called for "no heroics," he said, and that meant feeding tubes. But after a stay in the hospital for dehydration, his wife's physician, Maynard Holgado of Sicklerville Internal Medicine, said a feeding tube would keep his wife hydrated and out of the hospital, he said.

"My first reaction was, 'No. No tubes.' And I thought, 'Is this going to help her or cause more trouble?'" Beveridge recalled. "You wonder, 'Are you just prolonging this? Should you just let her go?' I do accept that she is at the end of life. It's just difficult to see her in any pain."

Beveridge lives in an apartment at Fountains at Cedar Parke in Camden County. A fit 84, he strides through the halls that take him from his assisted living apartment to the adjoining nursing home.

He said he met his wife at a USO dance in 1945, just before Beveridge shipped out with the Navy. Later, he worked as an engineer for Union Carbide.

A decade ago, Barbara Beveridge went out for a walk and could not find her way home. Things went down steadily.

"Occasionally, if she's feeling good I think she recognizes my voice," he said. "The thing that really gets me is that she should be spoiling her grandchildren now, but she doesn't even know they exist."

He agreed to the feeding tube, he said, after a short discussion with his physician, who did not respond to three requests for an interview. He said he received no support from bioethics experts or social workers when making the decision. Nor was he told about possible side effects.

"I don't think people realize what it's like until you get into this situation," he said, adding his only aim was to make his wife comfortable.

"I made the choice. I hope it was the right thing to do," he said before kissing his wife and leaving her room.



Carol Ann Campbell may be reached at ccampbell@starledger.com or (973) 392-4148.



© 2007 The Star Ledger
© 2007 NJ.com All Rights Reserved.

[rumpled]

This was in our NJ Sunday paper... makes you think... I still cannot get my husband to read it.

I just have been more tired. My muscle biopsy is set for the 28th of December. I want to do the normal holiday things but naps are um, a bit more tempting.

I am sorry to hear about your MIL. It will be hard on your hubby if he keeps it all in... but that is what they tend to do. Mine seems to want my advice but not really. Hang in there.

[Tootsie]

Every state has different laws and policies that deal with end of life issues. A living will, may not have any legal value. Sometimes, loved ones cross state lines, to be with various family members, as their ability to live on their own decreases. The documents they had in one state, may not be applicable in the one they move to. It really is up to each family, to find out what the law allows, and doesn't allow, and what is legally enforceable, in the state in which they live.

Hospice care is generally available in all communities now. Anyone can pick up the phone and find out how to get their loved ones into their program. Cheerio.

[joy]

I feel for each one of you during this difficult time. I found out tonight at church that our elderly neighbor had to be coded 2 times Sunday night. He has alzheimers and has done very well even with a broken hip. But it is wearing the poor wife out. He was put on a ventolator. The only good thing I can say is their only child, a son is continuing building the house in the state he lives in. I only wish he had started it all sooner. But at least the wife will have a place and help after the house if finished. A bit late but still more than some older people get.

[joy]

moved to a new post. Sorry, I did not want to alter this thread.

[Jo6]

Jennifer for posting this. Yes,if I were to ask K if he wants to read this he would get very angry and I have tried to just keep my mouth shut. That isn't easy for me.

It feels like the worse Mary gets, the angryer he gets at me. I'm having a very hard time dealing with this. We have always been close and this is a total turn around for me.

I don't want to say anything that I know will upset him. I guess I need to try harder. I do not think Mary will be with us for much longer. He knows it too, but he doesn't say it. I just pray she goes in peace. Jo

[Tootsie]

Jo, there may be some support services in your community that could help you deal with your husband's anger about the situation with his mother. His reaction is part of an adjustment mechanism, but it also very destructive to your relationship, and to you, personally.

You are not responsible for his mother's disease, and being made a scapegoat, and emotional recipient, of his anger, just doesn't help anything. A trained social worker or counselor could help here.

At least deal with the issue, head on. Tell him, that you are just as upset as he is over the ravages of Alzheimer's Disease, and the burden it has placed on both of you. However, you will not accept his emotional abuse to you. Then, suggest seeing a counselor. Cheerio.

[rumpled]

I agree with Tootsie. Sorry Jo... My husband is the same and will NOT go to any of the meetings or go get any help...
I called the Alzheimers society near me for help and talk to them. No sense in both of us suffering and this is no NOT uncommon (stubborn &*%$).
Some people cannot come to terms with this very well... we just had to wrestle my FIL for his thoughts on his and my MIL's arrangements and then he cried like he cannot face it even though we have tried to get this out of him for over a year.

[Tootsie]

It always has been more difficult for men to deal with emotional conflicts than it has for women. Just how many men do you see here, complaining, sharing, pouring out their sorrow and grief? We women do that so much better.

Alzheimer's Disease rarely has improved any family relationship, but it can offer an opportunity to repair any old resentments and hurt feelings before it is too late.There is phenomenal potential for emotional growth, if only people have the courage to take that first step. Certainly nowadays, there is so much more knowledge, help, support than when I had to deal with my mother twenty years ago. NO ONE wanted to talk to me about day care, lack of facilities, etc. Fortunately, I did have an HMO with a Psychiatry Dept and a social worker helped me through all those awful decisions. Cheerio.

[rumpled]

We have a phenomomenal case manager who is guiding us however, my FIL seems to close up his ears when certain topics come up and he just refuses to come to terms with making decisions.
When it came to day care, he wanted her home even though it would have been far better to have her out socializing and him to rest and get some friends of his own. He totally failed to understand the cost of care at home even though that is what he wanted. The medicaire vs medicaid and how much they could have in the bank and as assets, even though we told him and gave him articles, he refused to read them and messed up all that as well so with the lookback, now even though he wanted to leave his son something, he cannot. My hubby kept saying that his dad did not understand since he was not born here yet someone who emigrated with him made none of the same mistakes so I am not buying that excuse. His Dad just wanted to control things up to the very end and in doing so, well, the laws just work against you and his lack of trust of anyone - which is a sign of dementia and his hostility - another sign - made it impossible to work with him. For that, all the money they have will go to a home, and his dad still will not spend down what he needs too. It is just so sad that they will not declare him incompetent but his doc says he is just "stupid" not incompentent!

[Tootsie]

Jennifer, there is a certain mind set among the older generation that you save your money and take care of your own. That may partially be the problem with your FIL. My mother always wanted to have enough money so she could be taken care of without being a burden to anyone. Fortunately, she put all her finances in my name and I was able to invest some of it. I'm not sure what I would have done if she had outlived her assets. State law, here in the US has a lot to do with the decisions that must be made.

Here, there are many public seminars about how married couples, can legally split their assets, when one partner in a marriage, requires nursing home or custodial care, so that the other partner is not left penniless.

There truly needs to be more attention paid to the fact that we are living longer, and new resources and social services need to be designed keeping that in mind. Cheerio.

[Jo6]

I see we have new people and a lot of good advise. I will be back later and post. Jo

[rumpled]

My MIL passed away yesterday. Peacefully, pneumonia. Keeping to the way things were, arrangements are being made to my FILs specifications, not hers. Sad. We argued, but he never heard what she said and we did not want to upset him further.
I will still post to help others.

[joy]

Jennifer I am glad your MIL went quietly at the beginning of her peace.

I have come to expect to hear from you and I hope you do continue posting. If you find that you need some time before you begin posting here I hope you will let us hear how you are on this or any of the forums.
Many of us post on Forum for Emotional Support.

[Jo6]

I am very sorry for your loss. I know things have gone hard for you, but you have hung in there, helping, even when you pushed hard to go by your MIL's wishes.
I hope things will go smooth, but it's never easy to get thru these things. I am in the same boat more or less, it being my MIL. Some people don't understand how close one becomes to our in-laws. I know you loved her and tried to carry out her wishes.

Please take care and I hope you will do as Joy said. You have much to give here in the Alzheimer's Forum.
my love, Jo

[rumpled]

thank you...

[Cynthia Sosnowski]

I've have just become involved in these important end of life issues, not as a family member or loved one, but as a new member of the Southern Jersey Ethics ******** (SOJEA). As a person who has never experienced a loved one in an end of life situation, I was totally ignorant of the impact of the laws and the culture. I am quickly educating myself.

As a follow-up to the December Newark Star Ledger article and the more recent follow-up, and the release of the Tracking the Care of Patients with Severe Chronic Illness: The Dartmouth Atlas of Health Care 2008, a number of organizations have come together to mount a major conference on the topic. 'A Troubling Abundance of Care: Over-treatment at the End of Life" will be held at Richard Stockton College of New Jersey on Monday, May 12, 2008. Co-sponsored by University of Penn School of Medicine, AtlantiiCare Health Systems, and SOJEA, the conference will feature Carol Ann Campbell, author of the Star Ledger pieces, Dr. David Goodman from Dartmouth, Dr. Art Caplan, Arthur Caplan, PhD, Emanuel and Robert Hart Professor of Bioethics,
Chair of the Departmentof Medical Ethics & Director of the Center for Bioethics at the University of Pennsylvania and a variety of other speakers on the topic. We have informaiton posted about the conference at: www.stockton.edu/hshs. There is a cost for the conferece, with a discount for students, but it includes the food and a very large packet of resources.

I'm not trying to sell the conference, we already have a good crowd, but I don't want someone to miss it if the information would be useful, which I think it will be. You can reach me through the website if you need more information.

Thank you are all the caring and sharing that happens on this website and in your lives. I have a lot to learn.
Cynthia Sosnowski

[Tootsie]

Cynthia, thank you for your interest in end of life issues! It is definitely a subject that needs more light, not necessarily more heat! Passions are aroused easily, and each opinion needs to be respected.

One of the greatest challenges is that each state has their own legally enforceable code, as to what will be honored. A "Do not Resuscitate" order is not enough! The process needs to be further clarified with public hearing, discussions, classes, lectures, etc. in each individual state.

Perhaps a goal of the conference should be some kind of standardization of the process for making ones wishes known? Cheerio.