In America, too many people die in the hospital.

I don’t mean that they die due to medical error or incompetence, though that’s always a hot topic of discussion amongst doctors, researchers, administrators, and regulators.

What I mean is that if you ask most people, they say they’d rather die at home, surrounded by their loved ones, drifting off to sleep painlessly after having had last rites administered (feel free to plug in your religious/atheistic ritual of choice here).

Why, then, do so many who want this type of death instead die medically, here in the hospital, undergoing painful treatment and the deprivations and degradations of medical care?

The answer has both simple and complex aspects. But I’ll start by sharing something that most medical professionals believe:

When my time comes, the last place I want to be is in the hospital. Don’t get me wrong–I like GlassHospital–it’s a good place to work, teach, and learn. But when the grim reaper is calling my name, I want to be as far away from here as I can.

No IVs. No needle sticks to test my blood. No waking me up to check vital signs every shift. No hospital food. No fluorescent lights.

No feeding tubes; no bladder catheters (ouch!); for Heaven’s sake, no breathing machines (‘mechanical ventilators’).

These technologies have allowed us to extend life, by keeping people breathing and metabolizing as long as the heart can pump (we can even take that over for some time with machines now).

But what they don’t do is keep us alive in any meaningful way. I’ll admit that this is a judgment call, that how you define meaningful is the key element. Because what I think is not meaningful life, being strapped to a bunch of machines keeping me alive, is very meaningful to others. Alive is alive, no matter what people like me have to say about it.

There’s a big disconnect between what health professionals see and what people not in the field perceive about death. Presumably, for folks not ensconced in our world, a lot of death imagery comes from TV or the movies.

The simple reasons that people die in the hospital are:

1. Some people prefer it. Battlers to the bitter end.
2. (For those that don’t prefer it:) They aren’t empowered to do it any other way.

This second group is the one for whom death in the hospital is a shame. And though we’re getting better at comforting the dying, hospitals (believe it or not) are just not set up to deal with the dying process very well.

Hospitals are like giant factories where all the focus is on process: diagnosing, treating, rehabbing, and discharging. Death, while a natural endpoint, is still too frequently viewed as medical failure. Nothing could be further from the truth.

I’d like to empower the folks in that second group, and especially their family members and loved ones, who will be called on to help with decision making, to take the initiative and die at home. Or in hospice. Or on a mountain top in bright sunshine.

How can we do that?

Verbalize what you think you want. Write it down. Share it with your family and friends. When your time comes and you have a life-threatening illness, push your doctors to be candid in their appraisal of your chances for recovery or the imminence of death.

Here’s the other thing: You can change your mind. If you become old and feeble and decide that you want to fight until the last breath is taken from you, you can. And in fact, this happens a lot.

But having these discussions for the first time when you’re at death’s door is a surefire way to wind up dying in a way that you probably never envisioned.

One last note: Though I and most of my colleagues want no part of this place when we’re dying, you still have every right to come here and use our services.

We really do want to honor your wishes.

John Schumann is an internal medicine physician at the University of Chicago who blogs at GlassHospital.

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