At 8 am on her first day as an intern, Diane Meier attended the resuscitation of an 89 year old man with end stage congestive heart failure. The staff shocked the man’s heart repeatedly. They tried four times to place a central line. They injected pressors directly into his heart, stuck his femoral artery for blood gases, and performed chest compressions for over an hour before finally pronouncing him dead. Two decades later, after witnessing similar pre-death rituals countless times, Meier published the story of a 73 year old man with metastatic lung cancer who told his doctors he didn’t want invasive testing and treatment. His doctors consulted a psychiatrist, who said the man was “in denial” about his illness. After some pressure from his doctors, the man and his family agreed to further diagnostic testing and treatment, including placement of a gastrostomy tube. He was ultimately subjected to 47 days of painful and invasive treatments before dying.1

For Meier, who went on to win a MacArthur “genius grant” for her work in palliative care, it was not the patient who was in denial, but his doctors. Physicians are trained to believe that staving off death, even if only for days, is their overriding mission, and all available technology should be employed to achieve that goal. The cost of this self delusion in Meier’s eyes can be measured in the patient’s suffering, inadequate pain relief, and in time lost that could have been spent at home with family and loved ones. On a national level, the problem is daunting: annually, 65% of all deaths in the United States now occur in hospitals, multiplying the instances when …