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Illustration: Sarah Grillo/Axios

Medical culture has often framed death as a binary decision: preserve a patient's life at all costs, or give up and accept what happens. That framing does a disservice to the fear, uncertainty and philosophical questions about life and death that patients and their families experience.

The big picture: American health care, from medical education all the way through to the payment system, generally does not encourage doctors to listen to dying patients' needs or priorities.

Why it matters: The health care system isn't helping patients wrestle with these difficult questions, while advances in medicine are making them even harder to answer.

  • Today's technology can make it difficult to define what "dying" is, according to doctor and author Atul Gawande.
  • "At some point for each of our patients, we're not going to have a way to fix a problem," said Sunita Puri, a palliative care doctor and author. "We shouldn't set our patients up with false hope that medicine can solve anything."

"I would like to believe that I will be very clear-eyed and rational, that I will know when it's time to stop treatment," Diane Meier, a leading expert on palliative care, said when asked how she would like to die. "But I am not so arrogant as to think that I might not choose [more treatment] out of fear."

Where it stands: Experts say we have designed a system that fails to support both the chronically ill who are the costliest to treat and those who are closer to death.

  • Medical schools often cast aside courses on geriatrics and palliative care as "optional," and many schools "graduate young physicians who have never been adequately trained to listen to people," said Ira Byock, a physician and author.
  • Medicare's hospice benefit is restrictive. And despite some recent changes in policy, physicians don't have a strong financial incentive to spend time listening to patients' concerns.

There's some cause for hope. The hospice and palliative care movement has expanded rapidly: 75% of all hospitals with at least 50 beds now have some kind of palliative care program.

  • Plus, more people are dying at home, where they'd rather be, instead of in a hospital.

The bottom line: "Is death a friend or an enemy, to be acquiesced to or to be fought? American medicine is simply not sure about the answer to that question," bioethicist Daniel Callahan wrote in 1995.

Go deeper:

Go deeper

2 hours ago - World

Special report: Trump's U.S.-China transformation

Illustration: Aïda Amer/Axios

President Trump began his term by launching the trade war with China he had promised on the campaign trail. By mid-2020, however, Trump was no longer the public face of China policy-making as he became increasingly consumed with domestic troubles, giving his top aides carte blanche to pursue a cascade of tough-on-China policies.

Why it matters: Trump alone did not reshape the China relationship. But his trade war shattered global norms, paving the way for administration officials to pursue policies that just a few years earlier would have been unthinkable.

McConnell: Trump "provoked" Capitol mob

Senate Majority Leader Mitch McConnell (R-Ky.) said on Tuesday that the pro-Trump mob that stormed the U.S. Capitol on Jan. 6 was "provoked by the president and other powerful people."

Why it matters: Trump was impeached by the House last week for "incitement of insurrection." McConnell has not said how he will vote in Trump's coming Senate impeachment trial, but sources told Axios' Mike Allen that the chances of him voting to convict are higher than 50%.

3 hours ago - Politics & Policy

GOP leaders skip Trump sendoff in favor of church with Biden

House Speaker Nancy Pelosi (D-Calif.), Senate Majority Leader Mitch McConnell (R-Ky.), Senate Minority Leader Chuck Schumer (D-N.Y.) and House Minority Leader Kevin McCarthy (R-Calif.) in July. Photo by Erin Scott-Pool/Getty Images

Congressional leaders, including House GOP leader Kevin McCarthy and Senate Majority Leader Mitch McConnell, will skip President Trump's departure ceremony in Maryland tomorrow morning in favor of attending mass with incoming President Joe Biden ahead of his inauguration, congressional sources familiar with their plans tell Axios.

Why it matters: Their decision is a clear sign of unity before Biden takes the oath of office.