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Victoria Pynchon

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Read Negotiating Life's End from the Bottom Up

I've received numerous notes about (and seen numerous "hits" to) the series "Negotiating Life's End." Many of this series' readers do not otherwise read blogs.  The purpose of this note is simply to say that a blog (web log) reads in reverse chronological order, i.e., to start at the beginning, you need to scroll down to the end for the first post and then read the post immediately above that and the one above that, until you come to the end, which is the beginning. (see Little Gidding below) 

If you'd like to read the series in sections by clicking on links in the usual order -- first to last -- here they are:

Negotiating Life's End 

Negotiating Life's End:  Part Two

Negotiating Life's End:  Part Three

Negotiating Life's End:  A Note of Gratitude for My Friends and Readers

Negotiating Life's End:  Part Four

Negotiating Life's End:  Part Five

Negotiating Life's End:  Part Six

Negotiating Life's End in Mediation?

Negotiating Life's End:  the Coming Crisis and Likelihood of Litigation

The Truth of Departure

For Friends and Family

I Owe it All to Dad

Below, My sister Sharon, Dad, me and my nephew Daniel.

It's very gratifying to find that my own experience can be of some use to others.  Please feel free to use the comments section to share your own stories, dreams, fears, challenges, successes, failures, triumphs, losses and the like associated with the lingering death of a loved one.

Life's far to short not to avail ourselves of the opportunity to create community, particularly when we are most in need of the experience, strength and hope of others who share our predicament.

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.

T.S. Eliot, Little Gidding, The Four Quartets

 

For Friends and Family

Dad -- former Los Angeles Superior Court Commissioner Donald Wayne Pike -- passed away on his 84th birthday:  9 June 2008.  

I keep thinking I'll work and then I can't so, not knowing what else to do, am making my father a memorial blog.

Before taking the whole dad-thing over there --  http://donaldpike.blogspot.com/ -- I want to say a couple of things.

Thank you to everyone for your love and support.  If I haven't responded to you it's because I am completely unreliable at the moment.  I know you'll forgive me.  As will my readers AND the wonderful Kevin O'Keefe whose voice-in-my-head keeps telling me to STAY ON TOPIC!!

On Dad's behalf, I have this to say to as much of the world who might stumble across this message in a bottle:  

What a great country where a kid from a Nebraska farm, uprooted by the dust bowl, driven into poverty with the rest of the country during the Great Depression, who left home at 14 or 15, earned his high school diploma in night school while driving a milk truck, married to my mother with two kids, and, who never spent a single day in college -- can go to law school; become an attorney; and ascend to the bench of the largest state trial court system in the world.  A man who -- for all his flaws -- inspired his daughter to go to law school when it was still not a common career goal for women.

Thanks Dad.  And thanks America.  For all your flaws.  For all our flaws.  Given the opportunity, we can still do great things.

The Truth of Departure

                   9 June 1924              Donald Wayne Pike              9 June 2008

Dust Bowl Refugee, High School Drop Out, Western Union Messenger Boy, Merchant Marine, Salesman, Lawyer, Judge, Husband, "Daddy" Step-Father, Grand-Father, Brother, Uncle, Cousin, Mountain Climber, Sailor, River Rafter, Story-Teller, Proud Capitalist, World-Class Worrier  and Sometime Liberal Democrat (when married to one) 

The Truth of Departure

                          -- W.S. Merwin

With each journey it gets
worse
what kind of learning is that
when that is what we are born for

and harder and harder to find
what is hanging on
to what
all day it has been raining
and I have been writing letters
the pearl curtains
stroking the headlands
under immense dark clouds
the valley sighing with rain
everyone home and quiet

what will become of all these
things that I see
that are here and are me
and I am none of them
what will become
of the bench and the teapot
the pencils and the kerosene lamps
all the books all the writing
the green of the leaves
what becomes of the house
and the island
and the sound of your footstep

who knows it is here
who says it will stay
who says I will know it
who said it would be all right

This is the force of faith. Nobody gets
what they want. Never again are you the same. The longing
is to be pure. What you get is to be changed. More and more by
each glistening minute. . . .   

from Prayer by Jorie Graham

Negotiating Life's End: the Coming Crisis and Likelihood of Litigation

One of the reasons I began this series was to explore the type of professional behavior that tends to trigger professional malpractice litigation -- and how that litigation might be avoided.   

As you may recall, my first post cited a study finding that the top three reasons for filing litigation against a medical provider were:  

so that it would not happen to anyone else . . . 91%

I wanted an explanation . . . 91%

I wanted the doctors to realize what they’d done . . . 90%

In that same study, only 66% of respondents said they'd brought suit because they wanted money.   

Other studies have found that the failure to health care professionals to effectively communicate with patients and their families give rise to more litigation than negligence or bad results in treatment.  As reported in the March/April issue of Patient Safety and Quality Healthcare

ineffective communication with patients and families, rather than quality of care, was the underlying cause of patients' and families' decisions to file suit against their caregivers (Vincent et al., 1994; Hickson et al., 1992). Other researchers found that most patients would be less angry and less likely to sue if physicians honestly and compassionately disclosed medical errors that occurred, admitted responsibility, took steps to reduce the chances of repeat errors in the future, and offered sincere apologies for the suffering that may have resulted because of the bad outcomes (Gallagher et al., 2003). Similarly, research on apologies suggests that individuals receiving a full apology that both expresses sympathy and takes responsibility by the person who wronged them are more likely to accept settlement offers and negotiate towards a resolution rather than going to trial (Robbennolt, 2003). 

See Conflict Management From the Heart:  A Day in the Life of a Medical Ombuds/Mediator by Carole S. Houk, JD, LLM, and Leigh Ana Amerson, BA here.


In Why People Sue Hospitals and Health Care Professionals in Heatlh Industry Online we learn that 40% of respondents answered "yes" to the question whether anything could have been done to prevent litigation after an adverse medical incident.  Those pre-litigation interventions were reported as follows:  

Actions That Might Have Prevented Litigation

% of Respondents

Explanation and apology

39

Correction of Mistake

27

Pay compensation

18

Correct treatment at the time

16

Admission of negligence

15

If listened to

5

Disciplinary action

4

Honesty

4

Investigation by hospital

3

Conflict Associated with End-of-Life Decisions

Someone once told me that a divorce is a hologram of the marriage -- that all of the marital dynamics that have never been resolved -- or even surfaced -- by the divorcing couple -- take shape and form in one way or another in the course of the divorce.  Not surprisingly, the "weapons" of marital dissolution are its most precious assets -- relationship and children -- and its most symbolic -- money. /*

So it is that historic family dynamics (rife with unresolved conflict) will more or less naturally play themselves out around the bed of a loved one who is -- or may  be -- dying.  

How much conflict is there?

One recent study found that conflict associated with decisions about life-sustaining treatment were rife with conflict between medical staff and the families of dying patients.  An abstract of an Conflict associated with decisions to limit life-sustaining treatment in intensive care units reported: 

MAIN RESULTS:  At least 1 health care provider in 78% of the cases described a situation coded as conflict. Conflict occurred between the staff and family members in 48% of the cases, among staff members in 48%, and among family members in 24%. In 63% of the cases, conflict arose over the decision about life-sustaining treatment itself. In 45% of the cases, conflict occurred over other tasks such as communication and pain control. Social issues caused conflict in 19% of the cases.

CONCLUSIONS: Conflict is more prevalent in the setting of intensive care decision making than has previously been demonstrated. While conflict over the treatment decision itself is most common, conflict over other issues, including social issues, is also significant. By identifying conflict and by recognizing that the treatment decision may not be the only conflict present, or even the main one, clinicians may address conflict more constructively.

It's Not About Money But it Will Become About Money if Conflict is Not Treated at the Source

I have much more to say about this but I need to get out to the Valley to see my dad who is -- amazingly (to me at any rate) -- surviving without food or water into Day Nine.

For now, I will simply remind my readers of the following:

Why the Coming Crisis and Likelihood of Litigation?

The parents' of the baby-boom are dying.  Extraordinarily high levels of conflict in health care settings are associated with dying.  Hospitals and health care professionals are not yet up to par in resolving conflict at its source.  In the absence of programs to assist the families of the dying negotiate their way through this traumatic experience, people will seek out attorneys; attorneys will, as the law does, monetize pain, suffering, and injustice. 

The research is in.  The solutions are available.

It's up to us.  

______________________________________

*/   Money is symbolic?  Yes it is.  As my longer article on the many meanings people give to money notes:

It is money’s nearly infinite plasticity that makes exchange of unlike things not only possible, but nearly effortless. Unlike barter, which famously requires a “double coincidence of wants,”  money creates a bridge to the future; permits trade at a distance; allows the exchange of durable objects for perishable goods; and, is capable of reducing nearly every human activity into a quantitative monetary value. 

Although contemporary money seems to have shed all of its qualities except its quantity,  “its oneness or fiveness or fiftyness,” we do not in fact use money as if it were fungible. We experience the value of a dollar earned differently from the way we experience one that is stolen or given to us as a gift and we spend it differently as well. 

See The Cost of a Thing is Your Life here

Negotiating Life's End in Mediation?

Let's for a moment assume that I had not surrendered the control of Dad's final days to his wife, into whose hands he has so indisputably placed them.  

If you've been following this series, you may have concluded that my Dad's immediate family (step-children; my sister) are likely indifferent to, uninterested in or incapable of dealing with the end of Dad's life.  My compassionate default is that these blood- and step-siblings are neither uninterested nor callously indifferent to my father's fate, but simply incapable of responding to this intensely emotional experience for family-historical, social, psychological, emotional or practical reasons.  

Let's assume, however, that surrounding my father's hospital bed is a clamorous family, all expressing different concerns, desires, options, solutions and resolutions to the question whether to insert, or later remove, a feeding tube, remembering Ken Cloke's observation in his new book, Conflict Revolution, that a dispute occurs 

not only between individuals, but in a context, culture, and environment; surrounded by social, economic, and political forces; inside a group or organization; contained by a system and structure; among a diverse community of people; at a particular moment in time and history; on a stage; against a backdrop; in a setting or milieu. 

Do you have the hypothetical in mind?

What's a family to do?

In a comprehensive and award-winning article on this precise issue -- Negotiating Death, ADR and End of Life Decision-MakingGlenn Cohen -- who has accepted an appointment as an Assistant Professor at Harvard Law School, begining in the 2008-2009 academic year -- suggested in a Spring 2004 issue of the Harvard Negotiation Law Review that disputes in the death and dying context are often really "misunderstandings," in the sense that they are not real differences in opinion or belief about the "correct" treatment option.  Cohen quotes one bioethicist who adopts a mediative model as follows:  

[These] conflicts were often fueled by different perceptions of the medical facts, different understandings of the prognosis, different interpretations of patient behavior (generally relating to whether the patient was experiencing pain and suffering) and different personal value hierarchies. As we searched for ways to help patients, family members, and staff understand the clashing cultures and discordant assumptions that animated their arguments, we realized that the substantive parts of our interventions were more than outweighed by the process elements. Searching for the right theoretical model steered us to the frame and the techniques of mediation.

The mediators in my readership will not doubt the efficacy of neutral-intervention in these decisions.  As my own experience demonstrates, however, no one sends a mediator or even the palliative care nurse or social worker to your loved one's hospital room unless someone has "hipped" you to the fact that they are available to you. 

Listen, my first husband was a social worker and it wouldn't have occurred to me to ask for one at the hospital unless my health care executive friend had told me to do so.  Nor would I have known there was a palliative care nurse on staff unless my friend the hospital hospice director hadn't told me her name and how to contact her.

So What, if Anything, Could a Mediator Do to Assist the Family in the Circumstances Outlined in My Hypothetical?

Training Issues

Cohen has systems in mind, not merely interventions, so he begins his proposed five-step model with training (echoing my question to the social worker -- "don't they train these doctors in active listening?")

Much of what we have said before about managing emotions [/*] is relevant here, as is the clarification of "professional emotions" on the part of doctors. Negotiation training for doctors is a must. . . . Already the negotiation field is beginning to tailor training programs to health care professionals by using narratives and cases developed by doctors for doctors. , and discussion of appropriate techniques with simulation, exercises and feedback."  . . . . .

More specifically, [others] identify five types of ADR training and education: marketing efforts (convincing stakeholders to buy-in),awareness education (informing users what ADR is and what role it plays in the organization),conflict management and communication training (generic training not geared towards a particular type of ADR, [r]ather, it is focused on increasing participants' understanding and acceptance of conflict and on improving their communication skills, including active listening and direct communication"), consumer/user training (focusing on what to expect in the ADR proceeding, how to prepare for ADR, how to identify interests, options, etc.),and training of third-party neutrals. 

____________________

*/   But please don't let the family know that is what you are trying to do, i.e., manage, rather than support, their emotional responses to a loved one's final days.

____________________

Bio-ethical Mediators

[A] bioethical mediator [would] help[] to identify all the parties and their interests, and develop a common understanding of the medical facts and options. For instance, consultants might be called in to finely tune a prognosis. 

When coming into [a case], the [bioethical mediation] team asks: Who are the parties to this conflict? What are their interests? Are those interests in conflict and, if so, how might the conflict be resolved or consensus forged? This formulation grew out of the clinical finding that most of the events labeled "bioethical dilemmas" were really "conflicts" that pitted members of the hospital team against each other, or members of the team against some or all of the patient/family constellation. 

The Creation and Use of an ADR-Oriented Ethics Committee

Membership: . . . . What is indispensable is that the panel not be insiders. If having physicians sit on the panel is seen as essential, it may be useful to use physicians who teach at local medical schools or who do not practice at that particular hospital. . . . . .

Initiation: In keeping with the sequencing of low- to high-cost methods of dispute resolution, the process should be initiated at the request of the patient, her family, any member of the health care team, or the bioethical mediator if he or she is unsatisfied with the resolution at Step 2.

Methodology: Here there is a spectrum of formality that will depend on the individual hospital and its resources, ranging from advisory arbitration to mini-trial. In principle, there is no reason why the Committee might not offer multiple options along the spectrum of formality at the election of the parties. Depending on the level of formality chosen, the parties might represent themselves or seek legal representation. 

Opinion: This should be delivered in writing, be well elaborated, and be the kind of opinion that can give the parties information relevant to how a court might decide the dispute.

Bindingness: What is essential is that someone present at the arbitration process has the authority to bind the hospital. If power imbalances favoring the hospital are a concern in the process, one possibility to "retilt" the system might be to make the arbitration "asymmetrically binding," making the hospital abide by the arbitration decision while the opposing parties are not equivalently bound. If there are concerns about this, some kind of safety valve could be provided. For instance, the binding nature of the Ethics Committee decision could be overruled by a majority vote of the Hospital's board of directors.

Cohen's Conclusion?

Having used Terri Schiavo's case as a jumping off point, Cohen suggests that the experience of her care-givers, elevated for a time into a national controversy (see Cloke above) 

highlights what each of us fears about our own deaths: that we will not die with dignity, that our wishes may not be followed, that decisions on our treatment may tear apart our families and bring rancor to the lives of those we love. Terry Schiavo's case also shows that in quelling our fears, the adjudicatory model offers scant succor.

While in theory, advanced directives offer a promising resting point for American jurisprudence's unsatisfying oscillation between full-on adjudication and completely private determination, in practice they have never caught on. The ideas and techniques ADR has
cultivated over the last thirty years offer us, and our families, a chance to do better. ADR can:

  • Help to resolve "misunderstandings" that the adjudicatory model tends to treat as full-blown "disputes;" 
  • Identify intermediate options that satisfy both parties and remove the need for rights-oriented dispute resolution; 
  • Offer a lower-cost form of rights-oriented adjudication when a dispute must be "decided;" 
  • Enable the patient and free him from the debilitating "object" status accorded to him by adjudication; and 
  • Offer emotional settlement lacking in the typical litigation process.

Concerns about cost, due process protection, and institutional resistance to implementing such an approach add complexity, but this article has suggested possible approaches to solve those problems. Moreover, these concerns have to be compared to those attaching to the status quo regime that consists of large amounts of "lumping" it. While the details of an appropriate ADR framework will vary from institution to institution, this article has offered a five-step model for implementing an ADR-informed approach to end of life decision-making, as well as discussing alternative options at every stage. It is only by
combining the work of fields such as medicine, law, and organizational development that we are able to provide a thing of major concern to the aging population of America: the assurance of dying well.

The Coming Crisis in Health Care and End-of-Life Decisions Here

Negotiating Life's End: Part Six

Evil is not initially a grand thing, but begins innocuously with a constriction of empathy and compassion, creating . . . . the “smallest piece of evil.” This is simply the inability to find the other within the self. This smallest piece of evil can expand rapidly, replacing empathy with antipathy, love with hate, trust with suspicion, and confidence with fear. . . . A potential for evil is thus created every time we draw a line that separates self from other inside ourselves.  Kenneth Cloke, Conflict Revolution, Mediating Evil, War, Injustice, and Terrorism

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time

T.S. Eliot, The Four Quartets, Little Gidding

(photo:  Dad on our first rafting adventure in the Grand Canyon, 1990)

I re-connected with the father I'd idolized since childhood in 1984 when I moved from Northern California to Los Angeles.  By that time, Dad had taken up professional residence in the law and motion department in the downtown Los Angeles Superior Court.  Between my move to Los Angeles and Dad's retirement in the early 1990's, we met for lunch at least once a week, where we slowly replaced our idealized versions of one another with the flesh of blood reality of us in our all fallibility, complexity and texture.  After Dad retired, lunch morphed into early-morning hikes in the low lying Santa Monica mountain range that separates the San Fernando Valley from the Los Angeles Basin. 

Though I was never welcomed into Dad's second family, we formed a largely collegial adult relationship which eventually came to include extended-family "adventures" planned and underwritten by Dad -- rafting; mountaineering; canoeing; boating; kayaking; and, scuba diving.

This was not the father of my fantasies.  He did not show much interest in my life, my loves, my fears, or my difficulties, although he very much enjoyed hearing about my successes.  He liked money and status -- for its own sake -- and was pleased when I could deliver stories with big round numbers associated with the names of well-known law firms.

I can most easily communicate the chasm that yawned between us by telling you the following story.

I'm Not Interested in People's Personal Lives

Dad and I, along with my step-siblings, were flying home from a rafting trip on the Salmon River in the early '90s.  By that time, I'd begun taking fiction-writing classes through UCLA extension and had once again become a voracious reader of novels and short stories. Dad, whose reading material consisted primarily of World War II chronicles and biographies of great generals, had uncharacteristically failed to pull a book out of his luggage before we boarded the plane. I'd just finished reading my then-writing professor Bernard Cooper's haunting memoir Truth Serum (title story here) which was still in my carry-on. 

I handed Bernard's memoir to Dad, saying "try this" before losing myself in whatever book that had captured my attention.  As the plane touched down at LAX, Dad handed the memoir back to me even though he'd only read the first couple of chapters.

"Keep it," I said.  "You can give it back to me after you've finished it."  But dad pressed it on me nevertheless saying, "You know, I'm not really much interested in people's personal lives."

Not only did I finally and instantaneously "get" the two of us, I suddenly realized it was  O.K. with me.  By that time, I'd come to deeply appreciate the gifts Dad had given me -- in early childhood, genetically and by way of example -- his clamorous appetite for adventure; his soaring ambition; and, his appetite for life at its most dizzying edges.  He was not fearless.  But he conducted his life  as if he were.  

I was finally able to find dad within myself.  My heart expanded correspondingly. 

Morphine

My father has had a Filipino caretaker -- Jungao -- for several years now.  I don't think anyone loves dad more deeply or knows him better.  Jungao was a dentist in the Philippines and is now the likely bearer of the greatest number of dad's treasure of tales -- war stories; farm stories; fruit picking stories; childhood tales; chronicles of wine, women, song and other wild confabulations of memory and desire.   

Last Thursday, Dad was released to home hospice care.  He hasn't been fed or "hydrated" since then.  Seven full days. 

Jungao hovers attentively when I am present, reassuring me that my father knows I am there and  hears what I'm saying.  He interprets the meaning of Dad's eye movements and facial expressions.  The furrowed brow, the way Dad soundlessly opens and closes his mouth; his occasional startled physical movements; and, what might even be translated into a smile.  

I tell my friend Jay at my morning meeting that it feels as if Dad is trying to tell me something but I don't know what it is.  He says, "listen with your heart and you'll probably hear it."

Juanita and Jungao have had words about the morphine.  Juanita believes Jungao disapproves because of his religion, but she hasn't actually asked him why or what his religion might be.  She's merely instructed him to follow her orders.  She tells me Junagao insists Dad talks to him when the morphine begins to wear off.  She thinks Junagao is lying.    

I have surrendered control to Juanita even though the manner in which my father is dying continues to disturb me. 

This is what I know.  When Dad married Juanita, he'd already experienced some of Parkinson's most debilitating effects.  Juanita promised Dad she wouldn't put him into a nursing home.  They had years together to talk about when and how he wanted his life to end.  She knows more than I could possibly understand.  More importantly, when Dad was cogent, he had entrusted Juanita -- not me -- with the obligation, the right and the power to make these end-of-life decisions for him. 

This is his choice playing itself out in his life.  It is not my place to interfere.

Memories

I am sitting by Dad's bedside chattering about my fondest father-daughter memories -- sitting on his lap at five steering his Volkswagen down the sidewalk in front of our house.  The day he taught me to ride my first two-wheeler.  The ill-fated adventures from which we'd return home drenched, "play clothes" torn,  limbs scratched, knees bruised and faces dirty.  

Here's the best one:  When Dad lived with us, he was a milkman in a white milkman's suit, carrying a wire basket filled with milk, eggs, cream, and butter for delivery to suburban San Diego families.  For those of you too young to remember, this is what milkmen looked like.

If my sister and I successfully completed our weekly chores, our parents pasted gold or silver paper stars on our "chore chart." If we had enough of these by week's end, Dad would take us on a "surprise ride." On one particular Saturday when I was six, Dad took us to his dairy; introduced us to the ruminating cows, gave us a ride in his truck and -- BEST OF ALL -- slipped us into milk crates sitting motionless on a circular conveyor belt, flicked the "on" switch and let us ride, ride, ride, ride.

Blue Eyes

Dad has been gazing into my eyes for one full hour and I have run out of things to say.  I have no recollection of Dad ever before making eye contact with me.  I sit still, breathing, and we gaze into each others eyes for two more hours.  

Finally, when it is time to go, I admit that to him I have been struggling.  "I think you want to tell me something," I say, "but I don't know what it is."  His mouth opens and closes and his clear blue eyes shine more brightly than before.  "Can you tell me what it is?" I ask, leaning my head down to his open mouth.  But the only sound is that of his breath.  In, out, in, out, in, out.   

I remember what Jay said about listening with my heart.  Still, I can't hear anything.

Finally, I admit that I am completely at a loss.  I don't think.  I just begin to speak.

"I can't imagine what else there could possibly be for us to tell one another," I say, "except this:   

I love you and I know you love me.  I . . . . . love . . . . . YOU . . . . and . . . . I . . . . KNOW . . . YOU . . . . love . . . ME.   I love you.  And I know you love me.

And then I slip out the door, saying I'll return tomorrow.

Read on here.

Negotiating Life's End: Part Five

(me and Dad in San Diego's Balboa Park a year or so after the divorce)

Conflict Suppression, Denial, Avoidance, Engagement, Resolution, Transformation and Transcendence

If you've been reading this series, you already know my family's conflict resolution technique of choice -- denial.  Conflict denial works best when the parties aren't in contact.  The social psychologists call this "autistic hostility."  

When you're in a state of autistic hostility, writes Morton Deutsch, the E.L. Thorndike Professor and Director Emeritus of the International Center for Cooperation and Conflict Resolution at Teachers College, Columbia University,

[y]ou think you've been hurt by the other, you're angry, you break off communication with the other, you don't talk about it with the other, you ignore the other.

I have autistic hostility towards coffee. I don't know why, but as long as I can remember I have had an aversive reaction to thinking about it. I, as a result, never drink coffee. I avoid any taste of coffee, like coffee ice cream. I may be mistaken about coffee. Maybe I would like it.

Maybe if I experienced it, if I had contact with coffee. If I had communicated, so to speak. If I allowed to coffee to communicate with me, it would change my attitude. That's one thing that happens sometimes in conflict. You maintain your hostility autistically, within yourself, without any necessary reactor.

We Make Stuff Up

If you're a trial attorney, you know all too well that juries, in the absence of information, just make $#%^@ up.  Did you fail to construct a link in your evidentiary causal chain?  If the jury likes your client, your story, your presentation, your place in the social order, your expert or anything else about the product you are selling -- your case -- they'll forge that chain for you.  If not, not.  

When adults are in a state of autistic hostility, they tend to demonize one another -- an extremely common result of litigation.  

When children lose contact with a parent, however,  they tend to idealize the missing caretaker.  With no feedback mechanism against which to test a parent's merits, teenagers tend to retain the idealized images created in childhood, which tends to delay the healthy recognition during early adulthood that one's parents -- though loved and loving -- are simply fallible human beings like everyone else.  

In Dad's Case, Idealization Was a Piece of Cake

I could write Dad's biography, but a skeletal outline will suffice.  

Nebraska farm until age seven or so.  Dustbowl.  The family abandons the farm, fills the Model-T with nine children and all of their worldly possessions, heading for  Portland, Oregon where logging work work beckons

Dad's Dad -- a farmer with arthritis -- can't take the cold and the damp.  The family heads down south, picking fruit in the fertile fields of the Imperial Valley along the way

They land in the "back country" of San Diego -- first Julian and then Ramona

My granddad never works again.  My grandmother raises chickens and takes in laundry. 

 

Dad drops out of high school at 14, works as a Western Union messenger in downtown San Diego, delivering, among other things, whiskey to whore-houses.

(throughout this narrative, the reader must recognize that all great story tellers like my father are notoriously unreliable narrators; the essence is usually true; the details are often the stuff of fantasy)

World War II.  Merchant Marines

Marriage and children.  

Dad earns high school diploma when he is 35 and I am seven.  Two years later, he high-tails it out of town.  Sacramento.  Second wife and family.  

Dad moves to Los Angeles.  Goes to law school (!!!) without spending a single day in a college.  

He passes the Bar at 42 years of age and sets up a solo practice in Beverly Hills ("where the rich people are").  

Dad becomes a Juvenile Court Referee and then a Los Angeles Superior Court Commissioner, sitting as a Judge upon the stipulation of the parties. 

He amasses wealth by buying foreclosures in the San Fernando Valley

Rafts rivers, climbs mountains.

Not much need to make anything up.

Legendary.

Dad.

Part Six Here

Every Conflict Takes Place in a Context, Culture and Environment -- from Conflict Revolution

Let us begin with a few simple, yet profound and far-reaching truths. First, every conflict takes place not only between individuals, but in a context, culture, and environment; surrounded by social, economic, and political forces; inside a group or organization; contained by a system and structure; among a diverse community of people; at a particular moment in time and history; on a stage; against a backdrop; in a setting or milieu.

Second, none of these is conflict-neutral. Each contributes, sometimes in veiled and unspoken yet profound ways, to the nature, intensity, duration, impact, and meaning of our conflicts. And each, depending on circumstances, can play a determining role in the success of the conversations, interventions, and methods used to prevent, resolve, transform, and transcend conflicts.

Third, nearly any social, economic, or political issue can trigger or aggravate interpersonal conflicts. Indeed, social dysfunctions, economic disparities, and political incongruities are nearly always experienced as personal conflicts, leaving the systems that regularly create them in the shadows, unnoticed and unresolved. Moreover, nearly everyone is capable of taking even the most abstract, obtuse differences personally and, as a result, is less able to learn from or transform them.

Fourth, social, economic, and political systems, by reason of their embattled history and internally divided nature, generate chronic global conflicts and with them a culture of conflict avoidance. These give rise to a set of adversarial attitudes and behaviors regarding global problems that limits the ability of individuals, groups, and nations to work collaboratively and democratically, even in small ways, to overcome their differences and solve them.

Fifth, every conflict possesses elements and characteristics that are self-similar on all scales, so that a common set of attitudes, emotions, ideas, and behaviors connects purely internal conflicts with those that occur in relationships, families, communities, organizations, societies, economies, and nation-states. This self-similarity on all scales allows us to identify ways of adapting resolution techniques that have proven effective for resolving disputes on an entirely different level.

Sixth, nearly all conflicts, no matter how petty or personal, possess veiled social, economic, and political features that inform their evolution and eventual outcome. These include social prejudice, economic greed, and the autocratic exercise of political power. When these hidden aspects are identified and analyzed, they become fertile sources of methods and techniques for preventing future conflicts, reaching successful resolutions, transforming social, economic, and political relationships, and transcending chronic conflicts at their source through learning and systemic improvement. As a result, nearly all conflicts can trigger revolutionary changes in individuals, organizations, and institutions.

Even in entirely interpersonal conflicts, people may respond negatively to social or cultural differences, develop biases and stereotypes, interact based on unspoken social assumptions and expectations, or be influenced by status, wealth, and power. They may quarrel over money, compete for scarce resources, or disagree over the way power is being used. They may differ regarding future goals or prior history, critique or defend the status quo, or advance points of view that reflect conflicting roles and responsibilities. Each of these sources of discord conceals a subtle social, economic, or political element that leaves it less open to resolution.

Seventh, except when social, economic, and political issues are explicitly raised, it is rare for these contextual, environmental, or systemic elements to be openly identified, acknowledged, or resolved, either by the parties or their mediators. Instead, they linger in the background, generating distortions and misunderstandings that make matters worse.

Read on here.

Negotiating Life's End: Part Four

(Dad with his One True Love -- the Boat -- July 4, 1976) 

We tell ourselves stories in order to live.  . . . . We look for the sermon in the suicide, for the social or moral lesson in the murder of five. We interpret what we see, select the most workable of the multiple choices. We live entirely, especially if we are writers, by the imposition of a narrative line upon disparate images, by the "ideas" with which we have learned to freeze the shifting phantasmagoria which is our actual experience. Joan Didion, The White Album

The poem, then, is not a transcription of an already known world, but a process of discovery, and the act of writing . . . is one that demands personal risks.  [The poet does] not write solely in order to express himself, but to orient himself within his own life and take his stand in the world and it is this feeling of necessity that communicates itself to a reader.  [P]oems are more than literary artifacts.  They are a means of staying alive.  Paul Auster, The Poetry of Exile, from The Art of Hunger.

[T]he process of revising a poem is no arbitrary tinkering, but a continued honing of the self at the deepest level.  Jane Hirshfield, Nine Gates - Entering the Mind of Poetry.

[T]o safeguard what little equilibrium I still possessed, I chose to sit as I have been sitting all my life, in a chair, at a desk, under a lamp, substantiating my peculiar existing in the most consolidating way I know, taming temporarily with a string of words the unruly tyranny of my incoherence.  Philip Roth, Operating Shylock. 

Palliative and Hospice Care

"You can't tell families that their only choices are surgically attached feeding tubes or starvation," my friend Jay the hospice director is saying on the morning after my run-in with Dr. X. 

Jay and I are standing on the steps of the West Hollywood Kiwanis Club, where I attend a regular morning meeting with people whose history and spiritual values are similar to my own.  Although we're on a major urban thoroughfare undergoing reconstruction of the jack-hammer kind, the scent of night-blooming jasmine still lingers in the cool morning air. 

"We express love with food," Jay continues, "and care-taking.  When a child skins his knee, mom doesn't just put a band-aid on it, she offers cookies and milk 'to make it better.'"  

I relax for the first time since Juanita's call.  Jay gets it.  It's not just about the mechanics, the diagnosis, the prognosis, or the treatment plan.  It's about love.

Holding my hand while tears stream down my face, Jay tells me how to feed a man who can't swallow.  "The little honey bear," he's saying, "you tip it into your father's gum where the ball players keep their chewing tobacco.  Rub it into his gums.  Not only will it provide instant nourishment, it crosses the blood-brain barrier.  It will improve his cognitive functions as well." 

Jay pulls a clutch of business cards from his pocket -- cards he has gathered from every hospital in the greater Los Angeles area.  He scribbles the name of the hospital's palliative care nurse on the back of his own card.  

"Tell her I gave you her name," Jay says, knowing how irresistible it is for us to pay more attention to people we believe to be "inside" our circle of friends and colleagues.  "Call her on your way to the hospital," he says, giving me one more squeeze for courage before I go.

"It's Not Your Decision"

The palliative care nurse has already arrived in Dad's room by the time I make my way out into the deep reaches of the San Fernando Valley.  She and my step-mother are going over the details of a plan for home-hospice care.  Dr. X will confirm that dad has less than six months to live.  Once he delivers that verdict and signs the order releasing dad, the hospice people will arrange everything -- delivering a hospital bed; medication and equipment; assessing medical and nursing needs, even providing pastoral care.

"What about the new medication," I ask.  "And the new diagnosis?" 

"That's not the direction we're going in," says Juanita as I listen to my father struggle for breath behind her.  "We talked about this, your dad and I.  I'm sorry I let them put the feeding tube in.  I know what he wants and I'm the one he chose to make this decision for him."

"Will he be fed?  Hydrated?" I ask. 

"No honey," my step-mother responds.  "There's no quality of life here.  There's nothing left for your father to live for.  He's dying.  He's suffering.  It's time to let him go."

There's Nothing for Me to Negotiate Here

I've been trained to wrest control from the uncontrollable since law school.  Define goals.  Frame questions.  Information gather.  Brainstorm.  Plan strategically.  Marshal resources.  Make demands.  Couple them with consequences.  Be supple, flexible, responsive, but firm.  Stay "on message."  Negotiate on my terms and preferably on my turf.  Prepare, prepare, prepare.  Move, move, move.     

I'd been in crisis mode since Juanita's telephone call.  But I'd never stopped to ask myself the first question any advocate or negotiator should ask.  

What was my role here?  And if I had one, what were the scope of my duties?  What did my father -- my "client" want?  And if I didn't know the answer to that question, where could I look to ascertain it?

Dr. X had actually provided me with the answer to these central questions the first afternoon I'd arrived at the hospital.  But I wasn't ready to hear it.  And he wasn't trained to deliver it.

In one of those small waiting rooms where families await the fate the their loved ones, I'd sat with the hospital social worker later that same afternoon.   

"Don't they teach these doctors active listening?" I'd asked after recounting the Dr. X catastrophe to her.   

The social worker put her hand on my knee and said, "you're not the mediator here.  And you're not responsible for the result.  Your step mother has the power of attorney.  She's the one who will make the decision.  The only thing you have to be is be the daughter."

But I wasn't ready to hear it then either, even though the social worker was ever so much better at expressing it.

Next . . .

Negotiating Life's End: an Expression of Gratitude for My Friends and Readers

(image from Thunderbow Expeditions

Though my posts about my father's illness and imminent death may seem "off topic," as the poem below reminds us, we are all heading toward this particular destination. 

This recognition helps give perspective to all of our negotiations -- with our families, ourselves, our workplace, our churches and mosques and synagogues, our commercial actitivies and our local, state, national and international political affairs. 

This particular life passage -- so close at hand -- is revelatory for the work I do because it touches on the true bottom line of every negotiation with our fellows -- honorable relationship; gratitude for community; the necessity for compassion; the expression of empathy; the willingness to forgive; and, the miracle of reconciliation.  

Before sharing with you the poem written by my good friend Joe Mockus, I want to share two things with you.

First, the lessons my dad taught me rafting rivers from Costa Rica to Idaho -- keep your oar in the water ("for balance") and paddle through your fear.

Second, my gratitude for everyone who has written to express sympathy.  You don't know how much it means to me to have my readers "come to life" in the way that so many of you have. 

Thank you.

That said, here is a poem by one of my oldest and dearest friends -- whose own father is struggling with end-of-life issues himself.  Attorney, poet, rock 'n roll musician, dad, husband and friend Joe Mockus taught me more about how to read -- I mean really read -- than any one of our professors at U.C.San Diego where, for a time, we were both pursuing our undergraduate degrees in literature.  

This is the answer, by the way, to the question -- "what's the use of a liberal arts degree?"

Thank you Joe for writing this; for sending it; and for making this time in my own life not simply bearable, but beautiful as well.       

A Life

The primary activity is avoiding
Obstacles– rotting logs, mostly
Rocks. Rowing backwards
Against the flow. Slowing

The raft while the water
Moves fast. Picking the right
Spot and letting go
When the water turns white. Then

Near the end, finally pushing
Forward in the slack
Toward that beach
Where we all land

Negotiating Life's End: Part Three

(right:  Mom and Dad, late '40s)

Dr. X promptly sent me a social worker who was willing and able to answer all of my questions about my father's present condition; the common courses end-stage Parkinson's takes; and, the options available for his care -- aggressive treatment; tube feeding with hydration; palliative care; and, in-home hospice services.

I left the hospital that evening feeling not just better informed but comforted knowing there were people who were educated, trained, skilled, and talented at helping families make the type of decisions we were struggling to make with integrity and compassion.      

"This Man is Nowhere Near Death's Door"

I was awoken from a light and troubled sleep by a telephone call from my step-mother, who was now just as agitated with a physician as I had been the previous afternoon.  

She spoke with urgency. 

"That doctor you fought with," she said, "he sent a neurologist to your father's room at midnight.  Some woman I'd never met before.  I think I might have insulted her." 

"Good for you," I responded, thinking it progress for Juanita to question authority.    

"It's your doing," she said flatly. 

I was uncharacteristically silent.  I couldn't tell if she was expressing gratitude or blame.  

"It's because you yelled at Dr. X.  He wouldn't have sent that woman unless you'd done that."

I still couldn't tell.  It didn't really matter.  We were both doing the best we knew how. 

I asked for the story of the new neurologist as I slid out of bed to avoid waking my husband.  

Juanita was huffy.  "She examined your dad for an hour and then said his medication was completely wrong.  She prescribed him new medication and I don't know what right she has to do that."

"What did she say about his condition?"

I could hear Juanita take control of the conflicting emotions this doctor's diagnosis must have raised in her.        

"That doctor said, 'this man is nowhere near death's door.'"

The Parent Trap -- Hey, Hey, Hey

My parents' divorce in 1961 coincided with Walt Disney's upbeat movie about marital collapse and child custody -- The Parent Trap.  The brilliant Hayley Mills, squared into twins separated in infancy, divided like community property between the beautiful Maureen O'Hara and dashing Brian Keith upon their divorce, and re-united as teens to heroically reignite "their" parents' romance, was as far from my own experience as possible.  Children aren't capable, really, of processing this particular complex set of emotions:  relief that a violent father and physically fragile mother will no longer be scaring the wits out of their children; and, the aching loss a father leaves behind when he believes that divorce means removing from his life everyone associated with his marriage --  including his children.      

In other words, at nine years old, I didn't know whether to be happy or sad; guilty or justified, in response to my Dad's sudden departure.  But the idea of wilfully re-uniting this mismatched pair -- though perhaps some other child's Disney fantasy -- was not my own. 

Nearly forty years later when my father, in his first semi-psychotic episode, left and later divorced his second wife, his second set of children abandoned him.  

By the time my father lay in his hospital bed last week -- either "on the brink of" or "nowhere near" death -- the person with the absolute legal right to decide his fate was his wife of a mere five years duration.  And the only "child" with any interest in stepping forward to help make that decision was me.  

Next:  No Food, No Hydration

Negotiating Life's End: Part Two

(right:  Dad at 19; everthing about him was big -- not just the hair)

My step-mother's disembodied voice rose up from my answering machine last week with the words we're all afraid to hear: 

"Vickie, your Dad's in the hospital; his condition is not good;  please call me."

The last time I'd seen my dad, about two weeks earlier, he'd been sitting in his favorite chair with his eyes closed.  Part of him, the seeing part, wasn't much interested in being there.  

But dad was a talker; a spellbinding story-teller in the Irish tradition even though he liked to identify more with the Swedes in his lineage.  Vikings you know.  Warfare.  Being a manly man.   

Dad married the second time when I was in elementary school.  His first marriage to my mother having been a  failure of spectacular proportions, he took pains to begin my instruction in the basics of a happy marriage as soon as his second chance at marital bliss presented itself.  

"At the end of the day," he said when I was only 12 or 13, "the man gets to tell his stories first.  You can talk about your own day as much as you want.  But you have to make sure your husband goes first."    

Now, at 85, in the late stages of Parkinson's, Dad wasn't even having a day, let alone telling it, and certainly not telling it first.  

As dad sat immobile in his "easy" chair, you could hear the disease strangle the narrative out of him -- the mild dementia; the increasingly rigid muscles in his throat; the way he forgot the entire point of what he wanted to say by the third or fourth word he managed to slip past his captors.       

But he hadn't been anywhere near dying.

The Feeding Tube

As I drove out of the Los Angeles basin up through Laurel Canyon and down into the San Fernando Valley, Juanita, my father's third wife, was telling me by cell phone that Dad's Parkinson's was preventing him from swallowing.  He couldn't eat or drink.  He was choking.  The hospital was suggesting that a surgical feeding tube be attached and Juanita understandably wanted his children to help make the decision.

Dad, a life-long, semi-agnostic Protestant, was in a Catholic Hospital.  If his condition deteriorated badly -- if he entered a vegetative state -- I was worried about becoming immersed in a Terry Schiavo controversy.  I needed to know whether the hospital would later consent to the removal of a feeding tube.  That was my mission.  To find that out.  I called a friend in the healthcare industry who told me who I should talk to and what I should ask.  I was prepared.  

Your Father's on the Roof 

There's a old joke about friends -- we'll call them Bill and Jean -- who take care of the neighbor's cat while the neighbor -- we'll call him Phil -- is on vacation.  Upon his return, Phil rings his neighbors' doorbell only to have them immediately announce that Phil's cat is dead.  

Phil protests. 

'You're not supposed to come right out and say my cat is dead," says Phil.  "You're supposed to prepare me.  You're supposed to say something like, 'we were feeding the cat but he ran out the front door when we weren't looking.  He climbed up on the roof and couldn't get down.  We called the fire department and they raced over but the fire fighter who climbed up to the roof lost his footing on the way back down.  He managed to save himself but dropped the cat.  We rushed to the vet but there was nothing the vet could do.  We're terribly sorry but your cat had to be put to sleep.'"  

Everyone paused.  Finally, Bill said, "listen, we dropped by your mother's house last night and while we weren't looking she climbed up on the roof . . . . . . "

Dr. X Delivers Bad News

I arrived at my father's hospital room at the same time Dad's primary physician, Dr. X was making his rounds.  I introduced myself as Don Pike's daughter and asked about my Dad's condition.  For reasons I didn't understand, this seemed to irritate Dr. X.  

"What do you want to know?" he asked, eyeing me suspiciously.  "Your step-mother has already decided what will happen."

"And what is that?" I asked, not having yet had the opportunity to speak with my step-mother since our cell-phone conversation fifteen minutes earlier.  Something must have changed in the interim.

"It's quite simple," said the doctor, as if he were speaking to a child.  "Your father can't swallow.  His wife doesn't want the hospital to insert a feeding tube. We'll send him home with morphine to ease the pain.  Without food, he will quickly die of renal failure."

They say anxiety interferes with the functioning of the brain's higher "executive" functions.  So I wan't thinking very clearly.  

"You're going to let him die of starvation?" I asked.  "I mean," I was almost stuttering now, "you're gong to starve him?  Why?  What is his prognosis?"

Though the word "starvation" carried the most emotional wallop for me, it appeared to be my use of the word "prognosis" that disturbed Dr. X.

"Prognosis?" he asked, glaring at me now.  "Prognosis?  He's in the last stages of Parkinson's disease.  That's his PROG-NO-SIS."

My step-mother -- a member of a generation trained to accept whatever doctors say as holy writ  -- tried to intervene -- begging me not to "fight" with the doctor.  "Please, honey," she implored, "it's hard enough as it is; just do to what the doctor is telling you to do."

Throughout this debacle, my father was gurgling as if he were drowning.  Only when his moaning reached a certain pitch would the nurse come in to suction liquid from his throat, encourage him to cough up whatever fluid was in his lungs, and then suction that as well.  Like the dentist does, except you're generally not drowning when you're having a cavity filled.   

I didn't want to make trouble for my long-suffering step-mother, but I'd just heard that everyone had decided to starve my father to death in my absence because he was in the "last stages" of Parkinson's and I didn't know what that meant.

Information Gathering

"I don't know what end-stage Parkinson's means," I finally said, feeling dizzy and wishing I could sit down somewhere.  On my father's bed perhaps where I'd form a physical barrier between him and this angel of death in a white coat sporting his emblem of authority -- the ubiquitous hospital stethoscope.  

"I don't know what 'final stage' Parkinson's looks like," I muttered, feeling chastened but unwilling to simply "let the matter go."  

Perhaps he was emboldened in his anger by the way I was looking at my shoes, temporarily "unmanned" if a woman can use that term. For whatever reason, Dr. X took the opportunity to stride toward my father's bed and rip the sheet away from his frail, bruised and half-naked body, revealing not only a form that appeared to be entirely convulsed in uncontrollable spasms, but also exposing my father's one quiescent appendange -- his soft penis, curled passively just below the edge of his hospital gown.

"This," snarled Dr. X., sweeping his hand from the top of my father's head to the tip of his toes, "is what late-stage Parkinson's looks likeIs this what you wanted to know?"  he asked, as if in the very asking I'd brought this agony upon myself and my exhausted step-mother.  That I'd just made myself complicit in my father's continued suffering.  That this pitiable wreckage of the man who taught me to raft Class Four rapids was somehow my fault.   

Mea culpa, mea culpa, mea maxima culpa

"This is not your decision," Dr. X continued, without having the decency to cover up my father's nakedness.  "You have nothing to do with this and nothing to say about this.  Your step-mother has the Power of Attorney and she has already made the decision."

Then all hell broke loose.  I began to shout and, I must admit, also to cry, as my step-mother lunged out of her chair to push me back against the wall, away from Dr. X and my father.  "I'm his daughter," I remember repeating and "Juanita asked for my help in making this decision." I'd also lashed out at Dr. X, saying something about improving his "bedside manner."  But nothing had any effect until I said two words. 

They were "informed consent."

"I don't think I have enough information to give my informed consent," I finally said.  Though this phrase came automatically, it arose from my legal training.  It is an unquestionable code term for "make one more move and you'd better check your malpractice policy.  Doctor."

And then I recall telling the doctor to leave.  "Get out," I think, is what I said, "just get out!" as I reached over to pull the covers back up over my father's thin and trembling body.  As Dr. X obeyed this command, as he slipped behind the hospital curtain and made his way to the nurse's station where my father's chart resided, I shouted behind him, "and send me the hospital social worker!!"

Next, the social worker, a palliative care nurse and hospice services.  

Negotiating Life's End

(left:  Dad, middle, after the dust bowl in Julian, California)

I am told that my father is dying.  This is not news.  Dad has a progressive disease that ordinarily results in death only after years of suffering. 

I'm telling you this story (which will be the subject of several posts) because it's been suggested to me that I lodge a complaint with the local community hospital dad was checked into last week.  Or that I sue the doctor who will play a large role in this story.  I'm thus reminded of the type of conflict that causes people to go to the considerable trouble of finding and hiring legal counsel.  The experience I am about to relate considerably deepens my empathy for those people.    

Before I tell this story, I caution my readers not to take the easy way out.  These feelings accompany every kind of conflict -- personal and commercial.   

 

Essential Familial Tremor

Most of us on Dad's side of the family have something called Essential Familial Tremor.  That means our hands shake for reasons the medical community doesn't understand. 

Because denial was and remains my family's primary response to ill health , I was not diagnosed with this condition until I graduated from law school even though I began to suffer its effects at age 14.  When your primary family dis-ease is denial, it's more than a little painfully ironic to have a shared medical condition that quite visibly signals fear.  But we survived the American dust bowl.  We do not complain.  And we do not seek medical treatment.  

EFT and Parkinson's

I digress to EFT and denial because the "benign symptom" of EFT -- shaking -- is the same as one of the early symptoms of the disease Dad is dying from.  Parkinson's

For as long as I can remember, Dad's hands shook though my my step-mother (welcome to the family!) vehemently denied it.  "He doesn't shake," she'd snap if we noted dad's inability to get liquid from one container into another without spilling a fair part of it onto the dining table.  

So I can't say when Dad began to show the earliest signs of Parkinson's disease.  I can, however, say when it became undeniable. 

"I Left Your Step-Mother," 

dad is saying into a telephone I've just learned is located on the night-stand next to his bed in a Las Vegas hotel.  "She's sleeping with the gardener," he insists without a trace of skepticism at the fantastic idea that his second wife -- a woman ten years his senior -- has fallen into trampy ways with the "help" at 85 years of age.  "I think my phone is tapped," he continues without interruption.  "I'm going to fly to Sacramento to see my sister Lucille."  

This is the point at which my family is generally willing to first seek medical treatment.  Unmitigated disaster.  

So I sought and was granted (against strenuous opposition, I might somewhat irritably add) a continuance of a trial date that was breathing hot down the back of my neck, boarded a plane for Sacramento and got dad to doctors, psychologists and neurologists. 

Parkinson's is treatable and the dementia abated for a sufficient amount of time to allow dad to pretty cogently divorce his second wife of 35 years and marry the woman who served as his court clerk when he'd been on the bench two decades earlier.

You can't make this stuff up.

This is where we're headingFeeding tube and Reasons patients sue their physicians. Read Part Two Here  /* 

So that it would not happen to anyone else                              

91%

I wanted an explanation

91

I wanted the doctors to realize what they’d done

90

To get an admission of negligence

87

So that the doctor would know how I felt

68

My feelings were ignored

67

I wanted financial compensation

66

Because I was angry

65

So that the doctor did not get away with it

54

So that the doctor would be disciplined

48

Because it was the only way I could cope with my feelings

46

Because of the attitude of the staff afterwards

43

To get back at the doctor involved

23

_______________________

*/  figures represent the percentage of people who agreed with the statement to the left.

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