This chapter contains sections titled: In Cold Bold: The Moral Psychology of Fictional Serial Killers I Think I'll Eat Your Heart: The Lack‐of‐Empathy Explanation Dexter and the Extreme Lack of Understanding The Hot‐Blooded Reality: Sex, Rage, Fame My Evil Just Happened to Come Out: Empathy Inhibits? Serial Killing Because They Care? “Angels of Death” “I didn't want to hurt them, I only wanted to kill them”: Empathic Dissonance The Serial Killer Next Door?

This study explores the perceptions of Norwegian nurses who have received assisted dying requests from terminally ill patients. Assisted dying is illegal in Norway, while in some countries, it is an option. Nurses caring for terminally ill patients may experience ethical challenges by receiving requests for euthanasia and assisted suicide. We applied a qualitative research design with a phenomenological hermeneutic approach using open individual interviews. A total of 15 registered nurses employed in pulmonary (...) and oncology wards of three university hospitals and home care in one municipality were recruited. Four themes emerged from the analysis: (1) unprepared for the request; (2) meeting direct, indirect, and nonverbal requests; (3) working in a gray zone, and (4) feeling alone and powerless. The study found that nurses were unsure how to handle such requests due to professional uncertainty about assisted dying. Working in an environment where the topic is taboo made nurses morally uncertain, and some perceived this as moral distress. The hospital chaplain played a significant role in providing support to these nurses. (shrink)

This study examined the ethical issues experienced by nurses working in a small group of elderly persons’ care settings in the UK, using a survey questionnaire previously used in other countries for examining the cultural aspects of ethical issues. However ‘culture’ relates not only to ethnicity but also the organizational culture in which care is delivered. Nurses working in elderly persons’ care settings described a range of issues faced when caring for elderly terminally ill (...) people, which illustrated the different needs of patients, relatives, professionals and society. These issues related to the unique needs of elderly people (such as dementia sufferers) and could have an impact on patients’ quality of death. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:FEEDING THE COMATOSE AND THE COMMON GOOD IN THE CATHOLIC TRADITION ROBERT BARRY, O.P. University of Illinois Ohampaign-Urbana, IlUnoi8 AA RECENT convention :sponsored by the Catholic Health Associaition in Boston, Laurence J. O'Connell, vice-president for ethics and theology, ma.de the following comments: I am concerned that some of those who are legitimately alarmed by the potential abuses associated with the public policy that authorizes the withholding and withdrawing of (...) mechanical means of nutrition and hydration are sometimes publicly misrepresenting the Catholic moral tradition. In other words, in their well-intentioned and perfectly legitimate efforts to avoid the slippery-slope-that is, the wrongful withholding or withdrawing of nutrition or hydration from vulnerable dasses of patients-those advocates are placing the Roman Catholic moral tradition itself on the slippery slope. It is mistaken to say it is the church's teaching that we may never withhold or withdraw artificial nutrition and hydration. It is mistaken to uncritically refer to the removal of medically engineered nutrition in all cases as starvation-that is, the willful withholding of nutrition as morally obligatory. It is mistaken to say that the ethical standards of a single Catholic hospital are necessarily coextensive with the ethical standards of the Catholic Church. Just because an individual Catholic facility, for whatever reason, uniformly refuses to allow the withholding or withdrawing of technological feeding, does not mean that the Church itself disallows such withholdings or withdrawals.1 It is not clear how the Catholic moral tradition can be put on the " slippery slope " by opposing certain forms of with1 "Church and State Overlap in Ethical Debate", American Medicai News. February 27, 1987. p. I. 1 ROBERT BARRY, O.P. drawal of feeding from specific classes of patients. Dr. O'Connell has misrepresented the thought of most of those who oppose the recent American Medical Association's new opinion which holds that artificially administered nutrition and fluids can be removed from terminally ill patients, even when they are not imminently dying.2 There are no Catholic moralists who claim that it is always and everywhere morally wrong to withhold or withdraw feeding from patients. However, there are a number of moralists as well as bishops who now hold it to be wrong to withhold or withdraw feeding in those cases where the withholding or withdrawal becomes the fundamental and underlying cause of death. O'Connell is p11obably correct in saying that the policies of one hospital do not necessarily deteJ1IDine the moral doctrines of the universal Church, but neither does one national organization such as the Catholic Health Association with only a loose affiliation with the magisterial hierarchy of the Church necessarily do this either. The debate over the provision of,aissisted feeding is a debate over whether iit is morally legitimate ito withdraw feeding so 1tihat.t:he primary and fundamental reason why the person dies is that withdrawal. It is a debate over whether those with a certain " quality of life " can be permitted to be killed by omission. It is a debate over whether feeding provided by routine nursing measures that can significantly sustain the life is a medical treatment that should he governed by the criteria governing other treatments, or whether it is an 2 "Withholding or Withdrawing Life Prolonging :Medical Treatment" adopted by the Council on Ethical and Judicial.Affairs of the.Amercian Medical.Association on March 15, 1987, In its pertinent parts, it stated: The social commitment of the physician is to sustain life and relieve suffering. Where the performance of one duty conflicts with the other, the choice of the patient, or his family or legal representative if the·patient to act in his own behalf, should prevail. Life prolonging medical treatment includes medication and artificially or technologically supplied respiration, nutrition or hydration. In treating a terminally ill or irreversibly comatose patient, the physician should determine whether the benefits of treatment outweigh its burdens..At all times, the dignity of the patient should be maintained.•. FEEDING THE COMATOSE 8 aspect of normal care, like protection from exposure or hygienic care, that is to be accorded to all patients. In this piece, I wish to review the thoughts of some... (shrink)

Euthanasia has once again become headline news in the UK, with the announcement by Dr Michael Irwin, a former medical director of the United Nations, that he has helped at least 50 people to die, including two between February and July 1997. He has been quoted as saying that his ‘conscience is clear’ and that the time has come to confront the issue of euthanasia. For the purposes of this article, the term ‘beneficent voluntary active euthanasia’ (BVAE) will be used: (...) beneficent from the prima facie principle of beneficence, to do good, and voluntary to indicate that this must be carried out at the request of a competent client. This implies adherence to another prima facie principle, that of respect for autonomy. Active implies that something is done or given with the intention of hastening death. The word euthanasia itself simply means ‘good death’. This article examines the moral positions of two nurses and one junior doctor towards the subject of BVAE and an attempt is made to represent the main conflicting moral positions. The central arguments against BVAE and counterarguments are presented. The conclusion reached is that consenting adults should not be prevented from availing themselves of BVAE if another consenting adult (a medical doctor) is available and capable of carrying out their wishes. This being the case, it is suggested that BVAE should be available as an option in hospices and in the community. The aims of this article are: to generate debate among professionals; to present a three-way discussion that might be useful as a focus for educational purposes, particularly at undergraduate level; to challenge professionals to confront the issue of euthanasia; and to plead the case of those who request assistance in exercising autonomy by gaining control over their own deaths. (shrink)

Objective: Although nurses have an important role in the care process surrounding artificial food or fluid administration in patients with dementia or in terminally ill patients, little is known about their attitudes towards this issue. The purpose of this study was to thoroughly examine nurses’ attitudes by means of a literature review.Method: An extensive systematic search of the electronic databases PubMed, Cinahl, PsycINFO, The Cochrane Library, FRANCIS, Philosopher’s Index and Social Sciences Citation Index was conducted (...) to identify pertinent articles published from January 1990 to January 2007.Findings: Nurses’ arguments for or against could be categorised as ethical-legal, clinical or social-professional. The most important arguments explicitly for artificial food and fluid administration in patients with dementia or in terminally ill patients were sanctity of life, considering artificial food and fluid administration as basic nursing care, and giving reliable nutrition, hydration or medication. An explicit counter-argument was the high cost of treatment. Arguments used by opponents and proponents were quality of life and dignified death. The arguments were not strikingly different for the two patient populations. It turned out that the nurses’ ethical arguments remarkably reflected the current ethical debate. But some of their clinical presuppositions contradicted current clinical evidence.Conclusion: The interaction between clinical facts and ethical reflections makes the findings of this review extremely relevant for clinical ethics. A large need exists to clearly communicate to nurses the latest clinical evidence and the main results of ongoing ethical debates. (shrink)

In the mid 1980s it was apparent that the need for organ donors exceeded those willing to donate. Some University of Pittsburgh Medical Center (UPMC) physicians initiated discussion of possible new organ donor categories including individuals pronounced dead by traditional cardiac criteria. However, they reached no conclusion and dropped the discussion. In the late 1980s and the early 1990s, four cases arose in which dying patients or their families requested organ donation following the elective removal of mechanical ventilation. Controversy (...) surrounding these cases precipitated open discussion of the use of organ donors pronounced dead on the basis of cardiac criteria. Prolonged deliberations by many committees in the absence of precedent ultimately resulted in what is, to our knowledge, the country's first policy for organ donation following elective removal of life support. The policy is intricate and conservative. Care was taken to include as many interested parties as possible in an effort to achieve representative and broad based support. This paper describes the development of the UPMC policy on non-heart-beating organ donation. (shrink)

End-of-life issues have become an urgent problem in Japan, where people are among the longest lived in the world and most of them die while connected to high-technology medical equipment. This study examines a sensitive end-of-life ethical issue that concerns patients, families and nurses: the withdrawal of artificial food and fluid from terminally ill patients. A sample of 160 Japanese nurses, who completed a questionnaire that included forced-choice and open-ended questions, supported this act under only (...) two specific conditions: if the patient requested it, and if it relieved the patient’s suffering. They considered that the doctor’s orders, the family’s request, or the patient’s advanced age did not ethically justify this act. A small number of people who had recently lost a relative took part in semistructured interviews focusing on their experiences of their terminally ill relatives being given artificial food and fluid. Ethical, social and cultural factors surrounding this issue are discussed. (shrink)

This article is a review of the literature on the subject of how nurses who provide palliative care are affected by ethical issues. Few publications focus directly on the moral experience of palliative care nurses, so the review was expanded to include the moral problems experienced by nurses in the care of the terminally ill patients. The concepts are first defined, and then the moral attitudes of nurses, the threats to their moral integrity, the (...) moral problems that are perceived by nurses, and the emotional consequences of these moral problems are considered in turn. The results show that the moral behaviour of nurses, which is theoretically grounded in commitment to care and to the patient, appears to be shaped by specific processes that lead to engagement or to mental and behavioural disengagement in morally difficult situations. Nurses often appear to fail to recognize the moral dimensions of the problems they experience and also to lack the skills they need to resolve moral problems adequately. Although the findings show that several elements that are beyond the control of nurses, owing to their lack of autonomy and authority, influence their moral experience, intrinsic factors such as feelings of insecurity and powerlessness have a profound effect on nurses’ perceptions and attitudes in the face of moral problems. The moral problems perceived by these nurses are related to end-of-life issues, communication with patients, the suffering of patients, and the appropriateness of the medical treatment. (shrink)

Photo by Hannah Busing on Unsplash INTRODUCTION Religion has long provided guidance that has led to standards reflected in some aspects of medical practices and traditions. The recent bioethical literature addresses numerous new problems posed by advancing medical technology and demonstrates an erosion of standards rooted in religion and long widely accepted as almost axiomatic. In the deep soul-searching that pervades the publications on bioethics, several disturbing and dangerous trends neglect some basic lessons of philosophy, logic, and history. The bioethics (...) discourse on medical aid in dying emphasizes similarity over previously recognized important distinguishing features. For example, it overplays a likeness between assistance in dying and the withdrawal of life-saving technology. In many bioethics’ topics, arguments based on a logical continuum are used to question the lines demarcating important moral differences. l. The Line Between Ethical and Not: Logic Based on Continuum Careful case selection, often either end of a continuum, allows the tearing down or ridiculing of many rules and codes across most professions and fields of interest. This situation holds true for traffic laws as well as medical ethics guidelines. It is relatively simple for those who desire to attack a particular viewpoint by selecting a case that makes that position seem untenable. In the ethics realm, good and bad medicine exist at opposite ends of an ethical continuum, with many practices lying in between. For example, much of medical ethics exists between the Nazi criminal physicians and the most sainted nurse or physician. A gradual progression occurred over less than two decades from a utilitarian position that supported limited euthanasia for those with certain mental illnesses to genocide. German society embraced a utilitarian ethic in which the value of human life no longer was intrinsic but instrumental.[1] Many morally significant points on a continuum were then ignored as the misguided utilitarian policy rampantly continued. A point in the continuum to distinguish between ethically justifiable and that which is not can be difficult to identify compared to the two extremes. This continuum is not unique to ethics but can be applied to almost any other aspect of human life and endeavor. Between a severely ill schizophrenic person and a superbly well-adjusted individual, there is a continuum of mental and psychological function. The existence of a continuum should not paralyze thinking and prevent us from drawing lines and identifying moral differences based on objective criteria as well as moral philosophy. Yet, by focusing on a continuum, many bioethicists use logic to disregard dividing lines between an "ethical" and an "unethical" act. Unfortunately, sometimes bioethicists draw revolutionary conclusions that would change the scope of medical practices which is accepted as ethical. There are many examples of similar shifts on the continuum. Many authors argue for the ethical permissibility of abortion by pointing out that the human fetus is no different in various characteristics, one arguing it is as like an ape or chick as it is like a person,[2] and does not achieve unique human and individual characteristics until well into the first year of life.[3] While human fetuses arguably do not have certain distinctive qualities of personhood, most people shy away from the logical next conclusion: permitting infanticide. For example, Joshua Lederberg condemns infanticide, in the face of biological illogic, because of our emotional commitment to infants, to me, a relatively weak explanation. Sir Francis Crick suggests we might consider birth at two days of life in order to decide whether an infant is a "suitable" member of society.[4] Giublini and Minerva suggest that infanticide should be permissible since late pregnancy abortions are permissible, arguing there is no significant difference between a fetus just before birth and an infant just after birth.[5] Clearly the continuum approach would allow for subjective arguments in favor of later infanticide at other points many days post-birth. Years ago, with a cynical tone, I mentioned infanticide as a further step on the continuum beyond abortion, and I was rightly shouted down as being deliberately provocative to assert the logic would ever stretch so far. While it is not an accepted mainstream position, the movement in academic settings from widespread condemnation to limited possible acceptance of infanticide has taken place in an incredibly short time. Public opinion and medical opinion in these areas have shifted dramatically in a short time. In another area, from a biological and chemical point of view, there is a continuum from man down to a single carbon atom. Yet, it would not seem logical to ignore the emotional differences, the meaning of personhood, or the moral distinction between killing an insect and killing a person. ll. A False Continuum: Medical Aid in Dying I assert that there has been an erosion of ethical guidelines in recent years attributable to using continuums to camouflage important distinctions. James Rachels’ work on active and passive euthanasia, which contends that the two are ethically identical, exemplifies that logic.[6] He illustrates this thesis, using a continuum to compare different scenarios with like consequences as morally equivalent, by comparing the deliberate drowning of a child with a deliberate failure to rescue a drowning child when easily able to do so. The author's comparison proposes that since much of the medical profession has already made peace with withholding treatment in order to hasten death, consistency inexorably demands that we permit active euthanasia as well.[7] When permission for active euthanasia was first introduced, it was limited exclusively to patients suffering severely from an intractable, incurable, and irreversible disease. These guidelines have been continuously eroded. There is now a substantial serious consideration for permitting active euthanasia of healthy elderly individuals who feel that they have completed their lives and are "tired of living."[8] There are many moral and factual differences along the ethical continuum. In human life, there is a difference between a live baby and a fetus, between a viable fetus and one that is not, between a fetus and a zygote, and between a zygote and a sperm cell. Similarly, there is a difference between pulling a trigger to kill someone and not interfering in preventing his death, which is reprehensible though both may be. There is a difference between not resuscitating an 80-year-old man with cancer when his heart stops and injecting him with a fatal dose of potassium chloride. I argue that an overt act of taking life repels civilized human beings is to be commended and encouraged as the reverence for human life or even for just a moment of human life is one of the great contributions of our civilization. CONCLUSION As an orthodox Jew, I feel that divinely inspired guidelines that have stood the test of centuries shape my beliefs, and such guidelines contradict medical aid in dying. I cannot speak to the viewpoint of those who do not access religion in defining their moral stance, nor do I implicate them in the current bioethics' trends, as I am not aware of the personal role of religion in the lives of most such authors. While many nonreligious people have a firm philosophical grounding and oppose medical aid in dying, I suggest that in the absence of any religious or other absolute standards, developing logically defensible ethical guidelines may be challenging. At the least, religion may play a role in defining the points on the continuums that are ethically meaningful and refuting the trending beliefs that if the endpoint is the same, allowing different methods of arriving at that end are somehow ethically equal. The continuum of ways death may result does not negate analysis of whether death is brought about in ways that recognize the importance of life. The German philosopher Hans Jonas said, "It is a question whether without restoring the category of the sacred, the category most thoroughly destroyed by the scientific enlightenment, we can have an ethics able to cope with the extreme powers that we possess today and constantly increase and are compelled to use."[9] While countries vary on the role of religion in policy, with many emphasizing freedoms of religion, a recent position paper released by a group of Jewish, Christian, and Moslem leaders suggested the need for agreement on the unique sanctity of human life.[10] I would recommend that such a document serve as an example of consensus on critical foundational bioethical guidelines for democratic secular societies. - [1] Alexander L Medical science under dictatorship. New England Journal of Medicine, 241, p39-47 DOI10.1056/NEJM194907142410201 [2] Lederberg J. A geneticist looks at contraception and abortion, Annals of Internal Medicine 67, sup 2, 25-27. https:/doi.org/10.7326/0003-4819-67-3-25 [3] Ibid. [4] Editorial, Sociology: Logic of biology. Nature 220, 429 https://www.nature.com/articles/220429b0 [5] Giublini A Minerva F After-birth abortion: why should the baby live. J Med Ethics 39, 261- [6] Rachels J Active and passive euthanasia. New England Journal of Medicine 292, 78-80 [7] Ibid. [8] Cohen-Almagor R Euthanizing people who are "tired of life". in Euthanasia and Assisted Suicide-Lessons from Belgium. Ch 11 of Euthanasia and Assisted Suicide, Cambridge University Press pp173-187. 2017 and DOI; https://doi.org/10.1017/9781108182799.012 [9] Hans Jonas, Technology and Responsibility: Reflections on the New Tasks of Ethics, 1972, found as Chapter IX, Philosophical Essays, 1980. https://inters.org/jonas-technology-responsability [10] A position paper of the Abrahamic Monotheistic religions on matters concerning the end-of-life. Vatican Press 28 October 2019 https://press.vatican.va/content/salastampa/en/bollettino/pubblico/2019/10/28/191028f.html. (shrink)

Background Non-therapeutic trials in which terminally ill cancer patients are asked to undergo procedures such as biopsies or venipunctures for research purposes, have become increasingly important to learn more about how cancer cells work and to realize the full potential of clinical research. Considering that implementing non-therapeutic studies is not likely to result in direct benefits for the patient, some authors are concerned that involving patients in such research may be exploitive of vulnerable patients and should (...) not occur at all, or should be greatly restricted, while some proponents doubt whether such restrictions are appropriate. Our objective was to explore clinician-researcher attitudes and concerns when recruiting patients who are in advanced stages of cancer into non-therapeutic research. Methods We conducted a qualitative exploratory study by carrying out open-ended interviews with health professionals, including physicians, research nurses, and study coordinators. Interviews were audio-recorded and transcribed. Analysis was carried out using grounded theory. Results The analysis of the interviews unveiled three prominent themes: 1) ethical considerations; 2) patient-centered issues; 3) health professional issues. Respondents identified ethical issues surrounding autonomy, respect for persons, beneficence, non-maleficence, discrimination, and confidentiality; bringing to light that patients contribute to science because of a sense of altruism and that they want reassurance before consenting. Several patient-centered and health professional issues are having an impact on the recruitment of patients for non-therapeutic research. Facilitators were most commonly associated with patient-centered issues enhancing communication, whereas barriers in non-therapeutic research were most often professionally based, including the doctor-patient relationship, time constraints, and a lack of education and training in research. Conclusions This paper aims to contribute to debates on the overall challenges of recruiting patients to non-therapeutic research. This exploratory study identified general awareness of key ethical issues, as well as key facilitators and barriers to the recruitment of patients to non-therapeutic studies. Due to the important role played by clinicians and clinician-researchers in the recruitment of patients, it is essential to facilitate a greater understanding of the challenges faced; to promote effective communication; and to encourage educational research training programs. (shrink)

Over the last twenty years, ‘palliative care’ has evolved as a special nursing field in Germany. Its historic roots are seen in the hospices of the Middle Ages or in the hospice movement of the twentieth century. Actually, there are numerous everyday sources to be found about this subject from the nineteenth century. The article at hand deals with the history of nursing the terminally ill and dying in domestic care in the nineteenth century. Taking care of and nursing (...) the dying was part of everyday routine in the nursing care as practiced by the deaconesses and sisters in those days. Mit der Seelenpflege bei den unheilbar Kranken und Sterbenden schufen die Kaiserswerther Diakonissen sich einen von Ärzten unabhängigen Kompetenzbereich. Meine Analysen zur Privatpflege zeigen jedoch darüber hinaus, dass die in ihrer Aufmerksamkeit auf das Mutterhaus ausgerichteten Diakonissen auch in Leibespflege sehr viel unabhängiger von den Ärzten zu agieren schienen als die freien Krankenschwestern. The article takes a look not only at the actual nursing activities but also at the relationship between the sisters and their patients and their relatives and the family doctor. On the basis of the recorded letters which the nurses wrote to the deaconess motherhouse in Kaiserswerth, it is also possible to analyze how the deaconesses communicated and reflected their actions at the deathbed. (shrink)

Respecting and encouraging autonomy in the elderly is basic to the practice of geriatrics. In this paper, we examine the practice of cardiopulmonary resuscitation (CPR) and "artificial" feeding in a geriatric unit in a general hospital subscribing to jewish orthodox religious principles, in which the sanctity of life is a fundamental ethical guideline. The literature on the administration of food and water in terminal stages of illness, including dementia, still shows division of opinion on the morality of withdrawing nutrition. (...) We uphold the principle that as long as feeding by naso-gastric (N-G) or percutaneous endoscopic gastrostomy (PEG) does not constitute undue danger or arouse serious opposition it should be given, without causing suffering to the patient. This is part of basic care, and the doctor has no mandate to withdraw this. The question of CPR still shows much discrepancy regarding elderly patients' wishes, and doctors' opinions about its worthwhileness, although up to 10 percent survive. Our geriatric patients rarely discuss the subject, but it is openly ventilated with families who ask about it, who are then involved in the decision-making, and the decision about CPR or "do-not-resuscitate" (DNR) is based on clinical and prognostic considerations. (shrink)

This collection contains twenty-one thought-provoking essays on the controversies surrounding the moral and legal distinctions between euthanasia and "letting die." Since public awareness of this issue has increased this second edition includes nine entirely new essays which bring the treatment of the subject up-to-date. The urgency of this issue can be gauged in recent developments such as the legalization of physician-assisted suicide in the Netherlands, "how-to" manuals topping the bestseller charts in the United States, and the many headlines devoted to (...) Dr. Jack Kevorkian, who has assisted dozens of patients to die. The essays address the range of questions involved in this issue pertaining especially to the fields of medical ethics, public policymaking, and social philosophy. The discussions consider the decisions facing medical and public policymakers, how those decisions will affect the elderly and terminally ill, and the medical and legal ramifications for patients in a permanently vegetative state, as well as issues of parent/infant rights. The book is divided into two sections. The first, "Euthanasia and the Termination of Life-Prolonging Treatment" includes an examination of the 1976 Karen Quinlan Supreme Court decision and selections from the 1990 Supreme Court decision in the case of Nancy Cruzan. Featured are articles by law professor George Fletcher and philosophers Michael Tooley, James Rachels, and Bonnie Steinbock, with new articles by Rachels, and Thomas Sullivan. The second section, "Philosophical Considerations," probes more deeply into the theoretical issues raised by the killing/letting die controversy, illustrating exceptionally well the dispute between two rival theories of ethics, consequentialism and deontology. It also includes a corpus of the standard thought on the debate by Jonathan Bennet, Daniel Dinello, Jeffrie Murphy, John Harris, Philipa Foot, Richard Trammell, and N. Ann Davis, and adds articles new to this edition by Bennett, Foot, Warren Quinn, Jeff McMahan, and Judith Lichtenberg. (shrink)

The ethics of decision making for the critically ill elderly is an area of concern for all those involved in the decision-making process. The number of participants involved in decision making around end-of-life issues may be many: treatment and care decisions often bring together not only the patient and the physician, but the family, an extended medical care team, and impartial members of a hospital or institutional ethics committee. In addition, treatment and care decisions made at the end of (...) life occur in a variety of settings, not just the acute care hospital. Elderly patients who are critically ill, or in the final days or weeks of life, are found in intensive care or medical units of hospitals, in hospital and nursing home based hospice programs, in long-term care settings such as skilled nursing facilities, or at home, where they are tended by family caregivers. Differences in patterns of decision making regarding the care and treatment of critically ill older adults can be found across these settings, and decisions often vary according to the roles of the participants. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Helping a Muslim Family to Make a Life–and–Death Decision for Their Beloved Terminally Ill FatherBahar BastaniI live in a city in the Midwest with a population of around two million people. There are an estimated 2,000 Iranians living in this city, the vast majority of which belong to Shia sect of Islam. [End Page 190] However, the vast majority is also not very religious. Over the past two (...) decades that I have been living in this city, professionally in the capacity of a physician and university faculty at a school of medicine, and socially as one of the community leaders with a particular role in religious matters, I have acquired the trust of my community. Following one of my yearly routine travels to my homeland, Iran, I had just returned to work when I received a phone call from one of the Iranian community members. He informed me that his father was very ill and was hospitalized, and that the physicians had introduced the idea of stopping life support. The family was experiencing a significant emotional, moral and religious dilemma as to whether they could consent to this. I was requested by the patient’s children to help them make the right decision.I requested that the oldest son, who had called me, to ask the three other siblings and their mother to be present at the bedside of the patient that night, so that we could discuss the matters face–to–face. That same night, all requisite family members and myself gathered at the bedside of this 88–year–old husband and father, who had developed multi–organ failure, which commenced with an infection following a heart valve replacement, followed by bacteremia and sepsis. Moreover, the patient was hypotensive, had developed respiratory failure requiring intubation and artificial ventilation, and had also developed hematologic coagulation abnormalities secondary to sepsis. Because of the sepsis, hypotension, and multiple drugs, including antibiotics and vasopressors, his kidneys had also failed, and there was a need to start hemodialysis if his life was to be maintained. After speaking with the intensive care physicians who were taking care of this elderly gentleman, it became clear to me that further care was futile, and there was absolutely no hope for him to recover from his multiple organ failure. I presented all the facts that I had acquired to the family members, and expressed my own viewpoint that I agreed with those physicians and that further care of their beloved, terminally ill husband and father was futile and only extended his dying. My assurances made it easier for the family members, particularly for his four sons who were present, to come to the decision to withdraw life support. After I informed the intensive care physicians of the family’s decision, the patient was heavily sedated with morphine, and the intravenous fluids, antibiotics, vasopressors, and the ventilator machine were all stopped. Over the next several minutes, the patient developed agonal breathing, his blood pressure dropped to zero, and his heart stopped. During the last few minutes of his life, I held the hands of the family members, we all prayed Islamic prayers to bless his soul while departing from his body. The next day, I supported the family with funeral services that included the Islamic prayers for the dead, the ceremonial religious washing of the body of the deceased, and the ceremonial religious burial.The dilemma that this family faced was multi-factorial: (1) the children had spent all of their adult life in America, and were unfamiliar with Islamic end of life and funeral traditions; (2) they had been asked by their father’s physicians to make a decision regarding the withdrawal of life support, which posed a moral and ethical dilemma; (3) they did not know whether it was religiously acceptable to withdraw life support; and (4) they did not know what type of funeral service would be acceptable to the religious beliefs of their deceased father.My presence as a trusted community leader, physician and religious leader was reassuring to the family members that the decision to stop life support for their loved one with a terminal illness and multiple organ... (shrink)

The notion of 'quality of life' frequently features in discussions about how it is appropriate to treat folk at the beginning and at the end of life. It is argued that there is a disjunction between its use in these two areas (1). In the case of disabled babies at the very beginning of life, 'quality of life' considerations are frequently used to justify enforced death on the basis that the babies in question would be better off dead. At times, (...) babies with severe disabilities are thus allowed to die or even killed. In the case of terminally ill people 'quality of life' is also important in guiding the actions of doctors. However, in the case of individuals who do not wish to live any longer because their quality of life is so poor that they would rather be dead, quality of life is likely to be dropped as a guiding principle. Thus patients who wish to die and ask to be killed, will most often be forced to endure enforced life. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy and Rhetoric 35.3 (2002) 208-222 [Access article in PDF] Writing, Illness and Affirmation Jeremiah Dyehouse My formula for greatness in a human being is amor fati: that one wants nothing to be different, not forward, not backward, not in all eternity. Not merely to bear what is necessary, still less conceal it—all idealism is mendaciousness in the face of what is necessary—but love it. —Friedrich Nietzsche In her (...) widely circulated book On Death and Dying, Elisabeth Kübler-Ross, M.D., addresses herself to a changed historical context for work in medicine. In societies with increasingly effective medical care, she argues, doctors and nurses find themselves working with patients whose health problems range from imperceptible yet terminal sicknesses to psychosomatic ailments. Today, especially, it is easy to see the reality of her description of this situation: forms of terminal cancer can be detected earlier and earlier in a patient's life, rendering the disconcerting reality of a terminal illness with few or no symptoms. Equally strange for doctors and patients today are forms of environmental illness like chronic fatigue syndrome, a condition suffered by many but still disputed by doctors and researchers. To this situation of medical risk, personal suffering, and therapeutic care, Kübler-Ross prescribes a communicative engagement with the dying. This engagement, she argues, not only teaches doctors about death and dying, but it also provides respite for those who must experience these events.The problem of communicating with the dying, the main focus of Kübler-Ross's book, is nevertheless eclipsed by the other, more notable aspect of On Death and Dying. For out of this book emerged the now very popular understanding of the stages of death, the normal sequence of an individual's emotional reconciliation to dying: the processes of denial and isolation, anger, bargaining, depression—the whole series of intrapsychic processes leading up to a final acceptance of death and dying. Now we live amongst a whole panoply of staged progresses towards the acceptance of trauma: trauma associated not only with death and dying but also with substance abuse, catastrophe, and forms of violence. It is perhaps worth recalling, however, that the most famous of these stage models, the five stages [End Page 208] of death, emerged out of Kübler-Ross's attempt to learn what the dying can teach the living about communication.In what follows, I assume that writing about illness is another, more popular form of Kübler-Ross's descriptive and communicative project. To write pathography, as Anne Hunsaker Hawkins calls narratives of illness and dying in her survey of these texts, Reconstructing Illness: Studies in Pathography, is to engage with what sickness and dying teach about life and writing. As might be guessed, most pathographies orbit familiar centers of gravity: agency for the dying, reconciliation for the living, the whole leaden project of acceptance. Even so, pathography is not always and everywhere engaged in such projects. Pathography, as Hawkins demonstrates, is a highly variable project. Literary pathography is quite different from popular pathography, and texts within these categories differ with respect to the purpose of their writing. Pathography is conceived as a communicative engagement with sickness and dying, with the sick and the dying, but is hardly unified in its aims or its functions. It is a form of writing that not just potentially but actually admits a diversity of purposes and produces a variety of effects.It is my purpose here to propose a typology for pathographies. Although pathography as a genre of writing takes a bewildering variety of forms, these writings can be grouped according to their effects. I divide pathography into three types, according to the kind of response they offer to sickness and dying, to the sick and the dying. First, I treat pathography as a process of passive acceptance, the bearing of a burden proposed by the necessities of illness and death. Next, I characterize pathographies that approach the writing of illness or dying as a process of active acceptance. This type of pathography uses writing about illness and dying as a process for the... (shrink)

This collection contains twenty-one thought-provoking essays on the controversies surrounding the moral and legal distinctions between euthanasia and "letting die." Since public awareness of this issue has increased this second edition includes nine entirely new essays which bring the treatment of the subject up-to-date. The urgency of this issue can be gauged in recent developments such as the legalization of physician-assisted suicide in the Netherlands, "how-to" manuals topping the bestseller charts in the United States, and the many headlines devoted to (...) Dr. Jack Kevorkian, who has assisted dozens of patients to die. The essays address the range of questions involved in this issue pertaining especially to the fields of medical ethics, public policymaking, and social philosophy. The discussions consider the decisions facing medical and public policymakers, how those decisions will affect the elderly and terminally ill, and the medical and legal ramifications for patients in a permanently vegetative state, as well as issues of parent/infant rights. The book is divided into two sections. The first, "Euthanasia and the Termination of Life-Prolonging Treatment" includes an examination of the 1976 Karen Quinlan Supreme Court decision and selections from the 1990 Supreme Court decision in the case of Nancy Cruzan. Featured are articles by law professor George Fletcher and philosophers Michael Tooley, James Rachels, and Bonnie Steinbock, with new articles by Rachels, and Thomas Sullivan. The second section, "Philosophical Considerations," probes more deeply into the theoretical issues raised by the killing/letting die controversy, illustrating exceptionally well the dispute between two rival theories of ethics, consequentialism and deontology. It also includes a corpus of the standard thought on the debate by Jonathan Bennet, Daniel Dinello, Jeffrie Murphy, John Harris, Philipa Foot, Richard Trammell, and N. Ann Davis, and adds articles new to this edition by Bennett, Foot, Warren Quinn, Jeff McMahan, and Judith Lichtenberg. (shrink)

The law stipulates that death is irreversible. Patients treated in accord with the Pittsburgh protocol have death pronounced when their condition might well be reversed by intervention that is intentionally withheld. Nevertheless, the protocol is in accord with the medical "Guidelines for the Determination of Death." However, the Guidelines fail to capture the intent of the law, which turns out to be a good thing, for the law embodies a faulty definition of death. The inclusion of "irreversible" in the (...) legal definition makes that definition excessively demanding and out of step with the ordinary concept of death. On this basis the protocol is absolved of the moral but not the legal charge that it involves vivisection. (shrink)

It is unknown whether hospital-based medical professionals in Spain educate patients about advance directives. The objective of this research was to determine the frequency of hospital-based physicians’ and nurses’ engagement in AD discussions in the hospital and which patient populations merit such efforts. A short question-and-answer-based survey of physicians and nurses taking care of inpatients was conducted at a university hospital in Madrid, Spain. In total, 283 surveys were collected from medical professionals, of whom 71 per cent (...) were female, with an average age of thirty-four years. Eighty-four per cent had never educated patients about ADs because of lack of perceived responsibility, time, or general knowledge of ADs. Patient populations that warranted AD discussions included those with terminal illnesses, chronic diseases, and elderly patients. Regarding degree of AD understanding in medical professionals: 57 per cent of medical professionals claimed sufficient general knowledge of ADs, 19 per cent understood particulars regarding AD document creation, and 16 per cent were aware of AD regulatory policies. Engagement in AD discussions was considered important by 83 per cent of medical professionals, with 79 per cent interested in participating in such discussions themselves. The majority of hospital physicians and nurses do not educate their patients about ADs, despite acknowledging their importance. Patient populations of highest priority included those with terminal diseases or chronic illness or who are of advanced age. (shrink)

Shared decision-making is a well-recognized model to guide decision-making in medical care. However, the shared decision-making concept can become exceedingly complex in adolescent patients with varying degrees of autonomy who have most of their medical decisions made by their parents or legal guardians. The complexity increases further in ethically difficult situations such as terminal illness. In contrast to the typical patient-physician dyad, shared decision-making in adolescents requires a decision-making triad that also includes the parents or guardians. The multifactorial nature (...) of these cases can overwhelm treatment teams, with minimal guidance on how to best approach the patient–parents–physician dynamic in an ethically appropriate manner. Estimated time left to live is the paramount ethical consideration for such cases with respect to shared decision-making. This paper offers a sliding scale to serve as a grounding reference for clinicians who care for terminally ill adolescents and hospital ethics committee members for initiating and guiding the ethical discussion for these patients. This paper also elucidates several other ethically salient features inherent to many of these cases, including quality of life, treatability of disease, cultural influences, among others. Yet how each of these variables is weighed is dependent upon the specific circumstances of each individual case. Ultimately, shared decision-making in adolescent patients with terminal illnesses must be a collaborative and ongoing process that thoughtfully weighs the values and ethical responsibilities of the patient, parents, and physician to ideally reconcile differences and come to a consensus on the best management option for each individual patient. (shrink)

When it is considered to be in their best interests, withholding and withdrawing life-supporting treatment from non-competent physically ill or injured patients – non-voluntary passive euthanasia, as it has been called – is generally accepted. A central reason in support of the procedures relates to the perceived manner of death they involve: in non-voluntary passive euthanasia death is seen to come about naturally. When a non-competent psychiatric patient attempts to kill herself, the mental health care providers treating her are (...) obligated to try to stop her. Yet it has been suggested that death by suicide can be a part of the natural course of a severe mental illness. Accordingly, if the perceived naturalness of the deaths occurring in connection with non-voluntary passive euthanasia speaks for their moral permissibility, it could be taken that a similar reason can support the moral acceptability of the suicidal deaths of non-competent psychiatric patients. In this article, I consider whether the suicidal death of a non-competent psychiatric patient would necessarily be less natural than those of physically ill or injured patients who die as a result of non-voluntary passive euthanasia. I argue that it would not. (shrink)

The term “euthanasia” is used in conflicting ways in the bioethical literature, as is the term “assisted suicide,” resulting in definitional confusion, ambiguities, and biases which are counterproductive to ethical and legal discourse. I aim to rectify this problem in two parts. Firstly, I explore a range of conflicting definitions and identify six disputed definitional factors, based on distinctions between (1) killing versus letting die, (2) fully intended versus partially intended versus merely foreseen deaths, (3) voluntary versus nonvoluntary versus involuntary (...) decisions, (4) terminally ill versus non-terminally ill patients, (5) patients who are fully conscious versus those in permanent comas or persistent vegetative states, and (6) patients who are suffering versus those who are not. Secondly, I distil these factors into six “building blocks” and combine them to develop an unambiguous, value-neutral taxonomy of “end-of-life practices.” I hope that this taxonomy provides much-needed clarification and a solid foundation for future ethical and legal discourse. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Historical Violence, Censorship, and the Serial Killer: The Case of American PsychoCarla Freccero (bio)R.L.: Do you believe in God?B.E.E.: Are you asking me if I was raised in a religious family or if I go to church? I was raised an agnostic. I don’t know—I hate to fly, I have a fear of flying. That means either that I have no faith in air traffic controllers or that (...) I’ve done something really bad, and this is God’s way of getting at me. Maybe I’m caught in the middle.... But no, I don’t believe in God. That’s such a strange thing to admit in an interview.—Robert Love, “Psycho Analysis,” Rolling Stone interview with Bret Easton EllisBefore Capitol Hill acts on these dimwitted proposals, we should remember what the writer Bret Easton Ellis might have said, but didn’t: “Doing bad stuff is wrong.”—Ted Rall, “Meet the Cusp Kids”US mass media has become a much-publicized target of censorious commentary within American public culture in recent years. Censorship, as E. S. Burt notes, may take at least two forms: philosophical censorship, such as that discussed by Leo Strauss’s Persecution and the Art of Writing, and the more commonly applied form of US censorship enacted against “pornography” or “obscenity.” Philosophical censorship, in this reading, entails the state’s persecution of message-bearing texts or utterances that counter the doxa and threaten to disrupt the state, while the second form of censorship involves “a language use that falls outside the interpretive scheme defining the work as the intentional act of a moral being” [Burt 25]. In the United States, state censorship of the first kind may perhaps be practiced through the “incitement to riot” escape clause provision in the First Amendment, while obscenity censorship—in certain forms—is explicitly written into legislation as excluded from speech protection.Extending Strauss’s argument to the liberal state, Burt suggests in effect that these two forms of censorship become related insofar as the state’s censorious intent is directed not so much at the content of the expression as at the degree to which it confirms the axiom, what Burt calls the “very fundamental, convening assumption of the... liberal state” [25] that “virtue is knowledge” [see Strauss 25]. Thus obscenity is a form of expression that cannot be interpreted as productive knowledge but instead as a certain repetitive excess, “dirt for dirt’s sake” [Burt, quoting Judge Woolsey 28]. The problem here, of course, is that such distinctions do not apply comfortably to that category of utterance termed the literary, and especially to the use of figurative language, where “art for art’s sake” can be [End Page 44] seen precisely to resemble the nonproductivity of obscenity. The text I am going to discuss in depth here, Bret Easton Ellis’s American Psycho, has been attacked on both grounds—as an active (and violent) disruption of the doxa that is also obscenely nonproductive of knowledge—and as such, it serves as an illustrative, and I will argue, noncoincidental, case of “censorship” in the liberal state.It may be useful here to begin by surveying and making distinctions among the various popular and popularized censorships in recent US media: Ice-T’s “Cop Killer” was probably the most authentic case of “philosophical” censorship, even though its silencing did not derive directly from the state (the liberal state often does not function in some of the ways supposed when the definition of censorship is restricted to state censorship). “Cop Killer” is a song about killing policemen, and thus came closest—in the list I am going to propose of silenced works—to tempting the state’s retaliation. It was written and sung by a black man (a black man who often plays a gangster and a cop in popular films), in a genre already regarded as threateningly disruptive to the state: rap. The result is that the CD containing this song was pulled from the shelves of music stores and can no longer be purchased. There was no trial. The author withdrew his work from public circulation in the face of... (shrink)

continent. 1.2 (2011): 70-75. cartography of ghosts . . . And as a way to talk . . . of temporality the topography of imagination, this body whose dirty entry into the articulation of history as rapturous becoming & unbecoming, greeted with violence, i take permission to extend this grace —Akilah Oliver from “An Arriving Guard of Angels Thusly Coming To Greet” Our disappearance is already here. —Jacques Derrida, 117 I wrestled with death as a threshold, an aporia, a bandit, (...) a part of life. —Akilah Oliver Moraine in geological lingo is that which is left behind. Moraine- a euphemism for the de-stabilizing referent of the writer-ly body as a “troubled and troubling landscape marked by cultural and historical signifiers, the body as flesh memory [...] the body as transitory” (Oliver, Author Statement). Moraine— a geological metaphor of the poet as a holder of memory, as an accumulation of rocks and debris carried along the edge, terminal, dropped at the foot of language (in language). “Flesh Memory” according to Akilah Oliver is "that which my body recalls [...] everything has to do with the task of remembrance and its narrative reinvention [...] I was always translating an idea of the world as it presented itself at any given time. To write was a choice about how to be seen, how to enter the world as translator, actor, participant, in the dialogues that apparently made the real 'real'" (Levitsky). Flesh. Memory. The stuff some poems are made from. The stuff that gets abandoned, gleaned, and picked up by more flesh and memory. "My body, my life has always felt like a kaleidoscopic rip in the dominant fabric [...] has always been a dialogue with the impossible and the apparent” (Levitsky). The impossible-body or poet's body anticipates and performs (through language) an irretrievable death. IN APORIA I realized everything I must have been doing must have been Death. It was Christmas or Labor Day—a holiday—and every time you turned on the radio they said something like ‘four million’ or ‘going to die’.” — Andy Warhol I’m trying on egos, [a justification for the planet’s continuance]. Oh hello transgressor, you’ve come to collect utilitarian debts, humbling narrative space. Give me condition and wheatgrass, I his body disintegrating. I his body is ossification. Death my habit radius, yeah yeah. I his body can’t refuse this summons. I can’t get out this fucking room. Tell me something different about torture dear Trickster. Tell me about the lightness my mother told me to pick the one i love the best how it signals everything I ever wish to believe true just holy on my ship. I jump all over this house. this is it [what I thought is thought only, nothing more deceptive than]: I his body keeps thinking someone will come along, touch me. As like human or lima bean. I’m cradling you to my breast, you are looking out. A little wooden lion you & Peter carve on Bluff Street is quieting across your cheekbone. Not at all like the kind of terror found in sleep, on trembling grounds. It is yesterday now. I have not had a chance to dance in this century. Tonight I shall kill someone, a condition to remember Sunday morning. To think of lives as repetitions [rather than singular serial incarnations]. To understand your death is as exacerbating as trying to figure out why as schoolchildren in mid-nineteen-sixties Southern California we performed reflexive motions: cutting out lace snowflakes, reading Dick and Jane search for their missing mittens, imagining snow. Disintegrat ing . The -ing gerund catapults from the non-finite verb into past, present, future. The -ing as a tail pinned to death, a dog spinning to bite and never fully reaching itself, always shy of the end, circumreferential; a double copulative: deathing. Possessively AO calls it “habit radius” (a virtual fetish attribute) or an inescapable death presence that “confronts us with the paradox of an unattainable object [...] through it’s being unattainable” (Agamben, 27). A flirtation or dialogue with an unknowable thing and aporia utilized as investigative instrument to engage (death) while (in Southern California) we “perform reflexive motions,” cut lace snowflakes, imagine snow, and pay rent like “yeah, yeah” what else is new. And this too, fiction. The book I wish to right. The restored fallen, heroic. Did you expect a different grace from the world? Or upon exit? I’m working on “tough.” They think I am already. All ready. Who is the dead person? Is "I'm sorry" real to a dead person? Browning grass. My hands on this table. A contentious century. A place to pay rent. Redemptive moments. Am I now the dead person? Dead person, dead person, will you partake in my persimmon feast? The body inside the body astounds, confesses sins of the funhouse. I too have admired the people of this planet. Their frilly, orderly intellects. The use they’ve made of cardamom, radiation as well. How they’ve pasteurized milk, loaned surnames to stars, captured tribes, diseases, streets, and ideas too. The living-body as archive: is it possible to experience the living-body as archive without a (kind of) death? Sifting the rubble, rummaging through hoarded debris, skin sheds, memory-napping, and re-awoken (in flesh and) on terrain. “An investigative poetics seeks to unravel staid communities of thought and grasp at what might always be just beyond reach; a poetics of inquiry that lies between language as meaning, and language as rapturous entry into the world of posited ideas and idealism”( Levitsky). Something snaps. Lights blow out prior to embarking upon an investigative poetics. It begins with a question (often a sexy aporia) that leads to openings. "Every politics of memory [...] implies an intervention of the state. It's a state that legislates and acts with regard to the nonfinite mass of materials to be stored, materials which must be collected, preserved” (Derrida & Stiegler, 62). It seems poetic investigation already contains the potentiality of an (invisible) archive if the writer is “always writing” especially when not. Here’s my stupid digital romantic inclination: the living-body (of a poet) is a self-sustaining archive of non-finite memories. But not even I really believe that. AO innovated and sculpted an investigative poetic praxis. In a conversation with poet Rachel Levitsky, poetic-voice is viewed not as a precious identifier, but as a means to think through/about form, concluding that form is linked to framing. While poetic-voice may have tendency to precede form, it also erupts as a result of framing techniques. “They are frames that hold the shape of thinking (which is also to say of imagining) [...].”7 This reminds me of my rabbit who symmetrically chewed the corners of his hutch, which makes me wonder if it’s an expression of the shape of some animal anxiety tick I won’t ever have access to. Beyond the form/frame, death is an unoriginal yet unique limit; death is a damn deathless thing. It functions as a source of poetic investigation; that thing always “just beyond reach.” And how is death not a fetish (in this case an obsessive reverence for something non-material)? “Insofar as it [death] is a presence, a fetish [...] it is in fact something concrete and tangible; but insofar as it is the presence of an absence, it is, at the same time, immaterial and intangible, because it alludes continuously beyond itself to something that can never really be possessed [...] The fetish is [...] a sign of an absence, it is not an unrepeatable unique object; on the contrary, it is something infinitely capable of substitution, without any successive incarnations ever succeeding in exhausting the nullity of which it is the symbol” (Agamben, 33). AO utilized absence (the absent body [catapulted by the death of a beloved]) as an apparatus to investigate. In the process of conversing with absence or that which is absent, the absent body is affectionately objectified, incessantly summonsed back to a place of recognition, of objects, a desire for the absent body to remain intact while exiting the structural limits of grammar and syntax by moving into chant forms “to say what cannot be said” (Levitsky). from AN ARRIVING GUARD OF ANGELS THUSLY COMING TO GREET dear oluchi- the light is blinking rapidly on the black boxy machine. your room seems bigger than before and i am still planning to read some of those robert jordan books of yours. yesterday at the used bookstore where i was browsing the mysteries to “stall reality” (they are really not mysteries at all, they just employ death as the plot mistress but are unable to grasp its mystery at all)—well the point is, things were calm down here for a while and the world was little. i want to be big like you. or i want you not vast, not dead, not gone, but human small and here. i am so selfish. that is what i really want. to see you again. to oil your scalp. to hear you walk in the door, say ma i’m home . give me a chance to say welcome home son. or when leaving, don’t forget your hat . what do you wear out there? i wish you could have taken your new shoes with you. i’m so proud of you. i’m sorry for the way you died. i miss you all the time. even before, i missed you. out there, one time, some different men said: “shake for me girl, i wanna be your backdoor man.” who dat you love. 5/18/03 A letter-poem in sixteen lines “dear oluchi-” is safe-housed in epistolary form. Poetic voice is rendered as internal thought meanderings, a not-so-much confession, private/(pillow?) talk in the desire to be heard/witnessed by the referent and reader with an intent to absolve. The diminutive “i” bears a relation to poet Fanny Howe’s “little g God” in that “One of the (many) things I like about little g God is that you can have a vodka tonic while you talk to little g God, sing along to Bowie’s “I’m Afraid Of Americans,” and hum Coltrane’s “A Love Supreme,” though maybe not all at the same time” (Oliver, 2009). Towards the middle of the poem AO is at a used bookstore and remarks on the funny employment of death as a ‘plot mistress’ that ‘they’ (the dubious employed mystery authors) are ‘unable to grasp’, thereby giving death a mouthpiece, a modeling job, something to do to pass the time. from THE VISIBLE UNSEEN When I first saw graffiti, I recognized in it an ugly aesthetic, a dialectics of violence, a distortion of limbs, a hieroglyph. It was only later when I read the names of the dead that I then saw the path of ghosts charted there; its narrative of loss for the visible unseen whose place in history has been fictionalized and rendered unseen under the totalizing glare of history. Inscriptions, traces, specters. Graffiti begs a public face just as ghosts require non-ghosts (humans) to sense them. The “visible unseen” is a game of hide-and-seek between public viewer and graffiti-inscriber, an ephemeral-violent aesthetic on an ephemeral-policed canvas. Graffiti-inscribers already submit to being forgotten, expect to be washed away; perhaps it’s a holy urban mandala created by gangster-type monks without Buddhism. [...] in its refusal to disappear it forces a discourse in the public imagination we are forced to see what we would rather not, to make sense of an encoded language that we cannot read on the level of meaning. it irritates, forces its agency on us, speaks outside and beyond semiotic reach. An epic font-size pervading the public’s imagination, illegible, I could just close my eyes, remain passive, drive past, abandon it beyond reach, push it further away beyond death walls. In Barcelona I watched a clean up crew wash walls with an awesome water hose but I was more intrigued by their bodies; not a distortion of limbs, not hieroglyph but also not entirely legible; the laboring body permanently erasing specters of the city, and of course they knew it was also an invitation for the ghosts to return. Graffiti is death’s little sister, is also an aporia. [...] Graffiti (fr GK -graph(os), something drawn or written, to diagram or chart) attempts to stage the impossible: to erase the essence of its own subjectivity. Graffiti is a cartography of ghosts, a mapping of elegiac rapture (the transporting of a person from one place to another, as in heaven) and rupture (the state of being broken open.) Dwelling is a fiction stasis. [...] The notion of the past as being something done with, a look-back event, inhibits the possibility of reading graffiti as rapture, as rupture. If graffiti posits history as always in the process of becoming undone. [...] Because what is the body, if not also a complex temple, an unstable site through which to negotiate subjects, materiality, economies, gods, and modes of representations? The site where we are all already belated. Graphein meaning “to write.” “Derrida says every archive makes a law, and the law of genre is its own rupture” (Bloch, 39). However, graffiti is an (non/anti)-archive of erasure due to (the politics of) washing out its subjectivity, which only adds onto (or is symptomatic of) its character. The inhibition of “reading graffiti as rapture, as rupture” is partly due to it being a “look-back” event in that it’s process involves scratching through layers to reveal previous specters underneath. Graffiti (as an ancient genre) has always been a thing of ‘becoming undone’, and therefore ‘belated and always in arrival’ (Levitsky). It’s a Dionysian activity done at night with it’s back turned toward us. "The specter [...] is of the visible, but of the invisible visible, it is the visibility of a body which is not present in flesh and blood [...] appearing for vision, to the brightness of day [...] something becomes almost visible which is visible only insofar as it is not visible in flesh and blood. It is a night visibility. As soon as there is a technology of the image, visibility brings night. It incarnates in a night body, it radiates in a night light" (Derrida & Stiegler, 115). (shrink)

When it is considered to be in their best interests, withholding and withdrawing life-supporting treatment from non-competent physically ill or injured patients – non-voluntary passive euthanasia, as it has been called – is generally accepted. A central reason in support of the procedures relates to the perceived manner of death they involve: in non-voluntary passive euthanasia death is seen to come about naturally. When a non-competent psychiatric patient attempts to kill herself, the mental health care providers treating her are (...) obligated to try to stop her. Yet it has been suggested that death by suicide can be a part of the natural course of a severe mental illness. Accordingly, if the perceived naturalness of the deaths occurring in connection with non-voluntary passive euthanasia speaks for their moral permissibility, it could be taken that a similar reason can support the moral acceptability of the suicidal deaths of non-competent psychiatric patients. In this article, I consider whether the suicidal death of a non-competent psychiatric patient would necessarily be less natural than those of physically ill or injured patients who die as a result of non-voluntary passive euthanasia. I argue that it would not. (shrink)

Background: Achieving a “good death” is a major goal of palliative care. Nurses play a key role in the end-of-life care of older patients. Understanding the perceptions of both older patients and nurses in this area could help improve care during this period. Objectives: To examine and compare the preferences and perceptions of older patients and nurses with regard to what they feel constitutes a “good death.” Research design: A cross-sectional study. Participants and research (...) context: This study employed a self-report questionnaire that asked about various options for end-of-life care. It was distributed to older patients who attended the outpatient clinic of internal medicine and nurses who worked at two medical schools in Thailand from September 2017 to February 2018. Patients were asked to respond to the questions as if they were terminally ill, and nurses were asked to imagine how older patients would answer the questions. Ethical consideration: Approval from Institutional Review Board was obtained. Findings: A total of 608 patients and 665 nurses responded to the survey. Nurses agreed with concepts of palliative care, but they rated themselves as having poor knowledge. The patient respondents felt that it was most important that they receive the full truth about their illnesses. The nurses thought the most important issue was relief of uncomfortable symptoms. On seven out of the 13 questions, nurses overestimated the importance of the relevant issue to patients and underestimated the importance on one question. Discussion: Both nurses and older patients signified concepts of palliative care, but nurses felt that they lacked adequate knowledge. Nurses estimated that patients would have positive attitudes toward autonomy and the closure of life affairs to a significantly greater degree than the patient respondents. Conclusions: We recommend that palliative care education be improved and that steps be taken to allow for more effective nurse–patient communication with regard to the patients’ end-of-life wishes. (shrink)

An individual’s right to refuse life-sustaining treatment is a fundamental expression of patient autonomy; however, supporting this right poses ethical dilemmas for healthcare providers when the patient has attempted suicide. Emergency physicians encounter patients who have attempted suicide and are likely among the first medical providers to face the dilemma of honoring the patient’s DNR or intervening to reverse the effects of potentially fatal actions. We illustrate this issue by introducing a case example in which the DNR of a (...) terminally ill woman was not honored because the cause of her cardiac arrest was suicide. We argue that although a terminal diagnosis should change the way health care providers respond to a suicide attempt, many of the theoretical underpinnings for how one should treat suicide attempts—especially the criterion of external reasonability, that is the action to withhold or withdraw life-sustaining measures is reasonable independent of the precipitating event—are common to all situations :3–12, 2013). The presumption that patients who attempt suicide lack capacity due to acute mental illness is flawed because it fails to account for a competent individual’s reasonable preference to not be forced to live in an unbearable, terminal condition. In states without legislation allowing physician aid in dying, patients and providers must grapple with these limitations on a case-by-case basis. In cases where the patient has a limited life expectancy and there is not concern for psychiatric illness as the primary cause of the suicidal action, we argue that the negative right to refuse life-sustaining treatment should prevail. (shrink)

This chapter contains sections titled: The Epistemology of Murder Violence and Human Nature The Gestation of Terrorists and Serial Killers Conclusions.

A young man, terminally ill and in extreme suffering, asks to be removed from life support, requesting morphine first so he'll be asleep when the machine stops. His physician agrees, but the hospital's chief administrator intervenes, arguing that the morphine might itself cause death, leaving the physician open to criminal indictment for murder. To placate the administrator, the doctor and patient reach a grim compromise: life support will be disconnected first, and only after manifest signs of suffering appear will (...) the physician administer the morphine, to alleviate pain. The patient's request is ultimately respected, but many staff members feel he has been made to suffer needlessly. This is just one of many cases Ruth Macklin discusses in Enemies of Patients, an eye-opening look at the growing number of forces that are hostile to the interests of patients, including hospital administrators, lawyers who represent hospitals, insurance companies, government regulations, and even some well intentioned physicians. Macklin, a highly regarded medical ethicist, the author of Mortal Choices and the subject of a New York Times Magazine cover story, provides a behind-the-scenes look at how the patient's ethical rights are often violated. She describes, for instance, how a new breed of hospital administrator, the risk manager, acts consistently as an enemy of the patient, often urging physicians to continue aggressive, expensive treatments for critically ill patients--even when the patient and doctor agree the treatment should cease--for fear of lawsuits, bad publicity, or criminal indictment. (Macklin points out, for instance, that even though no physician has ever been convicted of a crime for withdrawing treatment from a patient in a permanent vegetative state, hospital lawyers and risk managers regularly assert that there is a danger of criminal liability in such cases.) The government also can become an enemy of patients. The most egregious case, according to Macklin, is the Federal government's "gag rule" which has prohibited health care facilities that receive Title X funds from discussing abortion with pregnant women, violating the patient's right to full information. And physicians themselves can become enemies of patients. Some, seeing themselves as fiscal gatekeepers, ration expensive health care procedures on financial rather than medical grounds. Some physicians refuse to treat patients who don't follow their advice (a cardiologist, for instance, who will not take care of patients who smoke) and others won't treat patients who pose a threat of lawsuit (such as a California woman in need of life-sustaining dialysis, who had previously sued another physician). Packed with numerous case histories drawn from the author's experience in a major urban medical center, Enemies of Patients will give readers a better understanding of their rights as patients and show them how to forge an alliance with their doctors against common enemies. (shrink)

Does it matter morally whether a bomber who kills civilians in a raid intends to do so as a means to weakening the enemy or merely foresees he will do so in his attempt to destroy a munitions factory? Does it matter morally whether a nurse who gives a terminally ill patient a lethal dose of painkiller intends to do so as a means to ending the patient's life or merely foresees she will do so in her attempt to (...) alleviate the patient's pain? Those who answer affirmatively rest moral weight on the notion of intending to do something as a means. But giving an adequate analysis of this notion has proved difficult. In ‘Intending as a Means,’ Kwong-Loi Shun criticizes two attempts at analyzing this notion, one which he attributes to Jonathan Bennett and the other which he attributes to Thomas Nagel. Shun thinks both Bennett's and Nagel's analyses identify intending to bring about S as a means with aiming at S and offers examples which he believes show ‘an agent need not aim at what he intends to bring about.’ In making his objection to Bennett and Nagel, Shun introduces his own criterion for intending as a means. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“We Need to Cut the Neck!”Confronting Psychological and Moral Distress during Emergency Cricothyrotomy1Stephanie CooperEnoughYou didn’t die in the ER, but rather, began your inexorable demise. The last, first, and only words I ever heard you utter was the weak mewl “tight, tight” as the blood pressure cuff constricted your left arm. You were 98–years–old, bed–bound, at the end. Your world was already partitioning itself from us, your brain tunneling (...) down the uneven corridors of consciousness. A concretion of otoliths muffled your hearing, and fatigue burdened your ancient heart.Your name–band encircled your skinny ankle like a bird. Deformed by arthritis, you were caged within yourself, imprisoned by senescence. You could not declare yourself to us. Words disintegrated into moans and your grimace became animal.When you came back from x–ray—hypotensive with multiple neck fractures confirmed—you could speak no more. Your pulse slowed, your blood pressure plummeted. I jammed a gloved finger against your femoral pulse, faint and tired. [End Page E5]“What’s her DNR status?” I gravely asked your nurse.The DNR paperwork for once had arrived with the patient. “No CPR” she said with relief. But then the paperwork went on, forcing me—the waitress of tragedy—to serve up the hash of an impossible menu.As health care providers, we are all often tasked with performing contradictory actions: the pain of IV insertion followed by the morphine push, drilling deeper into broken bone in order to plate it, the inadvertent cracking of ribs during chest compressions. We sometimes must perform violent action in the hope of sustaining and resurrecting life. We are asked to perform the impossible, the contradictory, the painful. And sometimes the actions we must take catalyze an inexorable chain reaction of actions, which can end in death–prolonging and painful interventions that we did not intend.Although our culture may imagine that one can choose one’s meal at the end–of–life fast–food franchise of death, such is not the case. You can’t suddenly decide you’re a vegetarian. You can’t order the cheeseburger without the cheese—and we all are getting the burger, in the end. Ordering the heart–squeezing drugs without the CPR to circulate them, or the antibiotics without the fluid to counter dehydration, is like ordering the burger without the bun. Sometimes the possible choices are not necessarily realistic choices. You get served what you get served, and perhaps we should question the assumption that we have the ability to choose at all.Your DNR form proclaimed no CPR but then said that antibiotics and intubation were okay—the cheeseburger without the cheese. An unfortunate choice for you, me, and the rest of us, as your death menu led to a very unhappy meal.You were comatose. I stuck a tongue blade deep into your desiccated throat. You did not gag. This means I should have intubated you, but morally, I couldn’t. To what end? You were 98 years old, broken, moribund. If you hadn’t suffered multiple neck fractures, or if you were a vibrant elder who had just walked off Mt. Rainier, maybe the story would have been different. But you? I doubted that you truly had a chance of ever feeling joy again. You were somebody’s wife, somebody’s mother. I knew this step would lead to the domino of unstoppable steps. I refused to flog your corpse.I called your daughter Kay on her cell phone, told her that you were in critical condition and that she should come to the ER immediately. But how to begin to tell a daughter her mother is dying, let alone over a cell phone? Gentle but surreal and impersonal, my voice tried to tell your daughter that the interventions you needed would likely kill you. I have seen enough human suffering to know. To me, the choices were clear: death by nature’s irrefutable course, versus a more painful, protracted, and violent death by what we’d do to you.Kay arrived in a wheelchair and scooted up to your bedside. Like all daughters, she wasn’t ready for you... (shrink)

Our research on the texts of the Byzantine historians and chroniclers revealed an apparently curious phenomenon, namely, the abandonment of terminally ill emperors by their physicians when the latter realised that they could not offer any further treatment. This attitude tallies with the mentality of the ancient Greek physicians, who even in Hippocratic times thought the treatment and care of the terminally ill to be a challenge to nature and hubris to the gods. Nevertheless, it is a very (...) curious attitude in the light of the concepts of the Christian Byzantine physicians who, according to the doctrines of the Christian religion, should have been imbued with the spirit of philanthropy and love for their fellowmen. The meticulous analysis of three examples of abandonment of Byzantine emperors, and especially that of Alexius I Comnenus, by their physicians reveals that this custom, following ancient pagan ethics, in those times took on a ritualised form without any significant or real content. (shrink)

The University of Pittsburgh Medical Center (UPMC) "Policy for the Management of Terminally Ill Patients Who May Become Organ Donors after Death" proposes to take organs from certain patients as soon as possible after expected cardiopulmonary death. This policy requires clear understanding of the descriptive state of the donor's critical cardiopulmonary and neurologic functional capacity at the time interventions to sustain or harvest organs are undertaken. It also requires strong consensus about the moral and legal status of (...) the donor during dying and confirmation of death. There has been no need for the clarity and precision that this policy relies upon, and thus the needed research and conceptual work has not previously been generated. The empiric base and societal consensus are both too frail to provide justification for this policy at this time. (shrink)

Should people suffering from untreatable psychiatric conditions be eligible for physician-assisted death? This is possible in Belgium and the Netherlands, where PAD for psychiatric conditions is permitted, though rare, so long as the criteria of due care are met. Those opposed to all instances of PAD point to Belgium and the Netherlands as a dark warning that once PAD is legalized, restricting it will prove impossible because safeguards, such as the requirement that a patient be terminally ill, will inevitably (...) be eroded or discarded. However, some supporters respond that limiting PAD to those suffering from terminal illness, or physical illnesses generally, is arbitrary and illogical. In addition, precisely because such patients are not terminally ill, their suffering may last for years, even the rest of their lives. Finally, severe depression may not be treatable. If PAD is justifiable under some conditions—as I shall assume in this article—then why wouldn't it be justifiable for these patients? Why shouldn't psychiatrists who have nothing else to offer their suffering patients be able to help them to die, if that is what they want? (shrink)

A patient suffering from a severe illness that is entering its terminal stage is forced to develop a coping process. Of all the coping patterns, the religious one stands out as being a psychological resource available to all patients regardless of culture, learning, and any age. Religious coping interacts with other values or practices of society, for example the model of a society that takes care of it's elder members among family or in an institutionalized environment or the way (...) the health system offers or not psychological support for a terminally ill patient. Health care providers should have at least some psychological coping patterns training because not all patterns of religious coping are equally effective, and some have been described as increasing the level of stress or producing other negative psychological effects on the patient. This article aims to review the complex models of religious coping that are unanimously accepted in psychooncology, arguments in favor of religious coping, the types of patients that use this model, ethical dilemmas that could be reinterpreted using religious arguments. Finally, we will also discuss the need of Romanian patients to embrace a religious coping in case of an incurable illness, and also the support that they can receive from both curative and palliative health care providers.  . (shrink)

INTRODUCTION BY NANCY FUMERO What is a translation that stalls comprehension? That, when read, parsed, obfuscates comprehension through any language – English, Portuguese. It is inevitable that readers expect fidelity from translations. That language mirror with a sort of precision that enables the reader to become of another location, condition, to grasp in English in a similar vein as readers of Portuguese might from João Guimarães Rosa’s GRANDE SERTÃO: VEREDAS. There is the expectation that translations enable mobility. That what was (...) written in one language be accessible in another. And that a translator is to serve as a mediator, acting ultimately in service to ideas within the source text. To disperse them. However, this notion of translation is partly antithetical to the ideas in Rosa’s work. Or, alternately, to convey the despair of terrain slipping beneath one’s feet, and to encounter the heightened suspense of magic, the translation, as part of its strategy, cannot devotedly rely on its original language, not as its source text. The work undertaken by Felipe W.Martinez is a new form of translation that risks everything in order to encounter the same treacherous knowing Rosa had traversed. And it takes its risks by not taking risks: by being, almost word for word, a literal translation. This is an approach that reductively converts, as opposed to translates. The idiomatic differences between English and Portuguese are not accented. The syntax is not finessed. Liberties are not assumed on account of improving readability. What stands, resoundingly amid such absences, is the awakened challenge of reading. The genuine peril of not knowing. That is, this translation, one that purports to know nothing, creates access into the guileful world Rosa had created in Portuguese. But not by translating. If anything, GRANDE SERTÃO: VEREDAS is speaking a cosmic language through a linguistic one. And W.Martinez does us the service of recognizing this, as what configures the shapes of words and sentences is not as simple as neologisms, portmanteaus, and digressions, but as terrifying as the path the fool traverses: all paths. As such, this translation doesn’t speak English, just as the original does not speak Portuguese. It is the assemblage of paradox as a new logic that can be navigated, if only one could suspend the comfort of readability, of expectation. If one could descend a mountain in the pitch dark of night, each step shocking the body, unable to acclimate to the unleveled heights. Without a doubt, the translation is incongruous to the Portuguese. Taking a small excerpt to compare: Eh, well, thereafter, the rest the Sir provide: comes the bread, comes the hand, comes the god, comes the dog. What is striking is the interplay between “god” and “dog”. To most English speakers, this anagram is a familiar one. But in Portuguese the words god (“deus”) and dog (“cão”) are not so closely linked. In fact, there is no direct mention of “deus” in Rosa’s text: Eh, pois, empós, o resto o senhor prove: vem o pão, vem a mão, vem o são, vem o cão. Both are fascinating. In Rosa’s excerpt, the rhythm is unmistakable and precise, despite, of course, the indices of hesitation: the commas, the Eh, the uncomfortable way of searching through prolongation and wait. This is the sort of paradox Rosa can engage within a sentence. W.Martinez’s does this as well, at a scale that reverberates beyond the sentence, and with one noticeable addition: deus. What may appear to be an overstep, to add such a weighted word that draws out wordplay but is, nevertheless, not in the source text, is exemplary of risk. The translation buzzes because of it. This is because throughout the text we encounter dogs frequently, as some primal beast on par with humans. The dog is one that masters and can be mastered. A creature that is at times its face, and at others a mask. It is a powerful presence. For the translator to be attuned to the reverent undercurrent attributed to this animal, and create within the translation such charged play in English from what was only an implication in Portuguese, is in tribute to the grand beauty within dissonance. What aberrant modes of writing and translation can teach us most assuredly, is that things, words, are not in states of rightness or wrongness, but of oscillation. This isn’t so different from what Rosa says himself: The Sir look…see: the most important and beautiful, of the world, is this: that the people are not always same, still were not completed — but that they go always shifting. They tune or detune. We find this so readily in W.Martinez’s translation, this tuning and detuning. Nancy Fumero Los Angeles GRAND SERTÃO: VEREDAS BY JOÃO GUIMARÃES ROSA TRANSLATED FROM THE PORTUGUESE BY FELIPE W.MARTINEZ Nonothing. Shots that the Sir heard were man brawling not, God be. Bleach white sights on the tree in the backyard, down in the river. By my right. I do this every day, I like; from the bad of boyhood. Thereof they came to call on me. Case of a calf: a white calf, errorful, eyes of to not be—saw selves—; and with a mask of a dog! They told me; I didn’t want to catch a sight. Same that, by the defects of birth, upturned lips, looked to be a laughing man. Folkface, dogface: they determined—it was the devil. Bananas. Killed it. Do not know who owned it. They came to borrow my guns. I caved. I’ve no power to impose. Oh, sir, you laugh certain laughs…Look: when it’s a true shot, first the dogs begin to bark, instantly—after, then, you see who’s handed death. Sir, endure, this is the Sertão. Some want that it is not: that situated Sertão is in and out of those general fields, they say, end of the road, highlands, the other Urucuia. Toleima. For those of Cortino and of Curvelo, then, isn’t here said Sertão? Ah! That there’s more! To place the Sertão it’s told: it’s where the pastures lack latches; where one can tear off ten, fifteen leagues without running into a houseinhabitant; where criminalousness lives out its christ jesus. Sifted out from the tightening grip of the law. The Urcuia comes from the western mountains. But today, its banks, give all—farmlands of farms, pastures of meadows of good yield, low tides, cultures that go kill for kill, until these virgins there are. The general fields run round. These general fields are without size. Ultimately, whichever one one approves, the Sir knows: bread or breads, it’s a question of heads…the Sertão is everywhere. Of the devi? No comment. Sir ask the dwellers. Falsely I fear they unspeak that name of his—only say: whatsitcalled. Volt! no… Whosoever over avoids it, lives with it. In the sentence of one Aristides—who exists in the first palm grove on the right hand side, called Vereda-of-Cow-Calm-of-Saint-Rita—everyone believes: he can't pass in three designated places: then can be heard the tiny cry, behind, a little voice warning:— "Here I come! Here I come!... "— that is the Capirote, the whatsitcalled... And one Jise Simplicio—who anyone from here will swear he keeps an imp in house, a little satanite, imprisoned and obliged to help in all greedful deeds; reason that Simplicio emprises en route to complete riches. As such, for this they say too that his beast bristles and refuses, denying his banner, unyielding, when he wishes to mount... Superstition. Jise Simplicio and Aristides, continue getting fatter, thence unheard or heard. Still the Sir study: right now, in these days of time, you have people purporting that the devil proper stopped, mid-passage, in Andrequice. A boy out of there, to whom'd appeared, and there lauded that, to get here—normally, by horse, a day-n-half—he was capable of such with only some twenty minutes enough... by coasting the River of Chico by the headwaters! Or, too, who knows—sans offense—will not have been, for example, even yourself the Sir who announced such, when you passed by there, for fun run funny? Thereof, not my given crime, I know that wasn't. And evil I wanted not. Only that one question, in hours, at times, brightens peaceful reason. But, the Sir understand: if such a boy, there was, he wanted to dupe. Because, hey, that, to cut the river off by the springs, would be the same thing as one redoubling in the internals of this our state of ours, costant of a journey of some three months... Then? Whatsitcalled? Dodo. The fantastication. And, the respect of giving him such these names of delicacy, is what it is for one to want to invoke that he form of form, with his presence! Not that is. I, personally, almost that have lost in him the creed, deserving to Deus; is the that to the Sir I say, to pure-secret. I know that it is well established, that it greases our Saintly-Gospels. On occasion, I conversed with a young seminarian, super suitable, conferring in the book of prayers and coated in vestments, with a stick of black-sage in hand—prosed that he went auxilitator to the father, to extract the Cujo, from the body living of an oldwoman, in Waterfalls-of-Bulls, he went with the vicar of Field-Round... I conceive. The Sir not is as I? I didn't believe a single thing. Compadre mine Quelemem describes that that which reveals effect are the low spirits meager, of third, adoing in the worst darkness and with anxieties of connecting selves with the livers—they give support. Compadre mine Quelemem is who much me consoles—Quelemem of Goias. But he has to live far from here, in Jijuja, Vereda of Buriti Dark... Ahrr, I leave myself there, that in enevildemonment or with support—the Sir too must have had known diverse, men, women. As not yes? For me, umpteen I've seen, that I've learned. Ma-Neigh, Blood-o'Other, or Legion-Lips, or Tear-em-Down, Cold-Cutter, or Sissy-Goat, one Treciziano, or Verdigris... or Hermogenes... o'them, pileload. If I could forget so many names... I'm not a man for calming horses! And, same, whom of yes of to be jagunço self enters, yea is for some competence entrant of demonion. Will it not? Will it? From first, I made and mixed, and to think not I thought. I didn't have the deadlines. I lived pulling difficult from difficult, fish alive on griddle: who lives asp'rously, no fantasies. But, now, fete of fate to me comes, and sans little disquietudes, I'm from creaky net. And myself invented in this like, of to speculate ideas. The devil exists and nonexists? I say the saying. Opennouncement. These melancholies. The Sir sees: exists waterfall; and since? But waterfall is gulch of ground, and water so pouring from it, retumbling; the Sir consume that water, or undo that bankment, remainder waterfall any? To live is negotiation much perilous. I explain to the Sir: the devil vigors inside of human, the wrinkles of human— or is the human ruin, or the human of adversess. I free, per se, citizen, is that not has devil notone. Notone!— is the that I say. The Sir approve? Me declares total, frank— is high merit that me make: and to beg might, increased. This case— by rashtravagance that me they see— is of mine certain importance. God grant not was... But, not say that the Sir, awised and instructed, that agrees in people of them?! Not? You I appreciate! Your high opinion composes my value. Yea I knew, waited for it— yea the field! Ah, a we, in oldness, we lack of to have plowing of rest. You I appreciate. Is devil notone. Nor esprit. Never I've seen. Someone ought to see, then was I myself, this your servant. Was I you to tell... Well, the devil regulate his state black, ins creatures, ins womens, ins humans. E'en: ins childrens— I declaim. Since not is said: "boy—trainee of the devil"? And ins thes uses, ins plants, ins waters, in terra, in wind... Manures. …The devil in the street, in the middle of the vortex... Hey? Hey? Ah. Figuration mine, of worse by back, the certain memories. Mal-make me! I suffer pain of to tell not…Meliorate, if chillingly: well, in a ground and with equal format of branches and leaves, not give to cassava-calm, that is eaten common, and the cassava-mad that kills? Now, the Sir yea saw a strangeness? A cassava-sweet can rapidly to turn agonizing— motives not I know, at times is said that is for replanted in the terrain always, with mutations then, of caules—go embittering, of s’much in s’much, of its self takes poisons. And, well look: the other, the cassava-mad, too is that at times can fix calm, the estimate, of is to eat sans notone mal. And what this is? Eh, the Sir yea saw, for to see, the ugliness of hate pleated, facetorqued, on the faces of one cobrarattlesnake? Observed the porker fat, capita day more felicity brute, capable of, could, snort and engulf for its own dirty coziness the world total? And sparrowhawk, blackbird, some, the features of they yea represent the need of cleave for before, rend and shred by beak, appears a knife much fine for ruin I desire. Total. Has even twisted races of stone, horrorous, venomous— that spoil mortal the aquas, if they are buried beneath of well; the devil inside of them sleeps: they are the devil. Is known? And the demon— that is only thus the significance of one mercury malign— have order of to follow the path of him, have license to brag?! Arr, he is variegated in all! What the what wastes, goes spending the devil of inside of the people, by itttybits, is the reasonable to suffer. And the delight of love—compadre mine Quelemem says. Family. Really? Is, and not is. The Sir think and not think. Total is and not is… Almost all more grave criminous ferocity, always is much good husband, good son, good father, and is good-friend-of-your-friends! I know of those. Solo that have the afters— and Deus, joined. I spy many nimbi. But, in veracity, son, too, softens. Look: one called Aleixo, resident a league from Step-of-Sour, in Of-Sand, was the man of major badness calm that yea you saw. Me agreed that near the house of his had a weir, amidst the palms, with traíras, for souls of enormous, desenormous, to the real, that received fame; the Aleixo gave of to eat to them, in hours just, they self accustomed to if assuch of lunacies, in order to gobble, seemed to be fishes instructed. One day, solo for grace rustic, he killed an oldman who by there passed, destitute begging alms. The Sir not doubt—have people, in this bored world, that kill solo in order to see someone make grimace… Eh, well, thereafter, the rest the Sir provide: comes the bread, comes the hand, comes the god, comes the dog. This Aleixo was man afamilied, had children small; they were the love of his, total, absurdity. Gave good, that not even a year there passed, of to killed the oldman poor, and the children of Aleixo there they asickened. Smallepidemic of measles, they said, but complex; they never heal. When, then, they healed. But the eyes of theirs vermillionized high in an inflame of spraining to rebellion; and nexthing— the that not I know is if they went of at once, or one later and later other and other— they remained blind. Blind, sans remission of one sweet of light of this Ours! The Sir imagine: stairset— three boys and one girl— all blind. Sans remediable. The Aleixo not lost the judgment, but he changed; ah, mutated complete— now lives of band of Deus, sweating to be good and charitous in all his hours of night and of day. Appears even that he fixed the felicity, that before not was. He himself says he was a man of luck, because Deus wanted to have pity of him, to transform for there the route of his soul. That I heard, and me it gave rage. Reason of the children. If being castigated, what culpa of the let-there-bes of Aleixo those little children had?! Compadre mine Quelemem reproved my uncertainties. That, for certain, inother life returnaound, the children too had been the most wicked, of the mass and part of the father, demons of the same kettle of place. Sir the what thinks? And the oldman, assassinated? — I know the Sir goes to discuss. Well, too. In order that he had a sin of crime, in the body, by to pay. If the people— conforming compadre mine Quelemem is who says— if the people turn to to incarnate renovated, I contemplate even that enemy of death can come as son of the enemy. Look see: if to myself I say, has a subject Pedro Pindo, neighbor of here more six leagues, man of good for all in all, he and the woman of his, always been good, of goodness. They have a son of some ten years called Valtei—name modern, is the that the population of here now appreciates, the Sir knows. Well this-little-thing, thislet, since that some understanding illuminated in him, deed demonstrated the that is: petition stepfather, acid burner, likeful of ruin of inside of the profundity of the species of its nature. In which that torments, to the slowly, of all beasts or raisinglings little that quarrel; one time he found a creole woman hooched foolish sleeping, he arranged a shard of bottle, lashed at three points on the stern of the legs of hers. The what this boy drooled seeing, is bleeding hen or to knife pig.— “I enjoy of to kill…”— one occasion he teeny me told. He opened in me a fright; because: birdy that self leans over— the flight yea is ready! Well the Sir oversee: the pa, Pedro Pindo, mode of to correct this, and the ma, they give in him, misery and mast—they cast the boy sans to eat, they tied to trees in the yard, he nude, unplumed, even in June cold, they tilled the bittybody of his with the trammel and with the goblet, after they cleansed the skin of the sanguine, with bottle gourd brine. The people know, spy, fix wasted. The boy yea relowered of thinness, the eyes entering, caress of bones, enskulled, and tuberculated, the time total hacking, coughness of the that draw parched pectorals. Arr, that now, visible, the Pindo and the woman self habituated of on him hit, of little bit in little they were creating in this a pleasure ugly of diversion— as they regulate the canings in hours certain comfortable, until they call people to see the example good. I think that boy not endure, yea there is in the ta-da, not arrive for the lent to come… Ooee-ooee, then?! Not being as compadre mine Quelemem to want, that explication is that the Sir bestowed? That boy had to be a man. He should, in swing, terrible perversities. Soul of his was in the pitch. Demonstrated. And, now, paid. Ah, but, happens, when he’s crying and paining, he suffers equal that as was as a boy good… Bird, I saw all, in this world! Yea I saw even horse with hiccups… —the that the thing most costous that is. Good, but the Sir may say, should of: and in the start— for offenses and arts, the people— as for that was that s’much amended was started? Ey, ey, ey all collided. Compadre mine Quelemem, too. Am solo a sertanite, in these high ideas I navigate mal. Am much poor poor-thing. Envy my pedigree and of ones conform the Sir, with total reading and doctoration. Not is that I be illiterate. I spelt, years and middle, midly speller, memory and palmer. I had master, Master Lucas, in the Curralinho, he memorized grammar, the operations, rule-of-three, even geography and study patria. On leaves great of paper, with caprice I traced handsome maps. Ah, not is for to speak: but, since of the start, me they thought sophisticated of side. And that I merited of to go to course latin, in Lesson Waterlily—that too they said. Time nostalgic! Going today, I appreciate a good book, despaced. On the farm The Lilittlelemon, of one mine friend Vito Soziano, so sign of this almanac thick, of logoglyphs and conundrums and other divided matters, all year come. In s’much, I place primacy is in the reading advantageous, life of saints, virtues and examples— missionary astute engambling the Indians, or Saint Francis of Assis, Saint Anthony, Saint Gerald… I like much of moral. To ratiocinate, exhort the others for the good way, to acounsel to just. Mine woman, that the Sir knows, vigils for me: much prayer. She is a blessable. Compadre mine Quelemem always says that I may to aquiet my fears on conscience, that being well-attended, terrible good-esprits me protect. Eep! With like… As is of saint effect, I help with mine to want to accredit. But not even always can I. The Sir knew: I total the mine life I thought for me, lining, I am born different. I am and I same. I divert of total the world… I almost that nothing not I know. But I disconfide of many things. The Sir, conceding, I say: in order to think long, I am dog master— the Sir loose in mine front an idea ease and I research that by profundity of total the backwoods, amen! Look: the should of to have, was of so reunited-selves the wise, politicos, constitutions graded, closed the definitive the notion— to proclaim for one time, art assemblies, that not have devil notone, not exists, not possible. Valor of law! Solo assuch, they gave tranquility good to the people. Because the government not cares?! Ah, I know that not is possible. Not me settled the Sir for philistine. One this is to place ideas arranged, other is to deal with country of people, of flesh and sanguine, of thousand-and-many miseries… S’many people—gives scare of to know—and notone so calms: All nascenting, crescendoing, so wedding, wanting collocation of employment, consumables, health, abundance, to be important, wanting rain and affairs good… Of luck that lacks of so to choose: or we t’weave of to live in the salacious common, or care solo of religion solo. I could to be: father clergyman, if not chief of jagunços; for other things not was I birthed. But mine oldness yea principaled I erred of total account. And the rheumatism… There as whom says: in the primers. Ahem. Hey? Hey? The that more I think, I testify and explain: all-the-world is mad. The Sir, I, we, the people all. For this is that so lacks principally of religion: in order to desendodorize, to disdodoate. Pray is that heals of lunacy. In the general. This is that is the salvation-of-the-soul…Much religion your servant! I here, not I lose occasion of religion. I profit of all. I drink water of all rivers… One solo, for me is little, maybe not me arrives. I pray christian, catholic, I burrow the certain; and I accept the prayers of compadre mine Quelemem, doctrine of he, of Kardec. But, when I can, I go in the Mindubim, where one Matias is believer, methodist: the people so accuse of sinner, reads high the bible, and why, singing hymns beautiful of his. Total me quiets, me suspends. Whatever small shade me refreshes. But is solo much provisory. I wanted to pray— the time total. Many people not me approve, they think that law of Deus is privileges, invariable. And I! Doof! I Detest! The what I am? — the what I do, that want, much curia. And in face of total I face, executed. I? —not I trammel. Look: I have a black girl, Maria Leoncia, long from here not she lives, the prayers of her afame much virtue of power. Well to her I pay, every month— ordering of to pray for me one third, every saint day, and, on the Sundays, a rosary. Value, so values. Mine woman not sees mal in this. And I am, yea mandated word for an other, of the voyage-voyage, a Izina Calanga, in order to come here, I heard of that prayer too with grand mermermerits, I go to effect with she treatment equal. I want handful of those, me defending in Deus, reunited of me in volta… Cuts of Christ! To live is much perilous… To want the good with too much force, of incertain way, can yea to be being so wanting the mal, per to initiate. These humans! All they pull the world for itself, for the to concert amended. But capita one solo sees and understands the things of one his world. Amountain, the most supro, most serious was Mediero Vaz. That one man ancient… his Joaozy Ben-Ben, the most brave of all, no-one never can decipher how he by inside consisted. Joca Ramiro— grand man prince!— was politico. Zé Bebelo wanted to be politico, but had and not had luck: fox that lingered. So Candelario so demonized, by to think that was with illness mal. Titao Passos was the by the appreciation of friends: solo per via of them, of his same amities, were that such high so ajagunçoed. Antonio Do— severe bandit. But by half, grand majority half that be. Andalecio, in the profound, a good man-of-good, being raving in his total justice. Ricardao, same, wanted was to be rich in peace: for this he warred. Solo the Hermogenes was that born formed tiger, and assassinite. And the “Ofidios White”? Ah, not me speak. Ah this… joyless mischeivious, that was— that was a poor boy of the destiny… So good, congruous. The Sir heard, I you told: the ruin with the ruin, they terminate by the spine-bushes so to crack— Deus awaits that spendance. Boy!: Deus is patience. The contrary, is the devil. So consumes. The Sir file knife on knife— and file— that so they scrape. Even the rocks of the profound, one of in the other, they go-so aroundabounding even, that the rivulet rolls. Per enquantity, that I think, total as hath, in this world, is because so merits and lacks. Afterly precise. Deus not so reports with rifle, not garrotes the regulation. For what? Quit: goof with goof—one day, some illumination and learn: smart. Solo that, at times, for most auxiliar, Deus begets, in the middle, a pinch of pepper… Therebe? Well, for example: some time, I went of train, there in Seven-Lagoons, for parts of to consult a medical, of name me indicated. He went vested well, and in car of first, by via of the doubts, not me they shadowed for jagunço ancient. It goes and happens, that, close same of me, enfront, he took aseat, returning from the wild North, a mac Jazevedao, delegate professionale. Came with a capanga of his, an undercover, and I well knew the two, of that s’much a was ruin, as the other ruin was. The veracity to say, first I had the strict of me to surpasss for one lonng, to mutate of my place. Judgement me told, meliorate stay. Well, looking, I looked. And— you I tell: never I saw face of man furnished of brutez or malady more, of the them in that. As that was ogre, trussed of thickset, relustered of crude in the eyes small, and armed a chin of stone, toweringbrow; not of mid nor forehead. Not laughed, not so laughed not even one time; but, speaking or silent, the people appeared always to him some teeth, prey pointed of canids. Arr, and blustered, an ittybit. Solo growled curt, low, the mid-words grizzled. He came relooking, historicizing the documents— one by one the leaves with portraits and with the blacks of the digits of jagunços, lifters of horses and criminouses of death. That application of work, in one thing of those, generated the ire in the people. The undercover, busybodyguard, total close, seated joined, attending, excelling of to be dog. Me made a dread, but solo in the goof of the corpus, not in the intern of the courages. One hour, one of those reports fell— and I bent quickly, I knew there precisely by why, not I wanted, not I thought— even today I raise shame of this— I picked the paper of the ground, and delivered to him. Thereof, I say: I had more rage, because I did that; but there yea it was done. The man not even me looked, not even said notone thankfulment. Event he soles of the shoes of his— solo looking— that soles rough thick, bent of enormous, appearing iron bronzed. Because I knew: This Jazevedao, when he apprehended someone, the primary quiet thing that proceeded was that he came entering, sans to have to to say, feigning some hurry, and go stepping on the top of the feet of the poorthings. And that on these occasions he gave laughters, gave… Well, geck! I delivered to him the leaf of paper, and went leaving of there, by to have hand on me of not to destroy by shots that subject. Meat that much they weigh… And umbilicated beginning of belly pot bellied, that me created will… With my lightness, joyful that I’d kill. But, the barbarities that this delegate made and happened, the Sir not even has callus in heart to be able me to hear. He achieved of many men and women to cry blood, for the simple universolo ours here. Sertão. The Sir knows: sertão is where mandates who is strong, with the guile. And bullet is a tidbit of metal… S’much, I say: Jazevedao— one assuch, should of to have, needed? Ah, need. Leather ruined is that calls goad of point. That there be that, after— business particular of he— in the life or in the other, each Jazevedao, accomplished the that he has, desclimbs in his time of pain, too, until to pay the that he gave— compadre mine Quelemem is there, in order to fiscalize. The Sir knows: the peril that is to live… But solo of the mode, of these, by ugly instrument, was that the jagunsaga so finished. Sir thinks that Antonio Do or Olivino Oliviano were going to fix goodies by pure spelling of itself, or by begging of the infelicitous, or by always to hear sermon of father? You I think! In the aims… Of jagunço comported active in order so to repent in the middle of his jagunsagas, solo I lay of one: called Joe Cazuzo— was in smashing of one shotshow, for on the summit of the place Sierra New, district of river rusted, on the stream Traçadal. We made mal minority small, and they closed in order summit of us the personnel of one Coronel Adalvino, forted politico, with many soldiers uniformed in the center, commanding of the Lieutenant Epiphany Helm, that after fixed captain. We lasted hour more hour, and yea gave almost of encircled. There, of misslip, that Joe Cazuzo— man much valiant— so kneeled turned on the ground of the thick, lifted the arms that not even shoots of Jatoba dry, and solo yell, howl clear and howl deaf:— “I saw the Virgin Ours, in the resplendor of the Heavens, with her children of angels!... ” He screamed not touched. — “I saw the Virgin!... ” He ensouled? We desequaled. Bolt for my horse—that I thought— I leaped in mal seat, noteven I knew in which rupture-time I unfastened the halter, of tied up it foot of timber. I flew, arrived. Bullet come. The pasture roared. In the brush, the fear of the people so goes to the whole, one fear intentional. I could to lash out, fated burro brute, giv-that, giv-that. Some two or three bullets so drovein the pad of the mine saddle, they perforated of to tear away almost much the kapok of the filling. Horse trembled in pro, in middle of gallop, I know: thinks in the owner. I not fit of to be more well shrunken. Bulleted came to the sack that I had on the back, with few mine things. And other, of fusil, in ricochet decreed, heated my thigh, sans me wound, the Sir see: bullet does the what to want—so pierced impressed, between in me and the harness! Times crazy… Burumbum!: the horse so kneeled in the fall, dead perhaps, and I yea falling for front, embraced in foliage full, branched and linias, that me swayed and skewered, done I was pendulating in web of spider… Whither? I traversed that life total… Of fear of anxiety, I ruptured to read with mine corpus that forest, I know there — and me fell world below, rolled for the hollow of a grotto closed of shrubs, always me grasped— rolled same assuch: after: after, when I saw mine hands, total on they that not was withdrawn sanguine, was smeared green, on the digits, of leaves living that I pulled and mashed… I landed on the sedge of the profound— and a beast dark gave a releap, with a sneeze, too mad of fright: that was a papa-mel, that I descried; in order to flee, this is solely. Bigger being I, me doused mine overcoat; I spigotted total. And of one bit of thought: if that beast irara lying there then there not had cobra. I took the place of his. Existed cobra notone. I could me to lose. I was solo spineless, softness, but that not deadened, inside, the collisions of the heart. I gasped. I conceived that they came, me kill. Not even did mal, me mattered not. Assuch, some moments, at least I guarded the license of term in order me to rest. Conforming I thought in Diadorim. Solo I thought was in he. One joão-congo sang. I wanted to die thinking in my friend Diadorim, hand-o-bro, who was on the Sierra of WoodO’Bow, almost on the border baiana, with our other half of the so-candelarios… With my friend Diadorim me embraced, sentiment my went-flew right for he… Ay, arr, but: that this mine mouth not has order notone. I am accounting outside, things divagated. In the Sir me confide? Til-that, til-that. Say the angel-of-the-guard… But, conforming I came: after so knew, that same the soldiers of the Lieutenant and the goats of Coronel Adalvino remitted of to respect the blast of that Joe Cazuzo. And that this ended being the man most pacificious of the world, fabricator of oil and sacristan, in the Saint Sundays White. Times! For total, cleaned revelation, I fix thinking. I like. Meliorate, for the idea if well to open, is travelling in train-of-iron. Could, lived to top and to bottom, inside of it. Information that I ask: same in the Heavens, end of end, how is that the soul wins so to forget s’much sufferments and maladies, in the received and in the given? The how? The Sir knows: are things of hideous ofmuch, have. Pain of corpus and pain of idea mark forted, that forted as the total love and rage of hate. Goes, sea… Of luck that, then, the Firmiano, by appellationed Louse-of-Snake, so leoprosized with the leg disconformed, thickening, of that disease that not so cures; and not discern almost more, constant the branchials in the eyes, of the cataracts. Of before, years, had to of so disarray of the jagunsaga. Well, one occasion, some was on the ranch of his, on the High Jeuitai, after accounted—that, turns time, comes subject, he would say: “Me give yearning is of to seize a soldier, and such, for one good flay, with knife blind… But, first, to castrate…” The Sir conceive? Who has more dose of demon in self is Indian, any race of brusque. Folk see nation ofthese, for there profound of the generals of Goias, theofwhere has vagarous grand rivers, of aquas always so clear pleasantly, running of down crystal rosed… Louse-of-Snake gave of sanguine of heathen. Sir me will say: but that he pronounced that out of mouth, manner of to represent that yet not was old decadent. Opus of to oppose, for fear of to be tame, and cause in order so to see respected. Total listened for such rule: palavered of ruins, for more so valued, because we to the environs is hard durability. The worst, but, is that they finish, through the same ford, given of one day to execute the declared, in the real. I saw s’much crudity! Pain not pays to account; if I go, I collide. And me dedrip, three that me sicken, this total. Me convokes that the personnel, today in day, is good of heart. This is, good in the trivial. Malices wildwants, and perversities, always have some, but scarcities. Generation mine, true, was not assuch. Ah, goes to turn a time, in which not is used more to kill people… I yea am old. Good, I was saying: question, this that me excavates… Ah, I formed that question, for compadre mine Quelemem. That me responded: that, for close to heaven, we so amplified so, that total the uglies past so exhaled of not to be—fated sans-modus from time of youngster, mal-arts. As we not lack of to have remorse of the which divulged in the pulsation of his nightmares of one night. Assuch that: fleeced-so, flourished-so! Ahem. For this said, is that the journey to the Heavens is delayed. I confide with compadre mine Quelemem, the Sir knows: reason of creed same that has—that, for total the mal, that so does, one day so repays, the exact. Subject assuch rises three times, in ante of to want to facilitate in any minutia reprehensible… Compadre mine Quelemem never speaks vacant, not subtreats. Solo that this to he not I go to expose. We never should have to declare that accept entire the alien—that is what is the rule of the king! The Sir look…see: the most important and beautiful, of the world, is this: that the people are not always same, still were not completed — but that they go always shifting. They tune or detune. Truth major. Is the that the life me taught. This that me animates, mound. And, other thing: the devil and the brutes; but Deus is treacherous! Ah, a beauty of treacherous— gives like! The force of his, when he wants— boy!— me gives the fear dread! Deus comes coming: no one not sees. He does in the law of gentle— assuch is the miracle. And Deus attacks beautiful, so amusing, so economizes. The well: one day in a tannery, the little knife mine I had dropped inside of a tank, solo soup of bark of tan, stryphnodendron adstringens, angico, there I know. —“Tomorrow I try…”— I said, withmyself. Because it was of night, light notone I not disputed. Ah, then, I found: on the other day, early, the knife, the iron of it, had been gnawed, almost by half, by that aqua dark, total quiet. I left, for more to see. Crack, fuse! Know the what was? Well, in that same of afternoon, there: of the little knife solo so found the handle… The handle, for not to be of cold metal, but of horn of deer. There is: Deus… Good, the Sir heard knows, the that knows me understands… We sum, not think that religion fractures. Sir think the contrary. Visible that, those other times, I painted—belief that the neoglaziovia variegata lifts the flower. Ah, good my joy… Boyhood. But boyhood is task for more later so to deny. Too, I of that of to think in vague in s’much, lost mine hand-of-man for the management hot, in the middle of all. But, today, that I ratiocinated, and think the endeavor, not nor for this not I give for low my competence, in a fire-and-iron. The to see. Would approach would come here with war on me, with bad parts, with other laws, or with excessive looks, and I even draw to ignite this zone, ay, if, if! Is in the mouth of the blunderbuss: is in the rete-te-tem… And lonelyonly not I am, there-of-the. For not this, I was I placed encircle my mine people. Look the Sir: here, close, vereda below, the Paspe — cropper my — is mine. More league, if that, have the Herpetotheres, and have the compadre Ciril, him and three children, I know that they serve. Band of that hand, the Alaripe: knew the Sir the that is that so boasts, in rifleation and by the knife, one cearense did this! After more: the João Innatal, the Quipes, Lophiosilurus-of-claws. And the Fafafa— this gave fights high, all side with me, in the combat old of the Anteater-such: we cleaned the wind of whom not had order of to respirate, and ante these we desencompassed… The Fafafa has a mass of mares. He raises horses good. Even a little more distant, on the ped-of-sierra, of band mine was the Sesfred, Jesualdo, the Nelson, and João Concliz. Some others. The Triol… And not I go valuing? I leave terra with them, of theirs the what is mine is, we close that we not even brothers. For what I want to gather richness? They are there, of arms aireated. Enemy to come, we cross called, gathering: is hour of one good shotshowerment in peace, they exp’riment to see. I say this to the Sir, of confidence. Too, not go to think in double. We want is to work, propose tranquility. Of me, person, I live for mine woman, that total mode-meliorate merits, and for the devotion. Well-to want of mine woman was that me assisted, prayers of hers, graces. Love comes of love. I say. In Diadorim, I think too— but Diadorim is the mine nebulina… Now, well: not I wanted to touch on this more— of the Tineaous; arrive. But has a nevertheless: I ask: the Sir believe, think trust of truth in that parlance, of with the demon so to able to deal with pact? No, no is no? I knew that not there. I spoke of favas. But I like of total good confirmation. To vend you proper soul… Inventionate false! And, soul, the what is? Soul of has to be thing internal supremed, much more of the of inside, and is solo, of the that one if thought: ah, soul sheer! Decision of to vend soul is fearless moll, fantasied of moment, has not the obedience legal. Can I to vend those good terras, thereof of between the Veredas-Four— that are of one Mr. Admiral, who resides in the capital federal? Can I some? Then, if one boy boy is, and for this not so authorizes of to negotiate… And we, this I know, at times is solo fated boy. Mal that in mine life I prepared, I was in a certain infancy in dreams — total runs and arrives so swift —; will be that if hath flame of responsibilities? If dream; yea so did… I gave rapadura to the chump! Ahem. Well. If his soul, and has, it is of Deus established, not even that the person want or not want. Not is vendible. The Sir not thinks? Me declare, frank, I beg. Ah, you I appreciate. You so see that the Sir knows much, in idea firm, beyond of to have letter of doctor. You I appreciate, for much. Your company me gives high pleasures. In terms, I liked that I would live here, or close, was a help. Here not so has conviviation that to instruct. Sertão. Knows the Sir: sertão is where the thought of the people so forms more forted of the than power of the place. To live is much perilous… Eh, that you so go? Yeayea? Is that not. Today, no. Tomorrow, no. Not I consense. The Sir me forgive, but in endeavor of mine friendship accept: the Sir stay. After fifth of-morning-early, the Sir wanting to go, then goes, same me leaves feeling your absence. But, today or tomorrow, no. Visit, here in house, with me, is for three days! But, the Sir really intends to trespass the field this sea of territotires, for sortment of to confer the what exists? You have your motives. Now— I say for me — the Sir comes, came late, Times were, the customs mutate. Almost that, of legitimate loyal, little surplus, not even no excess more nothing. The bands good of valientoughs they reparted their end; many who were jagunço, by ouch pain, beg alms. Same as the herdsmen they doubt of to come in the commerce vested of clothes entire of leather, they think that garb of jerkin is ugly and boor. And even the herd in the shrubbed pasture goes waning less mad, more educated: casted of zebu, dissee with the rest of corralers and captiveborns. Always, in the generals is to the poverty, to the sadness. A sadness that even gladdens. But, then, for a crop reasonable of bizzarancies, I recounsel of the Sir to entest journey more dilated. Not were my desmight, by acids and rheumatism, there I went. I guided the Sir till total. March 2013 San Diego, CA ORIGINAL TEXT NONADA. TIROS QUE O SENHOR ouviu foram de briga de homem não, Deus esteja. Alvejei mira em árvores no quintal, no baixo do córrego. Por meu acerto. Todo dia isso faço, gosto; desde mal em minha mocidade. Daí, vieram me chamar. Causa dumbezerro: um bezerro branco, erroso, os olhos de nem ser – se viu –; e com máscara de cachorro. Me disseram; eu não quis avistar. Mesmo que, por defeito como nasceu, arrebitado de beiços, esse figurava rindo feito pessoa. Cara de gente, cara de cão: determinaram – era o demo. Povo prascóvio. Mataram. Dono dele nem sei quem for. Vieram emprestar minhas armas, cedi. Não tenho abusões. O senhor ri certas risadas... Olhe: quando é tiro de verdade, primeiro a cachorrada pega a latir, instantaneamente – depois, então, se vai ver se deu mortos. O senhor tolere, isto é o sertão. Uns querem que não seja: que situado sertão é por os campos-gerais a fora a dentro, eles dizem, fim de rumo, terras altas, demais do Urucuia. Toleima. Para os de Corinto e do Curvelo, então, o aqui não é dito sertão? Ah, que tem maior! Lugar sertão se divulga: é onde os pastos carecem de fechos; onde um pode torar dez, quinze léguas, sem topar com casa de morador; e onde criminoso vive seu cristo-jesus, arredado do arrocho de autoridade. O Urucuia vem dos montões oestes. Mas, hoje, que na beira dele, tudo dá – fazendões de fazendas, almargem de vargens de bom render, as vazantes; culturas que vão de mata em mata, madeiras de grossura, até ainda virgens dessas lá há. O gerais corre em volta. Esses gerais são sem tamanho. Enfim, cada um o que quer aprova, o senhor sabe: pão ou pães, é questão de opiniães... O sertão está em toda a parte. Do demo? Não gloso. Senhor pergunte aos moradores. Em falso receio, desfalam no nome dele – dizem só: o Que-Diga. Vote! não... Quem muito se evita, se convive. Sentença num Aristides – o que existe no buritizal primeiro desta minha mão direita, chamado a Vereda-da-Vaca-Mansa-deSanta-Rita – todo o mundo crê: ele não pode passar em três lugares, designados: porque então a gente escuta um chorinho, atrás, e uma vozinha que avisando: – “Eu já vou! Eu já vou!...” – que é o capiroto, o que-diga... E um José Simpilício – quem qualquer daqui jura ele tem um capeta em casa, miúdo satanazim, preso obrigado a ajudar em toda ganância que executa; razão que o Simpilício se empresa em vias de completar de rico. Apre, por isso dizem também que a besta pra ele rupeia, nega de banda, não deixando, quando ele quer amontar... Superstição. José Simpilício e Aristides, mesmo estão se engordando, de assim nãoouvir ou ouvir. Ainda o senhor estude: agora mesmo, nestes dias de época, tem gente porfalando que o Diabo próprio parou, de passagem, no Andrequicé. Um Moço de fora, teria aparecido, e lá se louvou que, para aqui vir – normal, a cavalo, dum dia-e-meio – ele era capaz que só com uns vinte minutos bastava... porque costeava o Rio do Chico pelas cabeceiras! Ou, também, quem sabe – sem ofensas – não terá sido, por um exemplo, até mesmo o senhor quem se anunciou assim, quando passou por lá, por prazido divertimento engraçado? Há-de, não me dê crime, sei que não foi. E mal eu não quis. Só que uma pergunta, em hora, às vezes, clareia razão de paz. Mas, o senhor entenda: o tal moço, se há, quis mangar. Pois, hem, que, despontar o Rio pelas nascentes, será a mesma coisa que um se redobrar nos internos deste nosso Estado nosso, custante viagem de uns três meses... Então? Que-Diga? Doideira. A fantasiação. E, o respeito de dar a ele assim esses nomes de rebuço, é que é mesmo um querer invocar que ele forme forma, com as presenças! Não seja. Eu, pessoalmente, quase que já perdi nele a crença, mercês a Deus; é o que ao senhor lhe digo, à puridade. Sei que é bem estabelecido, que grassa nos Santos- Evangelhos. Em ocasião, conversei com um rapaz seminarista, muito condizente, conferindo no livro de rezas e revestido de paramenta, com uma vara de maria-preta na mão – proseou que ia adjutorar o padre, para extraírem o Cujo, do corpo vivo de uma velha, na Cachoeira-dos-Bois, ele ia com o vigário do Campo-Redondo... Me concebo. O senhor não é como eu? Não acreditei patavim. Compadre meu Quelemém descreve que o que revela efeito são os baixos espíritos descarnados, de terceira, fuzuando nas piores trevas e com ânsias de se travarem com os viventes – dão encosto. Compadre meu Quelemém é quem muito me consola – Quelemém de Góis. Mas ele tem de morar longe daqui, na Jijujã, Vereda do Buriti Pardo... Arres, me deixe lá, que – em endemoninhamento ou com encosto – o senhor mesmo deverá de ter conhecido diversos, homens, mulheres. Pois não sim? Por mim, tantos vi, que aprendi. Rincha- Mãe, Sangued’Outro, o Muitos-Beiços, o Rasgaem-Baixo, Faca-Fria, o Fancho-Bode, um Treciziano, o Azinhavre... o Hermógenes... Deles, punhadão. Se eu pudesse esquecer tantos nomes... Não sou amansador de cavalos! E, mesmo, quem de si de ser jagunço se entrete, já é por alguma competência entrante do demônio. Será não? Será? De primeiro, eu fazia e mexia, e pensar não pensava. Não possuía os prazos. Vivi puxando difícil de dificel, peixe vivo no moquém: quem mói no asp’ro, não fantaseia. Mas, agora, feita a folga que me vem, e sem pequenos dessossegos, estou de range rede. E me inventei neste gosto, de especular idéia. O diabo existe e não existe? Dou o dito. Abrenúncio. Essas melancolias. O senhor vê: existe cachoeira; e pois? Mas cachoeira é barranco de chão, e água se caindo por ele, retombando; o senhor consome essa água, ou desfaz o barranco, sobra cachoeira alguma? Viver é negócio muito perigoso... Explico ao senhor: o diabo vige dentro do homem, os crespos do homem – ou é o homem arruinado, ou o homem dos avessos. Solto, por si, cidadão, é que não tem diabo nenhum. Nenhum! – é o que digo. O senhor aprova? Me declare tudo, franco – é alta mercê que me faz: e pedir posso, encarecido. Este caso – por estúrdio que me vejam – é de minha certa importância. Tomara não fosse... Mas, não diga que o senhor, assisado e instruído, que acredita na pessoa dele?! Não? Lhe agradeço! Sua alta opinião compõe minha valia. Já sabia, esperava por ela-já o campo! Ah, a gente, na velhice, carece de ter sua aragem de descanso. Lhe agradeço. Tem diabo nenhum. Nem espírito. Nunca vi. Alguém devia de ver, então era eu mesmo, este vosso servidor. Fosse lhe contar... Bem, o diabo regula seu estado preto, nas criaturas, nas mulheres, nos homens. Até: nas crianças – eu digo. Pois não é ditado: “menino – trem do diabo”? E nos usos, nas plantas, nas águas, na terra, no vento... Estrumes. ... O diabo na rua, no meio do redemunho... Hem? Hem? Ah. Figuração minha, de pior pra trás, as certas lembranças. Mal hajame! Sofro pena de contar não... Melhor, se arrepare: pois, num chão, e com igual formato de ramos e folhas, não dá a mandioca mansa, que se come comum, e a mandioca-brava, que mata? Agora, o senhor já viu uma estranhez? A mandioca-doce pode de repente virar azangada – motivos não sei; às vezes se diz que é por replantada no terreno sempre, com mudas seguidas, de manaíbas – vai em amargando, de tanto em tanto, de si mesma toma peçonhas. E, ora veja: a outra, a mandiocabrava, também é que às vezes pode ficar mansa, a esmo, de se comer sem nenhum mal. E que isso é? Eh, o senhor já viu, por ver, a feiúra de ódio franzido, carantonho, nas faces duma cobra cascavel? Observou o porco gordo, cada dia mais feliz bruto, capaz de, pudesse, roncar e engolir por sua suja comodidade o mundo todo? E gavião, corvo, alguns, as feições deles já representam a precisão de talhar para adiante, rasgar e estraçalhar a bico, parece uma quicé muito afiada por ruim desejo. Tudo. Tem até tortas raças de pedras, horrorosas, venenosas – que estragam mortal a água, se estão jazendo em fundo de poço; o diabo dentro delas dorme: são o demo. Se sabe? E o demo – que é só assim o significado dum azougue maligno – tem ordem de seguir o caminho dele, tem licença para campear?! Arre, ele está misturado em tudo. Que o que gasta, vai gastando o diabo de dentro da gente, aos pouquinhos, é o razoável sofrer. E a alegria de amor – compadre meu Quelemém, diz. Família. Deveras? É, e não é. O senhor ache e não ache. Tudo é e não é... Quase todo mais grave criminoso feroz, sempre é muito bom marido, bom filho, bom pai, e é bom amigo-de-seus-amigos! Sei desses. Só que tem os depois – e Deus, junto. Vi muitas nuvens. Mas, em verdade, filho, também, abranda. Olhe: um chamado Aleixo, residente a légua do Passo do Pubo, no da-Areia, era o homem de maiores ruindades calmas que já se viu. Me agradou que perto da casa dele tinha um açudinho, entre as palmeiras, com traíras, pra-almas de enormes, desenormes, ao real, que receberam fama; o Aleixo dava de comer a elas, em horas justas, elas se acostumaram a se assim das locas, para papar, semelhavam ser peixes ensinados. Um dia, só por graça rústica, ele matou um velhinho que por lá passou, desvalido rogando esmola. O senhor não duvide – tem gente, neste aborrecido mundo, que matam só para ver alguém fazer careta... Eh, pois, empós, o resto o senhor prove: vem o pão, vem a mão, vem o são, vem o cão. Esse Aleixo era homem afamilhado, tinha filhos pequenos; aqueles eram o amor dele, todo, despropósito. Dê bem, que não nem um ano estava passado, de se matar o velhinho pobre, e os meninos do Aleixo aí adoeceram. Andaço de sarampão, se disse, mas complicado; eles nunca saravam. Quando, então, sararam. Mas os olhos deles vermelhavam altos, numa inflama de sapiranga à rebelde; e susseguinte – o que não sei é se foram todos duma vez, ou um logo e logo outro e outro – eles restaram cegos. Cegos, sem remissão dum favinho de luz dessa nossa! O senhor imagine: uma escadinha – três meninos e uma menina – todos cegados. Sem remediável. O Aleixo não perdeu o juizo; mas mudou: ah, demudou completo – agora vive da banda de Deus, suando para ser bom e caridoso em todas suas horas da noite e do dia. Parece até que ficou o feliz, que antes não era. Ele mesmo diz que foi um homem de sorte, porque Deus quis ter pena dele, transformar para lá o rumo de sua alma. Isso eu ouvi, e me deu raiva. Razão das crianças. Se sendo castigo, que culpa das hajas do Aleixo aqueles meninozinhos tinham?! Compadre meu Quelemém reprovou minhas incertezas. Que, por certo, noutra vida revirada, os meninos também tinham sido os mais malvados, da massa e peça do pai, demônios do mesmo caldeirão de lugar. Senhor o que acha? E o velhinho assassinado? – eu sei que o senhor vai discutir. Pois, também. Em ordem que ele tinha um pecado de crime, no corpo, por pagar. Se a gente – conforme compadre meu Quelemém é quem diz – se a gente torna a encarnar renovado, eu cismo até que inimigo de morte pode vir como filho do inimigo. Mire veja: se me digo, tem um sujeito Pedro Pindó, vizinho daqui mais seis léguas, homem de bem por tudo em tudo, ele e a mulher dele, sempre sidos bons, de bem. Eles têm um filho duns dez anos, chamado Valtei – nome moderno, é o que o povo daqui agora apreceia, o senhor sabe. Pois essezinho, essezim, desde que algum entendimento alumiou nele, feito mostrou o que é: pedido madrasto, azedo queimador, gostoso de ruim de dentro do fundo das espécies de sua natureza. Em qual que judia, ao devagar, de todo bicho ou criaçãozinha pequena que pega; uma vez, encontrou uma crioula bentabêbada dormindo, arranjou um caco de garrafa, lanhou em três pontos a popa da perna dela. O que esse menino babeja vendo, é sangrarem galinha ou esfaquear porco. – “Eu gosto de matar...” – uma ocasião ele pequenino me disse. Abriu em mim um susto; porque: passarinho que se debruça – o vôo já está pronto! Pois, o senhor vigie: o pai, Pedro Pindó, modo de corrigir isso, e a mãe, dão nele, de miséria e mastro – botam o menino sem comer, amarram em árvores no terreiro, ele nu nuelo, mesmo em junho frio, lavram o corpinho dele na peia e na taca, depois limpam a pele do sangue, com cuia de salmoura. A gente sabe, espia, fica gasturado. O menino já rebaixou de magreza, os olhos entrando, carinha de ossos, encaveirada, e entisicou, o tempo todo tosse, tossura da que puxa secos peitos. Arre, que agora, visível, o Pindó e a mulher se habituaram de nele bater, de pouquinho em pouquim foram criando nisso um prazer feio de diversão – como regulam as sovas em horas certas confortáveis, até chamam gente para ver o exemplo bom. Acho que esse menino não dura, já está no blimbilim, não chega para a quaresma que vem... Uê-uê, então?!Não sendo como compadre meu Quelemém quer, que explicação é que o senhor dava? Aquele menino tinha sido homem. Devia, em balanço, terríveis perversidades. Alma dele estava no breu. Mostrava. E, agora, pagava. Ah, mas, acontece, quando está chorando e penando, ele sofre igual que se fosse um menino bonzinho... Ave, vi de tudo, neste mundo! lá vi até cavalo com soluço... – o que é a coisa mais custosa que há. Bem, mas o senhor dirá, deve de: e no começo – para pecados e artes, as pessoas – como por que foi que tanto emendado se começou? Ei, ei, aí todos esbarram. Compadre meu Quelemém, também. Sou só um sertanejo, nessas altas idéias navego mal. Sou muito pobre coitado. Inveja minha pura é de uns conforme o senhor, com toda leitura e suma doutoração. Não é que eu esteja analfabeto. Soletrei, anos e meio, meante cartilha, memória e palmatória. Tive mestre, Mestre Lucas, no Curralinho, decorei gramática, as operações, regra-de-três, até geografia e estudo pátrio. Em folhas grandes de papel, com capricho tracei bonitos mapas. Ah, não é por falar: mas, desde o começo, me achavam sofismado de ladino. E que eu merecia de ir para cursar latim, em Aula Régia – que também diziam. Tempo saudoso! Inda hoje, apreceio um bom livro, despaçado. Na fazenda O Limãozinho, de um meu amigo Vito Soziano, se assina desse almanaque grosso, de logogrifos e charadas e outras divididas matérias, todo ano vem. Em tanto, ponho primazia é na leitura proveitosa, vida de santo, virtudes e exemplos – missionário esperto engambelando os índios, ou São Francisco de Assis, Santo Antônio, São Geraldo... Eu gosto muito de moral. Raciocinar, exortar os outros para o bom caminho, aconselhar a justo. Minha mulher, que o senhor sabe, zela por mim: muito reza. Ela é uma abençoável. Compadre meu Quelemém sempre diz que eu posso aquietar meu temer de consciência, que sendo bem-assistido, terríveis bons-espíritos me protegem. Ipe! Com gosto... Como é de são efeito, ajudo com meu querer acreditar. Mas nem sempre posso. O senhor saiba: eu toda a minha vida pensei por mim, forro, sou nascido diferente. Eu sou é eu mesmo. Diverjo de todo o mundo... Eu quase que nada não sei. Mas desconfio de muita coisa. O senhor concedendo, eu digo: para pensar longe, sou cão mestre – o senhor solte em minha frente uma idéia ligeira, e eu rastreio essa por fundo de todos os matos, amém! Olhe: o que devia de haver, era de se reunirem-se os sábios, políticos, constituições gradas, fecharem o definitivo a noção – proclamar por uma vez, artes assembléias, que não tem diabo nenhum, não existe, não pode. Valor de lei! Só assim, davam tranqüilidade boa à gente. Por que o Governo não cuida?! Ah, eu sei que não é possível. Não me assente o senhor por beócio. Uma coisa é pôr idéias arranjadas, outra é lidar com país de pessoas, de carne e sangue, de mil-e-tantas misérias... Tanta gente – dá susto de saber – e nenhum se sossega: todos nascendo, crescendo, se casando, querendo colocação de emprego, comida, saúde, riqueza, ser importante, querendo chuva e negócios bons... De sorte que carece de se escolher: ou a gente se tece de viver no safado comum, ou cuida só de religião só. Eu podia ser: padre sacerdote, se não chefe de jagunços; para outras coisas não fui parido. Mas minha velhice já principiou, errei de toda conta. E o reumatismo... Lá como quem diz: nas escorvas. Ahã. Hem? Hem? O que mais penso, testo e explico: todo-omundo é louco. O senhor, eu, nós, as pessoas todas. Por isso é que se carece principalmente de religião: para se desendoidecer, desdoidar. Reza é que sara da loucura. No geral. Isso é que é a salvaçãoda- alma... Muita religião, seu moço! Eu cá, não perco ocasião de religião. Aproveito de todas. Bebo água de todo rio... Uma só, para mim é pouca, talvez não me chegue. Rezo cristão, católico, embrenho a certo; e aceito as preces de compadre meu Quelemém, doutrina dele, de Cardéque. Mas, quando posso, vou no Mindubim, onde um Matias é crente, metodista: a gente se acusa de pecador, lê alto a Bíblia, e ora, cantando hinos belos deles. Tudo me quieta, me suspende. Qualquer sombrinha me refresca. Mas é só muito provisório. Eu queria rezar – o tempo todo. Muita gente não me aprova, acham que lei de Deus é privilégios, invariável. E eu! Bofe! Detesto! O que sou? – o que faço, que quero, muito curial. E em cara de todos faço, executado. Eu não tresmalho! Olhe: tem uma preta, Maria Leôncia, longe daqui não mora, as rezas dela afamam muita virtude de poder. Pois a ela pago, todo mês – encomenda de rezar por mim um terço, todo santo dia, e, nos domingos, um rosário. Vale, se vale. Minha mulher não vê mal nisso. E estou, já mandei recado para uma outra, do Vau-Vau, uma Izina Calanga, para vir aqui, ouvi de que reza também com grandes meremerências, vou efetuar com ela trato igual. Quero punhado dessas, me defendendo em Deus, reunidas de mim em volta... Chagas de Cristo! Viver é muito perigoso... Querer o bem com demais força, de incerto jeito, pode já estar sendo se querendo o mal, por principiar. Esses homens! Todos puxavam o mundo para si, para o concertar consertado. Mas cada um só vê e entende as coisas dum seu modo. Montante, o mais supro, mais sério – foi Medeiro Vaz. Que um homem antigo... Seu Joãozinho Bem-Bem, o mais bravo de todos, ninguém nunca pôde decifrar como ele por dentro consistia. Joca Ramiro – grande homem príncipe! – era político. Zé- Bebelo quis ser político. (shrink)

Objectives: To investigate the current situation of completing the informed consent for do-not-resuscitate (DNR) orders among the competent patients with terminal illness and the ethical dilemmas related to it. Participants: This study enrolled 152 competent patients with terminal cancer, who were involved in the initial consultations for hospice care. Analysis: Comparisons of means, analyses of variance, Student’s t test, χ2 test and multiple logistic regression models. Results: After the consultations, 117 (77.0%) of the 152 patients provided informed (...) consent for hospice care and DNR orders. These included 21 patients (17.9%) who signed the consent by themselves, and 96 (82.1%) whose consent sheet was signed only by family members. The reasons why patients were not involved in the discussions toward the consent (n = 82) included poor physical or psychological condition (44.9%), concerns of the consultant hospice team (37.2%), and the family’s refusal (28.2%). On a multivariate analysis, patients’ awareness of their poor prognosis (odds ratio = 4.07, 95% confidence interval = 2.05 to 8.07) and their understanding of hospice care (2.27, 1.33 to 3.89) were two independent factors (p<0.01) that influenced their participation in the discussions or their personal signature in the informed consent. Conclusion: The family-oriented culture in Asian countries may violate the principles of the Patient Self-Determination Act and the requirements of the Hospice Care Law in Taiwan, which inevitably poses an ethical dilemma. Earlier truth-telling and continuing education of the public by hospice care workers will be helpful in solving such ethical dilemmas. (shrink)

Background Nurses providing care to patients with end-of-life or terminal illnesses often encounter ethically challenging situations leading to moral distress. However, existing quantitative studies have examined moral distress using instruments that address general clinical situations rather than those specific to end-of-life care. Furthermore, qualitative studies have often been limited to participants from a single unit or those experiencing moral distress-induced circumstances. A comprehensive and integrated understanding of the overarching process of moral distress is vital to discern the unique (...) circumstances surrounding end-of-life care and its consequential impacts. Research objectives To explore the moral distress experiences of nurses who are frequently involved in caring for patients with end-of-life or terminal illnesses and apply it to two existing theories: the model of moral distress and the ecological model. Research design A qualitative descriptive approach was employed. Participants and research context Seven focus group interviews involving 30 nurses were performed. The subsequent transcriptions underwent rigorous content analysis. Ethical considerations We obtained Institutional Review Board approval from a university. Focus group interviews were conducted with nurses who agreed to participate and signed the consent form. Findings The moral distress-inducing factors and nurses’ perceived impact of moral distress were identified and categorized based on moral distress theories and ecological models. A total of 15 categories and 30 subcategories across the following 4 domains were derived: (1) intrapersonal, (2) interpersonal, (3) organizational, and (4) structural factors. Conclusions End-of-life-specific circumstances induced moral distress among nurses, with both negative and positive impacts identified. Effective organizational and policy support is essential to manage conflicts, form a healthy organizational culture, provide training, and prevent unnecessary expenses due to the negative consequences of moral distress. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Active Euthanasia and Assisted SuicidePat Milmoe McCarrick (bio)Although the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in its 1983 report, Deciding to Forego Life-Sustaining Treatment, described the words and terms "euthanasia," "right to die," and "death with dignity" as slogans or code words—"empty rhetoric," (I, p. 24), the literature reviewed for this Scope Note continues to use these terms. Therefore, to (...) discuss the termination of a patient's life by a physician at the patient's request, the phrase active euthanasia is used, and the supplying of a means by a physician whereby a patient can end his or her life is referred to as assisted suicide.Euthanasia, either as the "good death" from classical Greek or "mercy killing" to end unbearable suffering in the dying, has long been a topic of interest in western civilization (III, Brody 1989). In recent years, public awareness of this discussion about control over the time of one's death has been informed by a series of well-publicized events. They include the November 1991 rejection by a vote of 54 percent to 46 percent of the Washington state Initiative 119, which would have allowed the option of requesting one's physician to "aid-in-dying" for adult patients in a "medically terminal condition" (V, Gross 1991); two medical journal articles describing physician's actions in helping bring death to two patients (V, Anonymous 1988; V, Quill 1991); Dr. Jack Kevorkian's assistance in the suicide of three women (V, Belkin 1990; V, Wilkerson 1991); and the best seller status of a how-to book on committing suicide with opiates obtained from a physician (III, Humphry 1991).For the most part, material included in the annotated bibliography in Scope Note 18 has been chosen from works published in the four years since "It's Over, Debbie" (V, Anonymous 1988) appeared in early January 1988 in the Journal of the American Medical Association.Dr. Edmund D. Pellegrino (V, 1991, pp. 3118-19) presented opposing views about active voluntary euthanasia as follows:Those who favor voluntary euthanasia argue that it is a beneficent and compassionate act; it respects autonomy by preserving the patient's control of the manner, method, [End Page 79] and timing of death; it takes the matter outside the reach of "medical power" (accessed in this Scope Note's bibliography at V, Fletcher 1973; V, Nowell-Smith 1989) and scrupulosity; and it prevents the injustice that allows some patients to choose death by refusal of life-support measures, while denying others the right to do so by active euthanasia....The opponents of active euthanasia argue that it undermines the value of, and respect for, all human life (V, Kass 1989; V, Coyle 1990; V, Singer 1990). They fear that guidelines cannot avoid sliding down the "slippery slope" to involuntary euthanasia and selective devaluation of the lives of the most vulnerable among us.... If euthanasia is legal, it is predicted that patients will feel subtle pressure to conform so as to relieve the economic and emotional burdens they impose on family and friends.Euthanasia, its opponents further argue, is socially destructive: it undermines trust in physicians, desensitizes society to killing, and imperils the ground already gained in legitimating passive euthanasia(IV, Wolf 1989).Physicians were not particularly involved with a patient's death until after World War II when participation grew in proportion to the growth of technology. Since the complex, life-sustaining equipment that could forestall death was located in a hospital, death itself became almost completely medicalized (V, Dagi 1991). For terminally ill persons who would like to die a painless death, either by their own hand or with assistance, physicians have almost a monopoly on obtaining strong drugs for distribution to patients (V, Abrams 1990).Active euthanasia for human beings is not legalized anywhere in the world (V, VonDrehle 1991). It is classified as homicide or murder in all fifty states and in Great Britain, Canada, Australia, and the Phillippines (V, Nerland 1989). Twentysix states in the United States prohibit assisted suicide by statute (V, Rosenblum 1990).In 1969 in the Netherlands, a physician named Jan Hendrik van... (shrink)

Does it matter morally whether a bomber who kills civilians in a raid intends to do so as a means to weakening the enemy or merely foresees he will do so in his attempt to destroy a munitions factory? Does it matter morally whether a nurse who gives a terminally ill patient a lethal dose of painkiller intends to do so as a means to ending the patient's life or merely foresees she will do so in her attempt to (...) alleviate the patient's pain? Those who answer affirmatively rest moral weight on the notion of intending to do something as a means. But giving an adequate analysis of this notion has proved difficult. In ‘Intending as a Means,’ Kwong-Loi Shun criticizes two attempts at analyzing this notion, one which he attributes to Jonathan Bennett and the other which he attributes to Thomas Nagel. Shun thinks both Bennett's and Nagel's analyses identify intending to bring about S as a means with aiming at S and offers examples which he believes show ‘an agent need not aim at what he intends to bring about.’ In making his objection to Bennett and Nagel, Shun introduces his own criterion for intending as a means. (shrink)

Continuous sedation until death (CSD), the act of reducing or removing the consciousness of an incurably ill patient until death, often provokes medical–ethical discussions in the opinion sections of medical and nursing journals. Some argue that CSD is morally equivalent to physician-assisted death (PAD), that it is a form of “slow euthanasia.” A qualitative thematic content analysis of opinion pieces was conducted to describe and classify arguments that support or reject a moral difference between CSD and PAD. Arguments pro and (...) contra a moral difference refer basically to the same ambiguous themes, namely intention, proportionality, withholding artificial nutrition and hydration, and removing consciousness. This demonstrates that the debate is first and foremost a semantic rather than a factual dispute, focusing on the normative framework of CSD. Given the prevalent ambiguity, the debate on CSD appears to be a classical symbolic struggle for moral authority. (shrink)

A psychologist with a client who is terminally ill and wishes to discuss end-of-life options, specifically the option of hastening death, is faced with an ethical dilemma as to how to proceed with treatment. Specifically, he or she is bound by the American Psychological Association's (2002) potentially conflicting Principles A and E, which advise a psychologist to ?do no harm? as well as ?respect ? self-determination.? In addition, Standard 4 (Privacy and Confidentiality) mandates that a client's personal information is (...) to remain private, unless that client could be in danger of harming himself or herself or others. This article discusses such a nuanced case and provides considerations as well as guidelines for psychologists to effectively navigate through this sensitive and important dilemma. (shrink)

The ability of the medical profession to sustain life, or more appropriately, to prolong dying, in patients with terminal illness, creates a most complex and controversial situation for all involved: the patient, if mentally alert; the patient's family; and the medical care team including physicians, nurses and attendants. This situation is especially complex in large acute care hospitals where medical and nursing students, residents and house officers receive advanced medical training. A major problem, prolonging the dying of the (...) terminally ill, with its medical, legal, ethical and economic complexities now confronts American society. The problem is particularly acute in teaching hospitals, in which one finds a disproportionate number of terminally ill patients. The ability to work at these questions as a community rather than as adversaries will determine much about the ability of the health care system to respect the dignity and autonomy of those who seek aid and comfort when faced with serious illness and impending death. Better communication between the physicians, health care providers, the lawyers and ethicists must be developed in order to solve these problems. Over the next ten years society and our elected representatives will be making very demanding decisions about the use of the health dollar. One possible way to prevent increasing costs is to reach significant agreement on the proper care of the dying. Proper care for the dying is being considered, discussed, and evaluated by very thoughtful people. It is not governments which should decide who is to live or who is to die. There is the serious problem of the 'slippery slope' to euthanasia by omission if cost containment becomes the major force in formulating policy on the proper care of the dying. (shrink)

How is a terminally ill patient treated by the surrounding people in the U.S. and Japan? How does a terminally ill patient decide on his or her own treatment? These questions will be examined in a study of intensive medical care, received by a terminally ill Japanese cancer patient in the U.S. and Japan. This casereflects the participant observation by a Japanese anthropologist for about 8 years in the United States and Japan on one patient who was (...) hospitalized in both countries on and off for about eight years. The objective of this study is to illuminate the different concept of personhood between the U.S. and Japan that appeared in different cultural practices of both countries and in the subject’s own decision making process. The significant differences appeared between theU.S. and Japan in the concepts of (1) science, (2) suffering, (3) Power of Attorney and Doisho (Consent Form), and (4) organized care. The interpretation of such differences indicates that seemingly universal practices across countries suggest cultural specific concepts and their management. Therefore, ethical norms appeared differently accordingly to each country. (shrink)

Don't tell terrible stories—everyone here has enough of their own. Everyone here has a whole bloody sack of terrible stories, and at the bottom of the sack is a hammer the narrator uses to pound you on the skull the instant you dare not believe your ears. Or to pound you when you do believe. Not long ago I saw a tomboyish girl on Khreshchatyk Street demand money of an elderly woman, threatening to bite her and infect her with (...) syphilis. Don't stroll through Volodymyr Hill Park, don't stroll around the botanical garden, and especially don't stroll on Kontraktova Square. Don't stroll anywhere. Don't go to the pavilion with the Golgotha panorama near St. Alexander's Church. Not even the twelve-meter-tall crucified Christ will save you. Don't go outside when it's dark and people turn into shadows a shade darker than dark. Also don't go where you can be seen from far away. Not to imply that people used to be like a bunch of lilies, but now they stink like a cellar of cabbage.The city, which earlier might have had some fun, is now going crazy. It's like a fish in warm water: it doesn't react to anything, swims slowly like it doesn't care if it swallows a hook or not. The excitement and exaltation pass into oppression, just as our necks have sunk into our shoulders, our shoulders into our lumbars, our lumbars into our nether regions. The holiday turns into a funeral, the parades into explosions, depression into mania. Winter passes into summer, people turn into beasts, the hours into ages, and the ages into hours. It's worth simply walking around the city to see a soldier from an unknown army taking a piss near the opera. Farther on is a row of identical old widows selling ball gowns and candelabra. Then there are the aristocrats and manufacturers who throw so much at the prostitutes that they'll soon be richer than their wives.I returned late through the Kyryliv Wood, not heeding all the warnings that I myself have given here. It really is dangerous—the place is famous for it. There's a madhouse nearby, caves where criminals and the sick can hide out. Also, once upon a time, as they say in fairy tales, the great dragon Zmei Gorynich lived here beside the Puchai River. The stench in these places drives away the most committed misanthropes and even one type of philanthrope—that is, perverts. It sounds dumb, but the stench is cleansing. I don't know where it comes from. After the operating theaters and the rooms with amputees, the stench no longer repelled or attracted me; it just was. And this was a great place to think. As I walked, I considered an incident with our patient.The patient, a respectable individual whose name carries too much weight for me to state it directly, one day began to assault people. He nearly strangled a merchant who he believed asked too much for a beaver coat. He likewise wanted to kill his business partner when he didn't say hello loudly enough. But the worst was, he lost all shame of his own nakedness. At first it was the police who took care of it. When our future patient slipped off his pants and undergarments, he was taken to Kyrylivska, which has had means for dealing with such cases dating back to the day when unhinged Cossacks and composers from Kyiv Mohyla Academy were taken there.During the examination we determined that the patient was experiencing a severe breakdown. His wife added that lately, more than once, he had allowed himself strong words in front of the children and often suffered from ennui. Furthermore, she said, the patient had been undergoing treatment for “the French disease” for some years—which was, obviously, where we needed to start.“Syphilis!” Skorsky spat out the matchstick he was chewing on. He was a specialist on the psychological aspects of diseases related to the venereal. “Tertiary syphilis! When poorly treated, over time ‘the French disease’ can destroy the central nervous system. Hence the patient's chicanery. Such theater!”Skorsky and I had not spoken since the incident at Bilinsky's. Meanwhile, something significant had happened to him. The most boring person on earth, Skorsky had simply caught fire. He said hello and kibitzed. I even heard the doctor got drunk alone in his office, then wandered through the forest. Could he be using narcotic substances?“Cocaine!” was the doctor's second proclamation. It was his favorite treatment for the psychological complications of syphilis. Skorsky himself never took what he called “the universal drug”—good for alcoholism and toothaches, neuroses and morphine dependency—though he had read in an article by a respectable Viennese physician, who used cocaine as a panacea, that it was not addictive. That doctor subsequently recanted, but Skorsky paid no attention. He believed the retraction was made under pressure from pharmacologists who had no incentive to cease production of the medications that cocaine might supplant. Their representatives either paid or threatened the Viennese to repent.As the patient was escorted to his room, he assaulted the orderly, Alevtyna. They tried pulling him off her, but, though he released his fingers from her neck, he buried his teeth in her leg. The poor orderly, who had not until then been attacked by a psychotic, nearly died of fear. Later, panic set in over Skorsky's diagnosis. He told her about the consequences of syphilis: grotesque patterns on one's face due to infection of the skin, mucous membranes, cartilage, and bones. He went on about the devastation to the central nervous system, which they had just observed in real life: “The face starts to look like lace some mangy dogs fought over before rolling in the mud.”Alevtyna, who had not yet regained her faculty of speech, straightened up. Ignoring the slavering male orderlies, she bared her leg to get a better look at the wound. She then ran down the hall and out into the garden, where she fell on the ground to rip up grass and small bunches of daisies. Alevtyna ate them along with the soil in their roots.“Minor hysteria. She needs fifteen milligrams of cocaine.”Skorsky took a snuff box out of his pocket and scooped up some white powder with a toothpick made from a goose feather. He gave the order to close Alevtyna's mouth and one of her nostrils, forcing her to snort the medication.We fretted over her so long that evening fell. I decided to walk down, along the ravine, behind the church.It was unlikely there were any large beasts there, but something was rustling. The pits and mounds, ravines, paths, graves of witches whose living sisters flew in the treetops from time to time, the whispers of the forest spirits, the spirits of the nutcases who died in the hospital, the spirits of the monks from the St. Cyril Monastery, Zmei Gorynich and the bogatyrs who wanted to defeat him. The city would be calmer without this forest. I saw the gaps between the trees and went off in the direction of the tram tracks.As I was coming out of the forest, there was a patch of Amanita muscaria that had been trampled into porridge. A bit farther on, the body of Professor Bilinsky lay killed in the blackberry bushes. The way he was lying it looked as though he had not struggled before death. I quickly examined his body but saw nothing out of the ordinary. There were no wounds, no dirt under the fingernails. Animals had not yet smelled the carrion, but swarms of various insects covered him. Oh, why did I have to find the putrid body?The best thing would be to take the tram to his house to inform his relatives. The doors closed, and I noticed my own calm. This death had not evoked any emotions in me other than a feeling of responsibility, the need to tell the family. But also—some alarm at the thought of who the murderer could be. I knew that it was murder.“Your nose is bleeding.” A woman as round as an onion, carrying two baskets full of strawberries, offered me an ironed and starched handkerchief.“Have I dirtied my shirt?”“No, it's as neat as a pin. It's just your nose that's dirty. Wipe it now before you spray blood on my strawberries.”“No one will see the red on red.”“Ah, but it's salty!”“You know why it's not sweet? We'd drink it like syrup.”“Those with Christ in their heart do not talk that way.”“Are your strawberries expensive?”“Why? What?”“I'm checking to see if you have God in your heart.”“Child, if you knew how I have to work for this berry! I have to weed it a hundred times. In a week, the quitch grass grows as high as a horse. And I water it with water I carry from the stream, it kills my arms... ”“How much are the berries?”“They're not for sale. Anyway, soon money won't mean a thing. Soon all money, all these papers made from the skins of sinners on their satanic presses will be annulled. What matters is how we treat each other.”“So if I try your strawberries for free, my ‘thank you’ will be enough?”“Hands off!” she said and thwacked my fingers.I heard loud laughter behind me—same laughter as from the café near the Continental. There was no one sitting near Alina. (This is what fate looks like, remember.) Without asking, I sat next to her, away from the old lady.“Excuse me, but the night before last didn't you, yes, didn't you intrude on my privacy?” She started right away.“I saw it a little differently. Who was that young man with the mustache who paid me for you?”“Are you checking to see if you can flirt?”The tram stopped. People got on and off.“Are you coming back from the hospital?” she asked. “Don't be shocked. My uncle works there. He's told me all about you.”“An uncle by the name of Skorsky?”(Remember: this is what fate looks like.)“Yes. Skorsky's been strange recently—says things that make me wonder if he hasn't lost his mind. Have you noticed anything?”“I don't know.”“You know perfectly well.”“Where are you going?” I tried to change the subject.“I have to send something to my theater friends in Odesa. By the way, they'll be putting on Oedipus Rex soon in Kyiv—in Ukrainian.”“Greek tragedy in Ukrainian! That's a first.”“Exactly. The troupe is rehearsing now in Odesa. The theater where they will perform this fall is being remodeled.”“Wait. Now I remember where I've seen you before—it was at a performance! Vynnychenko's Black Panther and White Bear, at the Bergonier on Fundukleivska.“The same director is doing the Oedipus. He's my friend.”“He's your friend in what sense?”“Again with that tired subject. By the way, I've been thinking about you.”“And I about you.”“That's good. I was thinking not about you, to be precise, but about that elevator you invited me on.”“Who was that man with you?”“Like a broken record! Even if he had been my fiancé, I'm not bought or inherited. I'm not a brooch or a hundred acres of land, and I'm not a house in Kaniv!... Who was with you when you saw Black Panther?“Ah, so.”“Answer!”“That was my mother. She looks very young. She is coming to Kyiv the day after tomorrow. I can introduce you.”“Oh, this is my stop.”I looked out the window and realized that I had long since passed the stop for Bilinsky's.“Can we see each other again?”“We can. But you have only one chance.”Alina the anarchist wrote something on a scrap of paper and handed it to me.Morning, not morning but a thick porridge (I hate porridge). Dew, thick spit, crushed fruits, urine, all on the sparkling cobblestones. The sun, just barely having made its appearance, is already scorching. The human masses scurry and grumble like poorly digested food inside a stomach.I walked diagonally across St. Sofia's Square, then along the perimeter, then one edge, then again diagonally across. I went underground. The basement café of the Continental Hotel was practically empty. I again asked the server to bring the cloth with the embroidered portrait, but I couldn't remember the musician's last name, only that it ended with -sky. The server said that -sky was currently in the southern cities of Yalta and Odesa. I added that Kurbas, the director, Alina's friend, was also in Odesa, rehearsing Oedipus Rex, and that he'd previously put on Black Panther.I was bored, so I walked along Khreshchatyk and then headed down, calling to mind all the Kyiv churches of Podil: there's Birth of Christ, St. Nicholas on the Shore, Intercession, Pyrohoshcha, Holy Presentation, St. Dymytrii Rostovsky, St. Illia's. And also the Epiphany Brotherhood Monastery, Ascension Convent, and St. Katherine's, all these whipped-cream churches on the waffles of our streets. A few of them reminded me of themselves by appearing suddenly out of nowhere.The smells on Kontraktova Plaza where commerce buzzed were like multicolored light bulbs turning on one after another. Here you could catch the aroma of Balabukha jam, which blended with the next smell, English shoe polish at the Raiskys’ shop. Then the crunchy-smelling cabbage from old women standing in a row like herons and spitting out the shells of sunflower seeds. Farther on, the stench of a good-sized rat that crawled under Mrs. Shevchuk's shop where she sells broadcloth. Oh, she can't scream: no, she'll quietly dig that rat out herself so as to not scare off her clients.I bought a paper and two pairs of underwear. I asked two laughing young chambermaids who were secretly puffing in a grape-filled yard for a smoke. I wandered around Podil until evening when I came across a sawmill near the Dnipro that surprisingly smelled pleasantly of mazut fuel oil. The weather was dry, yet in the middle of the road was an enormous puddle, a deep dark black. A forty-year-old woman in a pale pink dress stood near it. The theatricality of it all provoked me to pose her a question,“Ma'am, what should I do?”But she paid me no attention. I shouted,“What should I do?”“What to do, what to do?” she said in Polish. “Jump in the water and swim so far away that you cannot return.”I quickly crossed a section of the forest. The wind brought a mixture of unpleasant air, like a stinky handkerchief held under one's nose. Passing the trees, I saw light in the spaces between them and exited at the hospital.Outside the windows, two orderlies lay in chairs with their heads thrown back. Two others—fools—ran around the yard in different directions, peering out at... something. The lights on the first floor of the hospital were on, and the staff milled about.“You're just in time!” said Ivan, a tall, young orderly.“For what?”“Your patient ran away! We went into his room and he wasn't there.”“What patient?”“The one who bit Alevtyna,” said Danylo, the other orderly, short and middle-aged.“That's Skorsky's patient, not mine.”I had no intention of helping them. This was all history—like my family, Kyiv, and my previous life. I had no intention of thinking about it. I wanted to go to my office, pack up my field surgery kit, and get out. So what? Their psychotic syphilitic ran away—it happened.Of course, that patient could have something to do with Bilinsky's murder. But that was no longer my problem.“What a strange coincidence!” the doctor on duty said. “Comrade doctor, the other one responsible for this patient was just here.”“And where is he now?”“He took off toward the church to look for the patient.”“Didn't the patient escape earlier?”“Don't know.”“How do you not know? You had better call the police, moron, before he kills someone. And get those sleeping orderlies to look for him.”“They can't... ”“Why not? Should I go wake them?”“They're on morphine.”“And you, I can see, have lost your mind. Go, catch your psycho! If it turns out that he killed Bilinsky—and on your watch—you can't imagine what's in store for you.”I adjusted my homburg and set off in the direction of St. Cyril's, that unwelcoming monolithic cube. I glanced around—what if our escaped syphilitic were to jump out of the bushes and bite or strangle me. I looked around because I wasn't sure of my actions, wasn't sure of my choices. Tripping over a clump of clover, I reached the open doors of the church. I couldn't stop myself from going in.The walls and ceiling were covered with frescoes. There was what used to be an angel rolling up the sky on the southern column of the narthex. But also graffiti: people scratched their names on it so as not to be forgotten—their idea of eternity. Prince Volodymyr the Great compared this activity to the desecration of graves. The vandals paid a fine and were beaten with canes. During the raids of Batu Khan, the church was deserted and cracks appeared all over it. Wild martens and feral dogs sought shelter here; insects swarmed under the ceiling with its red mosaics. Birches grew in its midst. Water seeped in the cracks, the water became ice, the ice widened the cracks, more water seeped in the cracks, becoming more ice that further widened the cracks, the wall split and nearly fell over, and then the wall fell over. Yet the angel is still rolling up the sky... When I reached the exit, I heard a rustling behind me. I turned after I stepped outside: in the depths of the church, like a stick in a pot of tar, stood a man with a large bag thrown over his shoulder and a revolver pointed right at me.“Is that you, Doctor?“Don't move!”“What's... Skorsky, what's with you?”“Don't move, I say!”“What are you doing here?”And finally I understood... Skorsky was himself the psycho! (Really, I had known for a while.)“You are the murderer! I knew it! But—why?”“Shut up.”“It was you. You! The stolen cigarettes, the strange behavior, Bilinsky. If I shout, everybody will come running. They've already called the police!”There was heavy breathing behind me. And then a gun rang out.The city is overgrown with new buildings. They encircle everything that was once on the periphery. Kyiv has become an old lady that can no longer restrain herself in the face of pastries. The city climbs farther. It steps over the swamps, turns the old rivers into a series of lakes; the other bodies of water it drives into canals. The grain that falls from the wild wheat is black. When the sun heats it, the grain melts and trickles into the earth. St. Cyril's stands indestructible. No one spackles the small cracks in its walls with either expensive putty or glues, nor with cheap cement and whitewash. One day a small fox appears in the doorway. It runs inside and along the floor of simple gray tiles. The gods watch from the walls, watch and fall into ruin. The fox runs to the iconostasis. Before it is a time-darkened Virgin Mother and Child in oil on sheets of zinc. The fox runs the metal steps that wind up to the second floor. The fox runs past all the vaults, naves, all the frescoes. A buckthorn seed flies in through a broken window. It will be the first. Soon the buckthorn will grow everywhere. A dumb hare will make its nest in the buckthorn bushes and nightingales will settle in the upper branches to sing until the end of the world. The fox runs between the thick rays that penetrate the windows. It catches one of the rays, squints its eyes, and warms itself in the sun.The shot rang out, but I did not fall. I looked around—and on the church threshold was our syphilis patient bearing a rod. His head lay on the rocks by the doorway.“If only he'd been at the stage of nose deformity! Just imagine: a hole instead of a nose plus a hole from the bullet—like an extra pair of eyes!” Skorsky laughed at the corpse.“We need to call the orderlies.”“They heard the shot. They'll run here on their own. You see, Professor Bilinsky believed it would take two or three years to wrap up this patient's case,” Skorsky told me. “But I took care of it much faster!”“Excuse me, but I'm going crazy in this city. I thought that you were Bilinsky's murderer.”“Just so. Why not? I am Bilinsky's murderer.”“Don't tease. You've changed a lot recently, so... ”“Yes, I've started killing people. You might term such a change significant.”“You have the right to irony.”“I am not being ironic.”“Let's call it sarcasm.”“It's the honest-to-God truth.”“And yes, you have the right to mock me.”“Well then, let's be done. To the horses!”“What horses?”“Alina's waiting!”Alina, her uncle Skorsky, a few others I didn't know, and I rode like the wind that ripped off my homburg and carried it back to Kyiv.“There's a fresco in the choir loft at St. Cyril's where Vrubel painted himself and patients from the hospital as the apostles. When I came across it by accident, I really believed they were saints,” Alina said.“I've never been up there. I've only seen the church from below.”“Remember the way back so you can see it sometime.”“The Puchai River used to flow here. You shouldn't trust the landscape,” Skorsky said, reaching for something, perhaps his bag, just when we left the darkness of the trees and saw the endless steppe ahead of us.We rode all night without stopping. Though no one was chasing us. Though we had nowhere to be. We rode like beasts released from a cage. The promises of the horizon turned what we'd left behind into a cage fit for those from whom freedom had been severed, like an anomaly, at birth.The pre-morning sky looked at first like a sack of turnips—filled with something heavy. But with each verst, the sky became lighter. When it was finally light enough to see clearly, we arrived at a knoll at the foot of a stone wall that from a distance had appeared to be a gigantic piece of halva. The exterior ruins of the castle gave no hint of how it was when all was fine here, when people defended themselves successfully from the nomads’ raids. From far off, the wreckage looked like a natural agglomeration of stones—a rocky elevation, no more: a cluster of cliffs. It would rain a few hundred more times, a few hundred more winds from a few hundred directions would blow on this heap, and it would collapse as though nothing had ever been here.A few stalks of wheat grew from one of the rocks. Someone had probably cast a handful of grain here for some birds that forgot to eat it.“Who could this castle belong to?” I asked Skorsky.“I reckon the Swan Princess,” the doctor rejoined, hoping to sound knowledgeable.From behind one of the piles of gray sandstone emerged a young man in a black reptilian coat and a white papakha as lush, bright, and out of place as a dahlia. His name was Artem. The heat was melting our brains, but he was dressed like that, in rooster fashion, which was popular among the otamans. Artem helped Alina dismount her horse and tried to kiss her on the lips, but she offered him a cheek instead.Had she been racing to see this clown?We entered the yard—the ruins had fashioned an internal space that was more or less protected, at least from strangers’ eyes. It turned out that there were even places where it was possible to hide from the rain, and from there the ruins didn't look half bad.In the center of the court was a table, and on it a wooden bucket with pink gladiolas. How romantic! It all looked like it came from outer space. Where on earth, in the middle of the steppe, far from any village or town, did this table, this simple table, come from? And the gladiolas? The steppe hadn't been plowed in so long that any cultivars would have gone wild, degenerated, dried up completely.A campfire crackled nearby—a little preview of what we would soon do to the houses, villages, and cities. Artem the otaman brought over a cezve from the fire and poured the first portion into a small, copper cup for Alina. He also got out a porcelain cup with images of rosy cherubim—but how...?“Who else would like coffee?”Only Skorsky and I responded. The question excited me, even distracted me from the thought of the kiss I had recently witnessed and the Kyiv I had recently left.“It's obvious who the professors here are; cultured people drink coffee. Are you both doctors?”“Uh-huh.”“For wolves of the steppe, like us, doctors are gold, even more precious than gold. Actually, a Hippocrates like you should eat more, because those in your profession will soon be worth your weight in gold. Work on your figures, both of you.”“Who will take pity on the horses that have to carry us?”“We'll find the horses. And very large doctors can be transported on machine-gun carts. We'll need to seat the otamans near you. Only a fool would shoot at a doctor.”“I think we'll find quite enough fools here.”“With your beard, Doctor, you look like Tsar Nicholas II. But even so you won't be shot. You might even be canonized!”“We've only just arrived and you're going on about executions,” Skorsky grumbled and checked to make sure that he still had his bag.“Apologies, apologies, pardonnez-moi. But you are not merely a doctor. A venereologist! Skorsky, you're a specialist! A venereologist is the most important person in wartime. The most valuable! You are the botanists of war. You can't imagine what varieties of flowers grow here, and these beds have long awaited a proper gardener. Or even just a man with a scythe!”“Bite your tongue,” Alina said. “I don't need to listen to this.”“Yes, yes, of course. Excuse me, my r—. ” He almost said “rose.”We rested all day. We went down to a surprisingly close river overgrown with lilies. We rowed the boats left by fishermen. I talked to Skorsky. He took his bag everywhere, refusing even to swim so he wouldn't have to part with it. I asked him what he had in it, but he said it wasn't my damned business.Alina rowed with the otaman to the middle of the river. They were having a loud discussion. She was waving her hands. The current carried their boat downstream slowly and smoothly. What a nuisance, that current!I tried to meet with Alina one-on-one, but she was avoiding me. In the morning I was confused, by lunch I was sad, and after lunch I got angry.In the evening, I lay on the hot grass and drank another cup (I have no idea where they got such good coffee), which had no effect at all on my sleep. I watched the Perseids. Every year, the Earth passes through the tail of Comet Swift-Tuttle. People can see the meteor shower and make a wish. I wished. I counted forty-seven falling stars. All forty-seven of my wishes were for the same thing.Around the campfire, they were sitting, talking. I saw how he tickled her face with a piece of grass and she brushed him off in annoyance. Then they were screaming at each other. Later they again spoke kindly, after which they again quarreled. My joy grew after each tiny mistake that Artem made. I wanted him to show the worst he was capable of.They were screaming at each other, but all I could hear was beautiful opera singing. The stars fell to the sound of their screaming. The stars blessed my joy.Then this happened: Alina kicked the fire, scattered burnt kindling, and burned some of the grass. Artem grabbed her by the arm, but she broke away from him and ran off to the horses.“Go then! I guarantee you'll get to Katerynoslav and return with your tail between your legs.”“I'm going to Huliai-Pole! To Father Makhno!”I jumped up and ran after her.“Where do you think you're going?” Artem shouted.Really—where was I going? I was going after her: to Huliai-Pole, to Katerynoslav, to Rome, to Washington, to Istanbul, to Montevideo... “Go to sleep,” he said. “Come morning, this coquette will be here, right as rain. We've already been through this show. Tomorrow she'll be right here next to my boot!”... No, she won't.In some sort of shape we entered some town. There were some buildings that were some colors, some trees, some streets, some roads, and some signs. Posts, flustered birds’ nests, echoes, colors, shapes—each of some kind. A wedding procession was coming toward us. If you want to make orange, you need to add yellow to red, and then bam—it's black. If you want to salt the soup, shake in a little, and then bam—two handfuls. You want to say a kind word, and then bam—a punch in the face. I was rocked around like a watermelon on a boat and threw up my breakfast straight into the horse's fluffy mane. Sanko found this hilarious, but I said I'd pulverize him. So Sanko sped ahead.No one knew anything about Alina. The daytime sky was like a poorly washed bowl. The sun was a squashed, rotten apricot. The night sky looked like the sole of a boot to me. The moon was a dirty cheap copper coin that had gotten stuck to the sole. Everything seemed spoiled to me, irrelevant, unnecessary. Without her, this journey was a waste of time.“You'd better stay away from everyone,” Artem said. “You'll infect us with your pining, and pining is worse than the clap.”The wedding procession was before us. The young couple, still utter children, walked so calmly it was as if they didn't see us. As if we were made of a light breeze—our bodies, clothes, our horses and their iron shoes—of the lightest gasses. As if we were visible only to ourselves and the coal-black dog that barked, panting and gasping.The wedding was headed straight for us. We were in the middle of the road, and so were they. We approached each other slowly, a wave going toward a wave. Some ten meters before their indifferent faces, I noticed the color of the bride's eyes. And the coral-colored tulips that fell on the road before her. Round goose eggs on meaty stems, the flowers were falling and falling before her. The bride's eyes were almond shaped.“Hey there,” Artem shouted at me. “Wake up!”I came to and saw the whole village, everyone there, not realizing my group had turned left onto a side street away from the procession. The tulips disappeared—where'd they get tulips in the fall? I was sitting alone on my horse in the middle of the road, and the entire wedding procession came to a stop. I moved to the side, and the throng marched on, cutting off our escape route. We rode a few more meters and came across the synagogue.“You know what, you're right,” said the otaman.“Who is?”“Oleksii is the only one here who's right.”“About what?”Artem turned his horse and raced back. Everyone stood still while he ran his horse into the crowd and began firing his revolver. People scattered in all directions. Artem trotted, cackling like an imbecile. The horse kicked an old guy in the mouth. The man fell, spitting out his gold teeth. We rode up to the commotion and formed ranks, but none of us wanted to join the otaman.The bride stopped in the middle of the street. On both sides were buildings and trees, as well as dust, sky, and sun. She stood still, beautiful, as if nothing had happened. Then she adjusted her garland and walked calmly on.“Well, should we get some sugar now?” Artem laughed, looking at the bride, and off he went toward the sugar factory.It was then I noticed that all of the houses had shutters—fuchsia, blue, ocher—and that all the shutters were closed.We flew toward the dirty building, whistling and shouting. If there had been aesthetes among the otamans, they would certainly have razed the abomination in this field after seizing it. They would have spread soil on top and sown buckwheat. Long live buckwheat!, that wonderful crop. Like hunting dogs hot on the trail, we raced to our defenseless victim, with the baying of hundreds of hounds behind us. The field shook beneath us. We became an artist's canvas, evolving from Realism to Romanticism, Romanticism to Expressionism, Expressionism to Suprematism. If we had been painted in black and white, we would have been splotches (until the ink ran, annihilating all remaining patches of white).Two men stood near the gate—unarmed and undressed, in nothing but their undershirts and boots. Our fervor, our kinship with the elements, our entirety, were all for naught.“Jesus Christ! What bores!” Artem exclaimed. “How boring you are!”“Maybe boring for us, but fireworks for them,” Sanko said, dismounting his horse.“The fear of death engenders creativity,” our otaman—a distinguished philosopher of the early twentieth century, that demonic breed—prophesied.He went on, “Excuse me, but with all due respect, we are not going to search you. Just show us right away where the money is. Why are there so few of you? Don't say there's not much money. I want piles and piles of money! If you don't show it to us, we'll print our own on your skin. Believe me, we will.”We entered the factory grounds. There were no workers, only an enormous mountain of sugar beets that looked like a pile of coal from a distance and a pile of dead rats from up close.“So, did you have a good year?” Artem asked a man in an undershirt.“Not really—too dry.”“Nah, that's fine. You wouldn't have been able to gather most of the harvest this year anyway. There's a fire burning across all of Ukraine, all of Russia. The whole world!”While Artem tossed thoughts like well-chewed sunflower seeds into the crowd, the two men quietly stepped aside and then ran fast ahead to the factory's main hall. The gigantic door slammed shut. The gate was locked behind us! The windows were smashed! The factory roared from inside like a cumbersome machine starting up. Bullets whirred through every window.“Bastards! It's a trap! Quick, after me!”Still on horseback, Artem bounded over to a vast window, low to the ground, and smashed it mercilessly. He broke the frame and jumped inside on his horse. I and a few others followed. We broke into their lair, threw open the doors, and let the other warriors inside.Iron vats of hot sugar were steaming, pipes were clattering; machinery groaned.“Parasites!” Artem gritted his teeth. “I'll get you. I'll get you red sons of bitches. Painted whores!”At the word “painted,” his horse fell to the ground. Lying prone, Artem continued fighting, but the red soldiers wouldn't let him stand. Fighting nearby, I rode over to assist but did not know where to aim. Artem got up, ran forward, and brought his sword down on the head of the closest soldier, all the way to the middle of his skull, to the bridge of his nose. It was like butchering a pig. Artem thrust the sword into the buttock of another who was fleeing and cut off his leg at the bend in the knee.“I'll cut off every last one of your asses! Cut off your asses!” Artem bellowed.A half hour later, the dead were lying, the captured sitting, and the victors doing anything they pleased.“Skorsky, are there a lot of casualties?” I asked the doctor, whose hour it was. I hoped not, because I was too tired to help him.“Just a few. The dead are already dead, and the wounded are not ours.”Though Skorsky rarely asked my help, and though I'd become an ordinary soldier, the doctor in me was still present in the most unpleasant attribute—knowledge. Others saw an eviscerated man, pieces of dusty flesh smeared with clay, soil, sand, and straw. I saw a perfectly formed kidney hanging perfectly from the rest of its body like a child's mitten from its coat. You could try this death on for size. Wear it like a sanbenito of the Inquisition.Artem counted the money and then lay on the floor alongside the gigantic sugar mountain in the middle of the room. From time to time, the crystals rustled as they fell.“I didn't think you'd be such a fighter!” the otaman said without turning toward me. “I thought you'd be healing us. You'd keep to the rear and we'd hide you like a girl. But here you are, in the vanguard, like a lion!”“I got excited,” I told him, choosing not to react to the “girl” part.“’Cause Alina said there was no sense counting on you to fight.”“Really?”“Does that sting?”“Why would it? I'm a doctor—not everyone is. It requires a brain. Unlike waving a sword.”“Yeah, yeah. I gave her gladiolas. We were lying in the boat near that castle, doing all manner of things, and she told me all about you. How you met.”“You were lying in that boat talking about me?”“It was the day before you left Kyiv. You agreed to go with the anarchists so quickly!”“Were you surprised? Doctors make fast decisions.”“But you probably had great prospects. Your parents are rich, right?”“And who are your parents?”“Probably all your relatives fled abroad—bourgeois. Why did you stay?”“What the hell's your point?”“Alina, by the way, died a while ago. Probably.”“Don't jinx her.”“Listen here,” he said, staring at the ceiling. “And listen good. If you have designs on her—dead or alive—it's best you castrate yourself now.”“After you.”“If I want to kill somebody, you know, I just do it.”At last he looked at me. I was lying on the floor nearby and looking in his direction, sweaty and relaxed, my appearance complemented by my disdain for his opinion, his authority, his stupid hat. His everything.Artem raised his arm above his head, stuck a finger in the sugar mountain, and licked it. We both got up. Had I anticipated this turn of events, I would have readied a gift for him. Artem held his revolver. Under my hand I found a knife the workers used for gathering beets: it was a deliberately sharpened arc they sank into the swollen brassicas. I jumped up and quickly stepped around the sugar mountain.Artem's bullet hit a pane and broke the glass.“Not man enough for hand-to-hand?”The otaman shot again.“You should've challenged me to a duel, you romantic!”Encrusted with white crystals, I charged Artem from the sugar mountain. We fell in, and the sugar stuck in our hair, mustaches, nostrils, armpits.The gang ran in to get us apart, then backed off because it had nothing to do with them. By now the sugar mountain had burst its banks. Of the once perfect pyramid, a deformed mound remained.Wounded, Artem fell on the sugar mound, turning the white red.I stood before the gang sugar-coated and holding a bloody hook. The old otaman was drawing his last breath. Blood trickled from the corner of Artem's mouth and streamed from the left side of his breast.“What's the commotion?” Old Roman had just come in.“Be quiet,” the boys told him. And a good thing they did.“You killed him? You killed the otaman!”“Shut your mouth,” the boys told him.“You... ”I slugged Roman's stinky herring mouth. How did that son of a bitch find pickled herring in a sugar factory? My fist was now bigger and stronger than ever before, a steel anvil that could split nails and shatter memorial plaques. The unfortunate man's jaw twisted like an upper millstone that had gone off track from the lower.“Let's get out of here and go to Makhno's camp,” I gave my first order.We galloped so fast the grass burned beneath us. The birds and bugs had no time to fly out of the way; hooves trampled the burrows of rodents who didn't dare crawl out of their holes for a long time after. We raced like no one had ever raced before.The steppe, that sly fox, pretended to be an innocent fool. The steppe said, “I'm like Adam: I don't even know my own name.” But its grass harbored the tracks of thousands of armies and the heels of Herodotus, the crunch of Trypillia vessels, and the smell of Scythian hemp, Roman coins, clay figures of wolf people, the chevrons of Denikin's army, glass from the Chekists’ ruby stars, traces of uranium from flying saucers. I threatened it: “Steppe, show me your layers, or I will burn you, plow you under, flood you.” But it just replied: “I'm like Adam: I don't yet know my name.”I lost geography as if it were a silver coin. It fell out of my pocket and rolled through the feather grass that blanketed the steppe in white foam. The open space ahead was so endless that the whole world might as well have been steppe. If people ended up here from somewhere else, they would conclude they were on another planet. The coin fell and became an argentum, became one with the ring on the hand of the princess who had one green eye and one blue, with the twisted candlestick at the monastery on the other side of the steppe, with melted ingots. It broke down into simpler elements, simpler and simpler yet. The horse carried me spreading the seeds of northern plants to the south, just as southern riders had once brought flowers and weeds to the north. And then I turned back. Just as I had no geography, I had no time. Every night I fell asleep with the thought that the next day I would again race. Through all spacelessness, all timelessness. I exchanged one horse for another, got on a train, on a boat, traversed forty versts on foot—in rain that brought the river up to the road, in heat that overturned cattle. The earth I walked on became mine. Mine was the water in the lakes and springs, clean water, dirty water, enlightened water, contaminated with oil, stinking of algae, of fish that died in wells, stinking of the memory of atrocities, water as clean as broken bread. The water did not become Alina.I was doing this for her: I got the basturma out from under my saddle, sodden with the horse's sweat, sliced the throat of a rich man whose daughter I had danced with at a ball, climbed into a vat of beet juice and took a sugar bath, carried out the expropriation of the savings banks, wiped the sweat from my face with my shirt—and the cloth turned red; I didn't know from what. If it was someone else's blood, I didn't care; if it was my own, even less.We mostly came across Reds. We scraped them up like old red paint on a door in order to repaint the boards black. Black looked better. Red is tasteless, but black has style. Healthy men died before us of myocardial rupture like bunnies found in the nest. The ones whose hearts were sewn of steel wire envied the deceased. Seizing estates, banks, distilleries, and prisons reminded us of gathering in the harvest. If you're too lazy to pick an apple, you can shake the tree; some of the fruit gets bruised when it falls. We seized buildings like we were shaking apple trees. No one picked the fruits, we just shook: shook under the beds, under the tables, behind the curtains. No, there was no picking. We just shook until the red juice spurted from the apples.Near the Khorol River with Father Makhno and me in charge, we captured sixteen machine guns and four cannons, as well as five hundred prisoners who immediately came over to our side. The villagers voluntarily gave us bread and cheese, chickens and kvas. People joined us. The front of the machine-gun cart said “You can't run,” and “You won't catch us” at the back. We took factory after factory. Millions of karbovantsi, thousands of poods of sugar, weapons. We smashed the telephone exchanges and captured the telegraphs. We made alliances with some and then with others. Lenin, Wrangel, Frunze, the Germans, Chinese, Australians, Kaiser Wilhelm II, Cleopatra, Maria Theresa Walburga Amalia Christina. We ran the steppe. There were a hundred thousand of us. There were three hundred thousand of them. There were three hundred thousand of us. There were a million of them. There were two million of them. We were all of humanity. We were so many that we were none.The nobles’ estates were long ago forsaken. In the people's deepest trunks lay silks and guipure laces that were once perhaps used only to cover a table. Five steps from the barn in the direction of the pear tree, some silver candlesticks are buried; there's a plaster figure of an angel in the chicken coop, covered with shit and feathers.I was reluctant to be going to my home, but I didn't see any way out. Fate intended me to be a different being from the one I was before.Here my grandfathers and great-grandfathers were born. Here the ones who caused my grandfathers and great-grandfathers to flee had stopped. When we were still far off I noticed that someone was in the house. It was our men—Skorsky had brought them here, about twenty in all. I asked Sanko, whom I had walked with side by side more than once, where the doctor was now. All the men answered that he was around somewhere, but I didn't see him that evening.In 1918, the spirit of my great-grandfather Stepan, along with my mother and uncle, had gotten into a britzka and scrambled off to Paris, to Napoleon, against whom my great-grandfather had fought with the Cossacks, to whom the Russians promised to return self-rule. Following him in the cart went the soul of Grandpa Oleh, who lost a finger when he cut down the old linden near the house; his second finger was blown off by a cannonball near Balaklava, and later his entire hand was cut off by some Turk. Next went the spirit of my father, also Stepan, who did not take part in any war but died of measles at the age of forty. They all got the hell out of here. First, they went to Kyiv, led by my mother, Tamara Makarivna, in order to collect Uncle's family and me, their son. And their son, it turns out, has now come back to rob his own home (I didn't drive my war buddies away, did I?). It's a shame that I didn't know where the bathtub was, or whatever they bathed me in when I was small. It would have been good to walk through the ranks of anarchists with that basin and tell them all to spit into it.Remembering every room, I carried Alina upstairs to my mother's bedchamber. There was no longer furniture or pictures, only bare walls. The bed and mattress remained, but that was enough. Mother hated noise, so she set up her room far away from the running in the halls and the creaks on the stairs. I adjusted the mattress; in a gap, looking like a stalk of wheat, there lay a gold bracelet that she lost in the haste and that the thieves could not find in the mayhem. I tucked it into my pocket.The place could still be saved. It was strong, built under the leadership of my grandfather, who knew how to do it right. He built a sawmill, a gristmill, a dress factory (today it's probably been ransacked, maybe even by our own men).Alina had a complete, displaced break in her right fibula. We needed water first. I went downstairs—the guys were dragging out the piano like an old cow to the slaughter.“What are you doing with that?”“Taking it out.”“Why?”“What's it to you? We want to have fun.”“Can you play?”“We're not your bourgeois lily-handed bitches.”They couldn't play, but they were famous at destruction. “Noise is the music of the new time,” one of the smarter among them might have said. “But noise is the opposite of music. Just as a rose is the opposite of your ugly mugs,” I'd have responded if there was anyone to say it to. I could also have said that this was a Bosendorfer grand piano, that it was very valuable—but do the guys not deserve such a luxury?“Why are you so boring? We're relaxing.”“Then let me play a little first.”“Go ahead, but fast. One-two.”So I played. As before. My fingers ran up and down the black and white keys, which weren't simply keys of these, the simplest, colors. These were the keys that remembered my fingers specifically—achieved by that slovenly German Katerina, our governess. She knew a bundle of languages, could play the piano, and was interested in the latest scientific discoveries. But she had not an ounce of sympathy for anyone who couldn't master anything on the first try. More than once she hit my pinkie against the black key that remembered every one of its four thousand touches. She would pound it on the key and shout, “Si bémol! Si bémol,” and later bang my fingers and translate, “B flach! B flach!”I played. I could not expose myself, so the only thing I could do was believe in miracles. What if these coarse men saw value in this bit of furniture so unintelligible to them? And what if they didn't destroy it, this emblem of my childhood, my land, my air, which I could protect in no other way? My air. My water.“Shchedryk, shchedryk, shchedrivochka,” one of them who recognized the tune began to sing along.“Look at you.” They did not expect music from me, who had until recently been drinking blood like water.They said, “Again, again!”A group of curious men gathered around me. They were ordinary farmers, thieves, and recidivists, peasants and workers, everyone except for Skorsky. They needed this music as they needed baths. The music cleansed them from the inside, perhaps. They had not heard anything besides the whistle of a bullet, the neighing of a horse, or the knocking of a chisel and the whirring of a saw, amputating limbs, for a long time.But it could not go on long. I did not close the piano lid, just stood and went to fetch water for Alina, leaving the unfinished song for later. The well was to the north—that is, at the “Head.” My father once promised to give me a compass if I could learn to identify the ends of the earth by means of the sun. And to make it easier to remember, I gave each one of them a name: the east where the day begins was “Right” (my right hand), the west “Left,” the north “Head,” and the south “Feet.” Back when I could still do whatever I wanted all day long, I would wake in the morning and say: I'm going to the Feet. The mound was at the Feet, Left had the river, Right had the forest. It was only to the Head that I rarely went, because a village was located there. When the villagers saw me, they would speak in whispers and avoid the master's son.... I wiped her brow and her burning, sunken cheeks. I lay down next to her to feel the heat of her skin.When the fire in Alina calmed slightly, I went out into our orchard. My father had once been given a gift from Japan—a tulip tree that blossomed with yellow-green flowers. It had to have grown in the time that I was away. It would have been fatal had it been cut down. I again took the stairs down into the drawing room and came across nobody—they had all disappeared in search of food or were hidden away in their burrows. In the middle of the hall, like an opened rib cage, was the piano, irreparably shattered.B Flach! B Flach!Translation © Ali Kinsella 2022. (shrink)

ABSTRACT In keeping with the pre‐eminent status accorded autonomy within Australia, Europe, and the United States, medical practice requires that patients authorize do‐not‐resuscitate (DNR) orders, intended to countermand the default practice in hospitals of instituting cardiopulmonary‐resuscitation (CPR) on all patients experiencing cardio‐pulmonary arrest. As patients typically do not make these decisions proactively, however, family members are often asked to act as surrogate decision‐makers and decide on the patient's behalf. Although the appropriateness of patients or their families (...) having to decide about the provision of CPR has been challenged, there has been little examination of how patients and their families talk about and negotiate such decisions, particularly in the context of the patient's imminent death. In this article, part of a larger study analysing interviews with 28 patients (13 female) with cancer within weeks of their death, and 20 others (predominantly family) attending, we argue that a common assumption underpinning participants' talk about the DNR decision (i.e. forgoing CPR) is that it requires a choice between life and death. Using illustrative examples, we demonstrate that in making decisions about CPR, patients and their families are implicitly required to make moral judgements about the value of the patient's life, including their relationships with significant others. We identify some implications of these empirical observations for the development of ethically appropriate policies and practices regarding patient autonomy and surrogacy at the end of life. (shrink)

Americans are increasingly turning to hospice services to provide them with medical care, pain management, and emotional support at the end of life. The increase in the rates of hospice utilization is explained by a number of factors including a “hospice movement” dating to the 1970s which emphasized hospice as a tool to promote dignity for the terminally ill; coverage of hospice services by Medicare beginning in 1983; and, the market for hospice services provision, sustained almost entirely by governmental (...) reimbursement. On the one hand, the growing acceptance of hospice may be seen as a sign of trends giving substance to the death-with-dignity movement and the growing strength of end-of-life decision-makers and planners who integrate medical, community, family and spiritual networks. On the other hand, the precise relationship between the death-with-dignity and commercial processes driving hospice utilization rates are not well understood. On May 2, 2013, the U.S. Government intervened in a lawsuit brought by former hospice employees alleging that behind Vitas Innovative Hospice Care, the largest for-profit hospice service provider in the United States, lie an intricate web of incentives for patient intake nurses, physicians and marketers which not only drove hospice patients to use more expensive crisis care services, but influenced patient and family decisions as to whether or not to discontinue curative treatment. The corporate, investment, and regulatory history behind Vitas provides an important insight into the market realities behind Americans' embrace of hospice care and the risks to patient autonomy and health that accompany the commercialization of this ethically and morally complex health care service. (shrink)