SUDDEN DEATH: Families bicker over whether that is preferable to a lingering one

Geraldine Reardon, an otherwise healthy 66-year-old, went to the hospital last year for a routine hernia operation. Days later, a ravaging infection corroded her fingers and toes with gangrene and forced doctors to medicate her into a coma to spare her unbearable pain. But Reardon?s condition did something else, too. It forced her daughter and son to decide whether their mother should live or die. Should they authorise treatment that would save Reardon?s life but involve months of surgery and the amputation of her hands and feet? Or should they remove her respirator and feeding tube, hastening her death on the assumption that she would rather die than live like that?

Reardon?s daughter, Jacki Folger, and her son, David Reardon, sharply disagreed over what to do. And the decision was made harder by their strained, complicated, sometimes stormy relationship. Jacki. 47, was close to her mother and was an emotional anchor to family and friends in Lancaster, a rural community west of Boston [US]. David Reardon, 46, was working to repair family wounds stemming from a past that included a long-ago conviction for brandishing an axe at a police officer, and a court order granting custody of his son to Folger.

The crisis posed by Reardon?s condition and her family?s rocky history was daunting but hardly unusual, doctors and other experts say. Medical advances are forcing more patients and families to confront ever more gruelling choices about living and dying. Such advances offer the hope of saving desperately ill patients but can also result in patients surviving in such severely compromised conditions that families become painfully confused.

?Every hospital in the country has families going through this all the time now,? said Dr Erik Steele, vice-president for patient care services at Eastern Maine Medical Center in Bangor, where a recent case involved four siblings so divided over whether to keep their 88-year-old mother alive that they first put her on a respirator and then took her off it. ?This is going to be an issue more and more for us, and I think it?s an issue almost unique to our generation,? Dr Steele said. ?For the first time, we have this degree of technical ability to keep people alive without the ability to always restore them to good health. At the same time we have a much higher expectation of what health care can do.?

While families often seem to pull together when dealing with treatable illnesses, they often splinter over an end-of-life decision, experts say. Old frictions surface and new ones form, based on family relationships and different ideas of what makes a life worth living. Living wills, advance directives and health care proxies are intended to resolve crucial questions about what a patient would want, but they often fall far short.

?Even with a directive, it?s very hard to be that specific,? said Jessica W. Berg, associate professor of law and bioethics at Case Western Reserve University?s law and medical schools. ?What would you say: If I can only open my eyes, if I can only recognise people sometimes? What if at the time your family is making the decision, the family says we?re happy with just this much of you?? Family conflicts over end-of-life decisions are more likely to be personal than philosophical, doctors, nurses and social workers say. They can reflect fault lines between relatives or emotions long buried.

Many practitioners who deal with such families have noticed a curious pattern: The relative most distant or estranged from the patient is often the one most reluctant to let the patient die. ?Often the family members who are taking care of that person can see the deterioration that?s taken place day by day,? said John F. Linder, a clinical social worker at the University of California Davis Cancer Center. ?People coming from a distance might say: ?Well, Mom was fine when I was talking to her three weeks ago. Let?s do what we can.??

Writing a living will or designating a health care proxy or surrogate can help families understand the patient?s general inclinations and philosophy. But ?some decision will come up that you haven?t discussed,? said Dr Karen . Kaplan, president and chief executive of Partnership for Caring, an organisation that works to improve care for dying patients.

At the same time, Kaplan tells people making living wills, ?You don?t want to be too specific ? like saying no antibiotics, for example ? because then you tie the hands of your doctors.? [After Folger won the long battle with her brother to have their mother?s respirator removed] Reardon died with her daughter by her side. After the funeral, Folger invited mourners to a gathering at Reardon?s house, overlooking the cemetery where she was buried. Folger said her brother left after about 15 minutes, apparently unhappy that people were congregating in his mother?s home.

For months afterward, they continued to argue, Folger said. But in late July this year, with Folger?s blessing, her brother moved into their mother?s old house. Folger said she finds it hard that someone other than her mother is living there, but she believes that the relationship with her brother has become less stormy. ?I?m hoping we?re on the other side of it now,? Folger said. ?It?s mixed emotions. It?s little steps.?