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Cummins, too, improved. He and his wife were able to meet the emotional challenges of terminal illness without the physical demands of agony. They listened to jazz; she offered spiritual guidance; they continued to decorate their East Harlem apartment with mosaics. "The quality of my life definitely improved," Cummins said, "and that goes hand in hand with prolonging it." Even his oncologist enthusiastically welcomed Shaiova's pain treatment. "He's happy about it," Cummins said. "He's a great doctor, but he's just not trained in pain management."
Most aren't. Medical schools have only just begun to introduce curriculums in managing pain and other symptoms of the dying. The subjects are difficult to teach because most professors don't know the material, and most textbooks say little about end-of-life care. It wasn't until 1997 that the American Medical Association began developing a continuing-education packet for doctors on the subject. The group that accredits hospitals began requiring them to implement pain-management plans only this year. "In the past few years, we have seen a sea change of improvements in the issue," says Foley, "but we've known how to do this since 1975."
Managing pain better would allow patients more comfortable deaths, but it can't guarantee easier ones. "When it comes to dying, pain comes in many flavors," says Robert Wrenn, who recently retired after 24 years of teaching about the psychology of dying at the University of Arizona. "Spiritual pain, social pain, even the unfinished-business pain that asks, 'Why am I here?'" Only the creepy would say dying should be cause to rejoice, and only the idealistic would say the health-care system could change our attitudes about it. But Byock, author of Dying Well, notes that dying's place in our culture has changed before. Until recently, most people died at home, because doctors couldn't do much. "Since the era when antibiotics were invented and surgery began to be safe, in the '30s, the focus has become to combat disease. The subject of the patient has too often been lost," says Byock.
As dying was medicalized, it was removed from our lives--to the ICU and the funeral home--both fairly new institutions if you consider how long people have been dying. Dislodged by modernity, dying became a taboo, slightly gross subject for polite conversation. Physicians and the families of their patients began to see death as a defeat, not an inevitable culmination. "We need education," says Dr. Kerry Cranmer of the American Medical Directors Association. "Instead surgeons get together when a patient dies to find out who screwed up."