Read this story and answer questions that follows. Thomas Monopoli was pregnant with her first child

Read this story and answer questions that follows.
Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die. It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had collapsed, and her chest was filled with fluid. A sample of the fluid was drawn off with a long needle and sent for testing. Instead of an infection, as everyone had expected, it was lung cancer, and it had already spread to the lining of her chest. Her pregnancy was thirty-nine weeks along, and the obstetrician who had ordered the test broke the news to her as she sat with her husband and her parents. The obstetrician didnt get into the prognosisshe would bring in an oncologist for thatbut Sara was stunned. Her mother, who had lost her best friend to lung cancer, began crying. The doctors wanted to start treatment right away, and that meant inducing labor to get the baby out. For the moment, though, Sara and her husband, Rich, sat by themselves on a quiet terrace off the labor floor. It was a warm Monday in June, 2007. She took Richs hands, and they tried to absorb what they had heard. Monopoli was thirty-four. She had never smoked, or lived with anyone who had. She exercised. She ate well. The diagnosis was bewildering. This is going to be O.K., Rich told her. Were going to work through this. Its going to be hard, yes. But well figure it out. We can find the right treatment. For the moment, though, they had a baby to think about. So Sara and I looked at each other, Rich recalled, and we said, We dont have cancer on Tuesday. Its a cancer-free day. Were having a baby. Its exciting. And were going to enjoy our baby. On Tuesday, at 8:55 P.M., Vivian Monopoli, seven pounds nine ounces, was born. She had wavy brown hair, like her mom, and she was perfectly healthy. The next day, Sara underwent blood tests and body scans. Dr. Paul Marcoux, an oncologist, met with her and her family to discuss the findings. He explained that she had a non-small cell lung cancer that had started in her left lung. Nothing she had done had brought this on. More than fifteen per cent of lung cancersmore than people realizeoccur in non-smokers. Hers was advanced, having metastasized to multiple lymph nodes in her chest and its lining. The cancer was inoperable. But there were chemotherapy options, notably a relatively new drug called Tarceva, which targets a gene mutation commonly found in lung cancers of female non-smokers. Eighty-five per cent respond to this drug, and, Marcoux said, some of these responses can be long-term. Words like respond and long-term provide a reassuring gloss on a dire reality. There is no cure for lung cancer at this stage. Even with chemotherapy, the median survival is about a year. But it seemed harsh and pointless to confront Sara and Rich with this now. Vivian was in a bassinet by the bed. They were working hard to be optimistic. As Sara and Rich later told the social worker who was sent to see them, they did not want to focus on survival statistics. They wanted to focus on aggressively managing this diagnosis. Sara was started on the Tarceva, which produced an itchy, acne-like facial rash and numbing tiredness. She also underwent a surgical procedure to drain the fluid around her lung; when the fluid kept coming back, a thoracic surgeon eventually placed a small, permanent tube in her chest, which she could drain whenever fluid accumulated and interfered with her breathing. Three weeks after the delivery, she was admitted to the hospital with severe shortness of breath from a pulmonary embolisma blood clot in an artery to the lungs, which is dangerous but not uncommon in cancer patients. She was started on a blood thinner. Then test results showed that her tumor cells did not have the mutation that Tarceva targets. When Marcoux told Sara that the drug wasnt going to work, she had an almost violent physical reaction to the news, bolting to the bathroom in mid-discussion with a sudden bout of diarrhea. Dr. Marcoux recommended a different, more standard chemotherapy, with two drugs called carboplatin and paclitaxel. But the paclitaxel triggered an extreme, nearly overwhelming allergic response, so he switched her to a regimen of carboplatin plus gemcitabine. Response rates, he said, were still very good for patients on this therapy. She spent the remainder of the summer at home, with Vivian and her husband and her parents, who had moved in to help. She loved being a mother. Between chemotherapy cycles, she began trying to get her life back. Then, in October, a CT scan showed that the tumor deposits in her left lung and chest and lymph nodes had grown substantially. The chemotherapy had failed. She was switched to a drug called pemetrexed. Studies found that it could produce markedly longer survival in some patients. In reality, however, only a small percentage of patients gained very much. On average, the drug extended survival by only two monthsfrom eleven months to thirteen monthsand that was in patients who, unlike Sara, had responded to first-line chemotherapy. She worked hard to take the setbacks and side effects in stride. She was upbeat by nature, and she managed to maintain her optimism. Little by little, however, she grew sickerincreasingly exhausted and short of breath. By November, she didnt have the wind to walk the length of the hallway from the parking garage to Marcouxs office; Rich had to push her in a wheelchair. A few days before Thanksgiving, she had another CT scan, which showed that the pemetrexedher third drug regimenwasnt working, either. The lung cancer had spread: from the left chest to the right; to the liver; to the lining of her abdomen; and to her spine. Time was running out. This is the moment in Saras story that poses a fundamental question for everyone living in the era of modern medicine: What do we want Sara and her doctors to do now? Or, to put it another way, if you were the one who had metastatic canceror, for that matter, a similarly advanced case of emphysema or congestive heart failurewhat would you want your doctors to do? The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the countrys long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit. Spending on a disease like cancer tends to follow a particular pattern. There are high initial costs as the cancer is treated, and then, if all goes well, these costs taper off. Medical spending for a breast-cancer survivor, for instance, averaged an estimated fifty-four thousand dollars in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy. For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the endto an average of sixty-three thousand dollars during the last six months of life with an incurable breast cancer. Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop. The subject seems to reach national awareness mainly as a question of who should win when the expensive decisions are made: the insurers and the taxpayers footing the bill or the patient battling for his or her life. Budget hawks urge us to face the fact that we cant afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But theyre debating the wrong question. The failure of our system of medical care for people facing the end of their life runs much deeper. To see this, you have to get close enough to grapple with the way decisions about care are actually made. Recently, while seeing a patient in an intensive-care unit at my hospital, I stopped to talk with the critical-care physician on duty, someone Id known since college. Im running a warehouse for the dying, she said bleakly. Out of the ten patients in her unit, she said, only two were likely to leave the hospital for any length of time. More typical was an almost eighty-year-old woman at the end of her life, with irreversible congestive heart failure, who was in the I.C.U. for the second time in three weeks, drugged to oblivion and tubed in most natural orifices and a few artificial ones. Or the seventy-year-old with a cancer that had metastasized to her lungs and bone, and a fungal pneumonia that arises only in the final phase of the illness. She had chosen to forgo treatment, but her oncologist pushed her to change her mind, and she was put on a ventilator and antibiotics. Another woman, in her eighties, with end-stage respiratory and kidney failure, had been in the unit for two weeks. Her husband had died after a long illness, with a feeding tube and a tracheotomy, and she had mentioned that she didnt want to die that way. But her children couldnt let her go, and asked to proceed with the placement of various devices: a permanent tracheotomy, a feeding tube, and a dialysis catheter. So now she just lay there tethered to her pumps, drifting in and out of consciousness. Almost all these patients had known, for some time, that they had a terminal condition. Yet theyalong with their families and doctorswere unprepared for the final stage. We are having more conversation now about what patients want for the end of their life, by far, than they have had in all their lives to this point, my friend said. The problem is thats way too late. In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending ones final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or Its O.K. or Im sorry or I love you. People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this systems expense. It is how we can build a health-care system that will actually help dying patients achieve whats most important to them at the end of their lives. For all but our most recent history, dying was typically a brief process. Whether the cause was childhood infection, difficult childbirth, heart attack, or pneumonia, the interval between recognizing that you had a life-threatening ailment and death was often just a matter of days or weeks. Consider how our Presidents died before the modern era. George Washington developed a throat infection at home on December 13, 1799, that killed him by the next evening. John Quincy Adams, Millard Fillmore, and Andrew Johnson all succumbed to strokes, and died within two days. Rutherford Hayes had a heart attack and died three days later. Some deadly illnesses took a longer course: James Monroe and Andrew Jackson died from the months-long consumptive process of what appears to have been tuberculosis; Ulysses Grants oral cancer took a year to kill him; and James Madison was bedridden for two years before dying of old age. But, as the end-of-life researcher Joanne Lynn has observed, people usually experienced life-threatening illness the way they experienced bad weatheras something that struck with little warningand you either got through it or you didnt. Dying used to be accompanied by a prescribed set of customs. Guides to ars moriendi, the art of dying, were extraordinarily popular; a 1415 medieval Latin text was reprinted in more than a hundred editions across Europe. Reaffirming ones faith, repenting ones sins, and letting go of ones worldly possessions and desires were crucial, and the guides provided families with prayers and questions for the dying in order to put them in the right frame of mind during their final hours. Last words came to hold a particular place of reverence. These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable conditionadvanced cancer, progressive organ failure (usually the heart, kidney, or liver), or the multiple debilities of very old age. In all such cases, death is certain, but the timing isnt. So everyone struggles with this uncertaintywith how, and when, to accept that the battle is lost. As for last words, they hardly seem to exist anymore. Technology sustains our organs until we are well past the point of awareness and coherence. Besides, how do you attend to the thoughts and concerns of the dying when medicine has made it almost impossible to be sure who the dying even are? Is someone with terminal cancer, dementia, incurable congestive heart failure dying, exactly? I once cared for a woman in her sixties who had severe chest and abdominal pain from a bowel obstruction that had ruptured her colon, caused her to have a heart attack, and put her into septic shock and renal failure. I performed an emergency operation to remove the damaged length of colon and give her a colostomy. A cardiologist stented her coronary arteries. We put her on dialysis, a ventilator, and intravenous feeding, and stabilized her. After a couple of weeks, though, it was clear that she was not going to get much better. The septic shock had left her with heart and respiratory failure as well as dry gangrene of her foot, which would have to be amputated. She had a large, open abdominal wound with leaking bowel contents, which would require twice-a-day cleaning and dressing for weeks in order to heal. She would not be able to eat. She would need a tracheotomy. Her kidneys were gone, and she would have to spend three days a week on a dialysis machine for the rest of her life. She was unmarried and without children. So I sat with her sisters in the I.C.U. family room to talk about whether we should proceed with the amputation and the tracheotomy. Is she dying? one of the sisters asked me. I didnt know how to answer the question. I wasnt even sure what the word dying meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die. One Friday morning this spring, I went on patient rounds with Sarah Creed, a nurse with the hospice service that my hospital system operates. I didnt know much about hospice. I knew that it specialized in providing comfort care for the terminally ill, sometimes in special facilities, though nowadays usually at home. I knew that, in order for a patient of mine to be eligible, I had to write a note certifying that he or she had a life expectancy of less than six months. And I knew few patients who had chosen it, except maybe in their very last few days, because they had to sign a form indicating that they understood their disease was incurable and that they were giving up on medical care to stop it. The picture I had of hospice was of a morphine drip. It was not of this brown-haired and blue-eyed former I.C.U. nurse with a stethoscope, knocking on Lee Coxs door on a quiet street in Bostons Mattapan neighborhood. Hi, Lee, Creed said when she entered the house. Hi, Sarah, Cox said. She was seventy-two years old. Shed had several years of declining health due to congestive heart failure from a heart attack and pulmonary fibrosis, a progressive and irreversible lung disease. Doctors tried slowing the disease with steroids, but they didnt work. She had cycled in and out of the hospital, each time in worse shape. Ultimately, she accepted hospice care and moved in with her niece for support. She was dependent on oxygen, and unable to do the most ordinary tasks. Just answering the door, with her thirty-foot length of oxygen tubing trailing after her, had left her winded. She stood resting for a moment, her lips pursed and her chest heaving. Creed took Coxs arm gently as we walked to the kitchen to sit down, asking her how she had been doing. Then she asked a series of questions, targeting issues that tend to arise in patients with terminal illness. Did Cox have pain? How was her appetite, thirst, sleeping? Any trouble with confusion, anxiety, or restlessness? Had her shortness of breath grown worse? Was there chest pain or heart palpitations? Abdominal discomfort? Trouble with bowel movements or urination or walking? She did have some new troubles. When she walked from the bedroom to the bathroom, she said, it now took at least five minutes to catch her breath, and that frightened her. She was also getting chest pain. Creed pulled a stethoscope and a blood-pressure cuff from her medical bag. Coxs blood pressure was acceptable, but her heart rate was high. Creed listened to her heart, which had a normal rhythm, and to her lungs, hearing the fine crackles of her pulmonary fibrosis but also a new wheeze. Her ankles were swollen with fluid, and when Creed asked for her pillbox she saw that Cox was out of her heart medication. She asked to see Coxs oxygen equipment. The liquid-oxygen cylinder at the foot of the neatly made bed was filled and working properly. The nebulizer equipment for her inhaler treatments, however, was broken. Given the lack of heart medication and inhaler treatments, it was no wonder that she had worsened. Creed called Coxs pharmacy to confirm that her refills had been waiting, and had her arrange for her niece to pick up the medicine when she came home from work. Creed also called the nebulizer supplier for same-day emergency service. She then chatted with Cox in the kitchen for a few minutes. Her spirits were low. Creed took her hand. Everything was going to be all right, she said. She reminded her about the good days shed hadthe previous weekend, for example, when shed been able to go out with her portable oxygen cylinder to shop with her niece and get her hair colored. I asked Cox about her previous life. She had made radios in a Boston factory. She and her husband had two children, and several grandchildren. When I asked her why she had chosen hospice care, she looked downcast. The lung doctor and heart doctor said they couldnt help me anymore, she said. Creed glared at me. My questions had made Cox sad again. Its good to have my niece and her husband helping to watch me every day, she said. But its not my home. I feel like Im in the way. Creed gave her a hug before we left, and one last reminder. What do you do if you have chest pain that doesnt go away? she asked. Take a nitro, Cox said, referring to the nitroglycerin pill that she can slip under her tongue. And? Call you. Wheres the number? She pointed to the twenty-four-hour hospice call number that was taped beside her phone. Outside, I confessed that I was confused by what Creed was doing. A lot of it seemed to be about extending Coxs life. Wasnt the goal of hospice to let nature take its course? Thats not the goal, Creed said. The difference between standard medical care and hospice is not the difference between treating and doing nothing, she explained. The difference was in your priorities. In ordinary medicine, the goal is to extend life. Well sacrifice the quality of your existence nowby performing surgery, providing chemotherapy, putting you in intensive carefor the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focussing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists arent much concerned about whether that makes peoples lives longer or shorter. Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer. When Cox was transferred to hospice care, her doctors thought that she wouldnt live much longer than a few weeks. With the supportive hospice therapy she received, she had already lived for a year. Creed enters peoples lives at a strange momentwhen they have understood that they have a fatal illness but have not necessarily acknowledged that they are dying. Id say only about a quarter have accepted their fate when they come into hospice, she said. When she first encounters her patients, many feel that they have simply been abandoned by their doctors. Ninety-nine per cent understand theyre dying, but one hundred per cent hope theyre not, she says. They still want to beat their disease. The initial visit is always tricky, but she has found ways to smooth things over. A nurse has five seconds to make a patient like you and trust you. Its in the whole way you present yourself. I do not come in saying, Im so sorry. Instead, its: Im the hospice nurse, and heres what I have to offer you to make your life better. And I know we dont have a lot of time to waste. That was how she started with Dave Galloway, whom we visited after leaving Lee Coxs home. He was forty-two years old. He and his wife, Sharon, were both Boston firefighters. They had a three-year-old daughter. He had pancreatic cancer, which had spread; his upper abdomen was now solid with tumor. During the past few months, the pain had become unbearable at times, and he was admitted to the hospital several times for pain crises. At his most recent admission, about a week earlier, it was found that the tumor had perforated his intestine. There wasnt even a temporary fix for this problem. The medical team started him on intravenous nutrition and offered him a choice between going to the intensive-care unit and going home with hospice. He chose to go home. I wish wed gotten involved sooner, Creed told me. When she and the hospices supervising doctor, Dr. JoAnne Nowak, evaluated Galloway upon his arrival at home, he appeared to have only a few days left. His eyes were hollow. His breathing was labored. Fluid swelled his entire lower body to the point that his skin blistered and wept. He was almost delirious with abdominal pain. Sometimes I just want to curl up with a good book and burn it. They got to work. They set up a pain pump with a button that let him dispense higher doses of narcotic than he had been allowed. They arranged for an electric hospital bed, so that he could sleep with his back raised. They also taught Sharon how to keep Dave clean, protect his skin from breakdown, and handle the crises to come. Creed told me that part of her job is to take the measure of a patients family, and Sharon struck her as unusually capable. She was determined to take care of her husband to the end, and, perhaps because she was a firefighter, she had the resilience and the competence to do so. She did not want to hire a private-duty nurse. She handled everything, from the I.V. lines and the bed linens to orchestrating family members to lend a hand when she needed help. Creed arranged for a specialized comfort pack to be delivered by FedEx and stored in a mini-refrigerator by Daves bed. It contained a dose of morphine for breakthrough pain or shortness of breath, Ativan for anxiety attacks, Compazine for nausea, Haldol for delirium, Tylenol for fever, and atropine for drying up the upper-airway rattle that people can get in their final hours. If any such problem developed, Sharon was instructed to call the twenty-four-hour hospice nurse on duty, who would provide instructions about which rescue medications to use and, if necessary, come out to help. Dave and Sharon were finally able to sleep through the night at home. Creed or another nurse came to see him every day, sometimes twice a day; three times that week, Sharon used the emergency hospice line to help her deal with Daves pain crises or hallucinations. After a few days, they were even able to go out to a favorite restaurant; he wasnt hungry, but they enjoyed just being there, and the memories it stirred. The hardest part so far, Sharon said, was deciding to forgo the two-litre intravenous feedings that Dave had been receiving each day. Although they were his only source of calories, the hospice staff encouraged discontinuing them because his body did not seem to be absorbing the nutrition. The infusion of sugars, proteins, and fats made the painful swelling of his skin and his shortness of breath worseand for what? The mantra was live for now. Sharon had balked, for fear that shed be starving him. The night before our visit, however, she and Dave decided to try going without the infusion. By morning, the swelling was markedly reduced. He could move more, and with less discomfort. He also began to eat a few morsels of food, just for the taste of it, and that made Sharon feel better about the decision. When we arrived, Dave was making his way back to bed after a shower, his arm around his wifes shoulders and his slippered feet taking one shuffling step at a time. Theres nothing he likes better than a long hot shower, Sharon said. Hed live in the shower if he could. Dave sat on the edge of his bed in fresh pajamas, catching his breath, and then Creed spoke to him as his daughter, Ashlee, ran in and out of the room in her beaded pigtails, depositing stuffed animals in her dads lap. Hows your pain on a scale of one to ten? Creed asked. A six, he said. Did you hit the pump? He didnt answer for a moment. Im reluctant, he admitted. Why? Creed asked. It feels like defeat, he said. Defeat? I dont want to become a drug addict, he explained. I dont want to need this. Creed got down on her knees in front of him. Dave, I dont know anyone who can manage this kind of pain without the medication, she said. Its not defeat. Youve got a beautiful wife and daughter, and youre not going to be able to enjoy them with the pain. Youre right about that, he said, looking at Ashlee as she gave him a little horse. And he pressed the button. Dave Galloway died one week laterat home, at peace, and surrounded by family. A week after that, Lee Cox died, too. But, as if to show just how resistant to formula human lives are, Cox had never reconciled herself to the incurability of her illnesses. So when her family found her in cardiac arrest one morning they followed her wishes and called 911 instead of the hospice service. The emergency medical technicians and firefighters and police rushed in. They pulled off her clothes and pumped her chest, put a tube in her airway and forced oxygen into her lungs, and tried to see if they could shock her heart back. But such efforts rarely succeed with terminal patients, and they did not succeed with her. Hospice has tried to offer a new ideal for how we die. Although not everyone has embraced its rituals, those who have are helping to negotiate an ars moriendi for our age. But doing so represents a strugglenot only against suffering but also against the seemingly unstoppable momentum of medical treatment. Just before Thanksgiving of 2007, Sara Monopoli, her husband, Rich, and her mother, Dawn Thomas, met with Dr. Marcoux to discuss the options she had left. By this point, Sara had undergone three rounds of chemotherapy with limited, if any, effect. Perhaps Marcoux could have discussed what she most wanted as death neared and how best to achieve those wishes. But the signal he got from Sara and her family was that they wished to talk only about the next treatment options. They did not want to talk about dying. Recently, I spoke to Saras husband and her parents. Sara knew that her disease was incurable, they pointed out. The week after she was given the diagnosis and delivered her baby, she spelled out her wishes for Vivians upbringing after she was gone. She had told her family on several occasions that she did not want to die in the hospital. She wanted to spend her final moments peacefully at home. But the prospect that those moments might be coming soon, that there might be no way to slow the disease, was not something she or I wanted to discuss, her mother said. Her father, Gary, and her twin sister, Emily, still held out hope for a cure. The doctors simply werent looking hard enough, they felt. I just couldnt believe there wasnt something, Gary said. For Rich, the experience of Saras illness had been disorienting: We had a baby. We were young. And this was so shocking and so odd. We never discussed stopping treatment. Marcoux took the measure of the room. With almost two decades of experience treating lung cancer, he had been through many of these conversations. He has a calm, reassuring air and a native Minnesotans tendency to avoid confrontation or overintimacy. He tries to be scientific about decisions. I know that the vast majority of my patients are going to die of their disease, he told me. The data show that, after failure of second-line chemotherapy, lung-cancer patients rarely get any added survival time from further treatments and often suffer significant side effects. But he, too, has his hopes. He told them that, at some point, supportive care was an option for them to think about. But, he went on, there were also experimental therapies. He told them about several that were under trial. The most promising was a Pfizer drug that targeted one of the mutations found in her cancers cells. Sara and her family instantly pinned their hopes on it. The drug was so new that it didnt even have a name, just a numberPF0231006and this made it all the more enticing. There were a few hovering issues, including the fact that the scientists didnt yet know the safe dose. The drug was only in a Phase I trialthat is, a trial designed to determine the toxicity of a range of doses, not whether the drug worked. Furthermore, a test of the drug against her cancer cells in a petri dish showed no effect. But Marcoux didnt think that these were decisive obstaclesjust negatives. The critical problem was that the rules of the trial excluded Sara because of the pulmonary embolism she had developed that summer. To enroll, she would need to wait two months, in order to get far enough past the episode. In the meantime, he suggested trying another conventional chemotherapy, called Navelbine. Sara began the treatment the Monday after Thanksgiving. Its worth pausing to consider what had just happened. Step by step, Sara ended up on a fourth round of chemotherapy, one with a minuscule likelihood of altering the course of her disease and a great likelihood of causing debilitating side effects. An opportunity to prepare for the inevitable was forgone. And it all happened because of an assuredly normal circumstance: a patient and family unready to confront the reality of her disease. I asked Marcoux what he hopes to accomplish for terminal lung-cancer patients when they first come to see him. Im thinking, Can I get them a pretty good year or two out of this? he said. Those are my expectations. For me, the long tail for a patient like her is

Read this story and answer questions that follows. Thomas Monopoli was pregnant with her first child

Read this story and answer questions that follows.
Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die. It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had collapsed, and her chest was filled with fluid. A sample of the fluid was drawn off with a long needle and sent for testing. Instead of an infection, as everyone had expected, it was lung cancer, and it had already spread to the lining of her chest. Her pregnancy was thirty-nine weeks along, and the obstetrician who had ordered the test broke the news to her as she sat with her husband and her parents. The obstetrician didnt get into the prognosisshe would bring in an oncologist for thatbut Sara was stunned. Her mother, who had lost her best friend to lung cancer, began crying. The doctors wanted to start treatment right away, and that meant inducing labor to get the baby out. For the moment, though, Sara and her husband, Rich, sat by themselves on a quiet terrace off the labor floor. It was a warm Monday in June, 2007. She took Richs hands, and they tried to absorb what they had heard. Monopoli was thirty-four. She had never smoked, or lived with anyone who had. She exercised. She ate well. The diagnosis was bewildering. This is going to be O.K., Rich told her. Were going to work through this. Its going to be hard, yes. But well figure it out. We can find the right treatment. For the moment, though, they had a baby to think about. So Sara and I looked at each other, Rich recalled, and we said, We dont have cancer on Tuesday. Its a cancer-free day. Were having a baby. Its exciting. And were going to enjoy our baby. On Tuesday, at 8:55 P.M., Vivian Monopoli, seven pounds nine ounces, was born. She had wavy brown hair, like her mom, and she was perfectly healthy. The next day, Sara underwent blood tests and body scans. Dr. Paul Marcoux, an oncologist, met with her and her family to discuss the findings. He explained that she had a non-small cell lung cancer that had started in her left lung. Nothing she had done had brought this on. More than fifteen per cent of lung cancersmore than people realizeoccur in non-smokers. Hers was advanced, having metastasized to multiple lymph nodes in her chest and its lining. The cancer was inoperable. But there were chemotherapy options, notably a relatively new drug called Tarceva, which targets a gene mutation commonly found in lung cancers of female non-smokers. Eighty-five per cent respond to this drug, and, Marcoux said, some of these responses can be long-term. Words like respond and long-term provide a reassuring gloss on a dire reality. There is no cure for lung cancer at this stage. Even with chemotherapy, the median survival is about a year. But it seemed harsh and pointless to confront Sara and Rich with this now. Vivian was in a bassinet by the bed. They were working hard to be optimistic. As Sara and Rich later told the social worker who was sent to see them, they did not want to focus on survival statistics. They wanted to focus on aggressively managing this diagnosis. Sara was started on the Tarceva, which produced an itchy, acne-like facial rash and numbing tiredness. She also underwent a surgical procedure to drain the fluid around her lung; when the fluid kept coming back, a thoracic surgeon eventually placed a small, permanent tube in her chest, which she could drain whenever fluid accumulated and interfered with her breathing. Three weeks after the delivery, she was admitted to the hospital with severe shortness of breath from a pulmonary embolisma blood clot in an artery to the lungs, which is dangerous but not uncommon in cancer patients. She was started on a blood thinner. Then test results showed that her tumor cells did not have the mutation that Tarceva targets. When Marcoux told Sara that the drug wasnt going to work, she had an almost violent physical reaction to the news, bolting to the bathroom in mid-discussion with a sudden bout of diarrhea. Dr. Marcoux recommended a different, more standard chemotherapy, with two drugs called carboplatin and paclitaxel. But the paclitaxel triggered an extreme, nearly overwhelming allergic response, so he switched her to a regimen of carboplatin plus gemcitabine. Response rates, he said, were still very good for patients on this therapy. She spent the remainder of the summer at home, with Vivian and her husband and her parents, who had moved in to help. She loved being a mother. Between chemotherapy cycles, she began trying to get her life back. Then, in October, a CT scan showed that the tumor deposits in her left lung and chest and lymph nodes had grown substantially. The chemotherapy had failed. She was switched to a drug called pemetrexed. Studies found that it could produce markedly longer survival in some patients. In reality, however, only a small percentage of patients gained very much. On average, the drug extended survival by only two monthsfrom eleven months to thirteen monthsand that was in patients who, unlike Sara, had responded to first-line chemotherapy. She worked hard to take the setbacks and side effects in stride. She was upbeat by nature, and she managed to maintain her optimism. Little by little, however, she grew sickerincreasingly exhausted and short of breath. By November, she didnt have the wind to walk the length of the hallway from the parking garage to Marcouxs office; Rich had to push her in a wheelchair. A few days before Thanksgiving, she had another CT scan, which showed that the pemetrexedher third drug regimenwasnt working, either. The lung cancer had spread: from the left chest to the right; to the liver; to the lining of her abdomen; and to her spine. Time was running out. This is the moment in Saras story that poses a fundamental question for everyone living in the era of modern medicine: What do we want Sara and her doctors to do now? Or, to put it another way, if you were the one who had metastatic canceror, for that matter, a similarly advanced case of emphysema or congestive heart failurewhat would you want your doctors to do? The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the countrys long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit. Spending on a disease like cancer tends to follow a particular pattern. There are high initial costs as the cancer is treated, and then, if all goes well, these costs taper off. Medical spending for a breast-cancer survivor, for instance, averaged an estimated fifty-four thousand dollars in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy. For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the endto an average of sixty-three thousand dollars during the last six months of life with an incurable breast cancer. Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop. The subject seems to reach national awareness mainly as a question of who should win when the expensive decisions are made: the insurers and the taxpayers footing the bill or the patient battling for his or her life. Budget hawks urge us to face the fact that we cant afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But theyre debating the wrong question. The failure of our system of medical care for people facing the end of their life runs much deeper. To see this, you have to get close enough to grapple with the way decisions about care are actually made. Recently, while seeing a patient in an intensive-care unit at my hospital, I stopped to talk with the critical-care physician on duty, someone Id known since college. Im running a warehouse for the dying, she said bleakly. Out of the ten patients in her unit, she said, only two were likely to leave the hospital for any length of time. More typical was an almost eighty-year-old woman at the end of her life, with irreversible congestive heart failure, who was in the I.C.U. for the second time in three weeks, drugged to oblivion and tubed in most natural orifices and a few artificial ones. Or the seventy-year-old with a cancer that had metastasized to her lungs and bone, and a fungal pneumonia that arises only in the final phase of the illness. She had chosen to forgo treatment, but her oncologist pushed her to change her mind, and she was put on a ventilator and antibiotics. Another woman, in her eighties, with end-stage respiratory and kidney failure, had been in the unit for two weeks. Her husband had died after a long illness, with a feeding tube and a tracheotomy, and she had mentioned that she didnt want to die that way. But her children couldnt let her go, and asked to proceed with the placement of various devices: a permanent tracheotomy, a feeding tube, and a dialysis catheter. So now she just lay there tethered to her pumps, drifting in and out of consciousness. Almost all these patients had known, for some time, that they had a terminal condition. Yet theyalong with their families and doctorswere unprepared for the final stage. We are having more conversation now about what patients want for the end of their life, by far, than they have had in all their lives to this point, my friend said. The problem is thats way too late. In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending ones final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or Its O.K. or Im sorry or I love you. People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this systems expense. It is how we can build a health-care system that will actually help dying patients achieve whats most important to them at the end of their lives. For all but our most recent history, dying was typically a brief process. Whether the cause was childhood infection, difficult childbirth, heart attack, or pneumonia, the interval between recognizing that you had a life-threatening ailment and death was often just a matter of days or weeks. Consider how our Presidents died before the modern era. George Washington developed a throat infection at home on December 13, 1799, that killed him by the next evening. John Quincy Adams, Millard Fillmore, and Andrew Johnson all succumbed to strokes, and died within two days. Rutherford Hayes had a heart attack and died three days later. Some deadly illnesses took a longer course: James Monroe and Andrew Jackson died from the months-long consumptive process of what appears to have been tuberculosis; Ulysses Grants oral cancer took a year to kill him; and James Madison was bedridden for two years before dying of old age. But, as the end-of-life researcher Joanne Lynn has observed, people usually experienced life-threatening illness the way they experienced bad weatheras something that struck with little warningand you either got through it or you didnt. Dying used to be accompanied by a prescribed set of customs. Guides to ars moriendi, the art of dying, were extraordinarily popular; a 1415 medieval Latin text was reprinted in more than a hundred editions across Europe. Reaffirming ones faith, repenting ones sins, and letting go of ones worldly possessions and desires were crucial, and the guides provided families with prayers and questions for the dying in order to put them in the right frame of mind during their final hours. Last words came to hold a particular place of reverence. These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable conditionadvanced cancer, progressive organ failure (usually the heart, kidney, or liver), or the multiple debilities of very old age. In all such cases, death is certain, but the timing isnt. So everyone struggles with this uncertaintywith how, and when, to accept that the battle is lost. As for last words, they hardly seem to exist anymore. Technology sustains our organs until we are well past the point of awareness and coherence. Besides, how do you attend to the thoughts and concerns of the dying when medicine has made it almost impossible to be sure who the dying even are? Is someone with terminal cancer, dementia, incurable congestive heart failure dying, exactly? I once cared for a woman in her sixties who had severe chest and abdominal pain from a bowel obstruction that had ruptured her colon, caused her to have a heart attack, and put her into septic shock and renal failure. I performed an emergency operation to remove the damaged length of colon and give her a colostomy. A cardiologist stented her coronary arteries. We put her on dialysis, a ventilator, and intravenous feeding, and stabilized her. After a couple of weeks, though, it was clear that she was not going to get much better. The septic shock had left her with heart and respiratory failure as well as dry gangrene of her foot, which would have to be amputated. She had a large, open abdominal wound with leaking bowel contents, which would require twice-a-day cleaning and dressing for weeks in order to heal. She would not be able to eat. She would need a tracheotomy. Her kidneys were gone, and she would have to spend three days a week on a dialysis machine for the rest of her life. She was unmarried and without children. So I sat with her sisters in the I.C.U. family room to talk about whether we should proceed with the amputation and the tracheotomy. Is she dying? one of the sisters asked me. I didnt know how to answer the question. I wasnt even sure what the word dying meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die. One Friday morning this spring, I went on patient rounds with Sarah Creed, a nurse with the hospice service that my hospital system operates. I didnt know much about hospice. I knew that it specialized in providing comfort care for the terminally ill, sometimes in special facilities, though nowadays usually at home. I knew that, in order for a patient of mine to be eligible, I had to write a note certifying that he or she had a life expectancy of less than six months. And I knew few patients who had chosen it, except maybe in their very last few days, because they had to sign a form indicating that they understood their disease was incurable and that they were giving up on medical care to stop it. The picture I had of hospice was of a morphine drip. It was not of this brown-haired and blue-eyed former I.C.U. nurse with a stethoscope, knocking on Lee Coxs door on a quiet street in Bostons Mattapan neighborhood. Hi, Lee, Creed said when she entered the house. Hi, Sarah, Cox said. She was seventy-two years old. Shed had several years of declining health due to congestive heart failure from a heart attack and pulmonary fibrosis, a progressive and irreversible lung disease. Doctors tried slowing the disease with steroids, but they didnt work. She had cycled in and out of the hospital, each time in worse shape. Ultimately, she accepted hospice care and moved in with her niece for support. She was dependent on oxygen, and unable to do the most ordinary tasks. Just answering the door, with her thirty-foot length of oxygen tubing trailing after her, had left her winded. She stood resting for a moment, her lips pursed and her chest heaving. Creed took Coxs arm gently as we walked to the kitchen to sit down, asking her how she had been doing. Then she asked a series of questions, targeting issues that tend to arise in patients with terminal illness. Did Cox have pain? How was her appetite, thirst, sleeping? Any trouble with confusion, anxiety, or restlessness? Had her shortness of breath grown worse? Was there chest pain or heart palpitations? Abdominal discomfort? Trouble with bowel movements or urination or walking? She did have some new troubles. When she walked from the bedroom to the bathroom, she said, it now took at least five minutes to catch her breath, and that frightened her. She was also getting chest pain. Creed pulled a stethoscope and a blood-pressure cuff from her medical bag. Coxs blood pressure was acceptable, but her heart rate was high. Creed listened to her heart, which had a normal rhythm, and to her lungs, hearing the fine crackles of her pulmonary fibrosis but also a new wheeze. Her ankles were swollen with fluid, and when Creed asked for her pillbox she saw that Cox was out of her heart medication. She asked to see Coxs oxygen equipment. The liquid-oxygen cylinder at the foot of the neatly made bed was filled and working properly. The nebulizer equipment for her inhaler treatments, however, was broken. Given the lack of heart medication and inhaler treatments, it was no wonder that she had worsened. Creed called Coxs pharmacy to confirm that her refills had been waiting, and had her arrange for her niece to pick up the medicine when she came home from work. Creed also called the nebulizer supplier for same-day emergency service. She then chatted with Cox in the kitchen for a few minutes. Her spirits were low. Creed took her hand. Everything was going to be all right, she said. She reminded her about the good days shed hadthe previous weekend, for example, when shed been able to go out with her portable oxygen cylinder to shop with her niece and get her hair colored. I asked Cox about her previous life. She had made radios in a Boston factory. She and her husband had two children, and several grandchildren. When I asked her why she had chosen hospice care, she looked downcast. The lung doctor and heart doctor said they couldnt help me anymore, she said. Creed glared at me. My questions had made Cox sad again. Its good to have my niece and her husband helping to watch me every day, she said. But its not my home. I feel like Im in the way. Creed gave her a hug before we left, and one last reminder. What do you do if you have chest pain that doesnt go away? she asked. Take a nitro, Cox said, referring to the nitroglycerin pill that she can slip under her tongue. And? Call you. Wheres the number? She pointed to the twenty-four-hour hospice call number that was taped beside her phone. Outside, I confessed that I was confused by what Creed was doing. A lot of it seemed to be about extending Coxs life. Wasnt the goal of hospice to let nature take its course? Thats not the goal, Creed said. The difference between standard medical care and hospice is not the difference between treating and doing nothing, she explained. The difference was in your priorities. In ordinary medicine, the goal is to extend life. Well sacrifice the quality of your existence nowby performing surgery, providing chemotherapy, putting you in intensive carefor the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focussing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists arent much concerned about whether that makes peoples lives longer or shorter. Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer. When Cox was transferred to hospice care, her doctors thought that she wouldnt live much longer than a few weeks. With the supportive hospice therapy she received, she had already lived for a year. Creed enters peoples lives at a strange momentwhen they have understood that they have a fatal illness but have not necessarily acknowledged that they are dying. Id say only about a quarter have accepted their fate when they come into hospice, she said. When she first encounters her patients, many feel that they have simply been abandoned by their doctors. Ninety-nine per cent understand theyre dying, but one hundred per cent hope theyre not, she says. They still want to beat their disease. The initial visit is always tricky, but she has found ways to smooth things over. A nurse has five seconds to make a patient like you and trust you. Its in the whole way you present yourself. I do not come in saying, Im so sorry. Instead, its: Im the hospice nurse, and heres what I have to offer you to make your life better. And I know we dont have a lot of time to waste. That was how she started with Dave Galloway, whom we visited after leaving Lee Coxs home. He was forty-two years old. He and his wife, Sharon, were both Boston firefighters. They had a three-year-old daughter. He had pancreatic cancer, which had spread; his upper abdomen was now solid with tumor. During the past few months, the pain had become unbearable at times, and he was admitted to the hospital several times for pain crises. At his most recent admission, about a week earlier, it was found that the tumor had perforated his intestine. There wasnt even a temporary fix for this problem. The medical team started him on intravenous nutrition and offered him a choice between going to the intensive-care unit and going home with hospice. He chose to go home. I wish wed gotten involved sooner, Creed told me. When she and the hospices supervising doctor, Dr. JoAnne Nowak, evaluated Galloway upon his arrival at home, he appeared to have only a few days left. His eyes were hollow. His breathing was labored. Fluid swelled his entire lower body to the point that his skin blistered and wept. He was almost delirious with abdominal pain. Sometimes I just want to curl up with a good book and burn it. They got to work. They set up a pain pump with a button that let him dispense higher doses of narcotic than he had been allowed. They arranged for an electric hospital bed, so that he could sleep with his back raised. They also taught Sharon how to keep Dave clean, protect his skin from breakdown, and handle the crises to come. Creed told me that part of her job is to take the measure of a patients family, and Sharon struck her as unusually capable. She was determined to take care of her husband to the end, and, perhaps because she was a firefighter, she had the resilience and the competence to do so. She did not want to hire a private-duty nurse. She handled everything, from the I.V. lines and the bed linens to orchestrating family members to lend a hand when she needed help. Creed arranged for a specialized comfort pack to be delivered by FedEx and stored in a mini-refrigerator by Daves bed. It contained a dose of morphine for breakthrough pain or shortness of breath, Ativan for anxiety attacks, Compazine for nausea, Haldol for delirium, Tylenol for fever, and atropine for drying up the upper-airway rattle that people can get in their final hours. If any such problem developed, Sharon was instructed to call the twenty-four-hour hospice nurse on duty, who would provide instructions about which rescue medications to use and, if necessary, come out to help. Dave and Sharon were finally able to sleep through the night at home. Creed or another nurse came to see him every day, sometimes twice a day; three times that week, Sharon used the emergency hospice line to help her deal with Daves pain crises or hallucinations. After a few days, they were even able to go out to a favorite restaurant; he wasnt hungry, but they enjoyed just being there, and the memories it stirred. The hardest part so far, Sharon said, was deciding to forgo the two-litre intravenous feedings that Dave had been receiving each day. Although they were his only source of calories, the hospice staff encouraged discontinuing them because his body did not seem to be absorbing the nutrition. The infusion of sugars, proteins, and fats made the painful swelling of his skin and his shortness of breath worseand for what? The mantra was live for now. Sharon had balked, for fear that shed be starving him. The night before our visit, however, she and Dave decided to try going without the infusion. By morning, the swelling was markedly reduced. He could move more, and with less discomfort. He also began to eat a few morsels of food, just for the taste of it, and that made Sharon feel better about the decision. When we arrived, Dave was making his way back to bed after a shower, his arm around his wifes shoulders and his slippered feet taking one shuffling step at a time. Theres nothing he likes better than a long hot shower, Sharon said. Hed live in the shower if he could. Dave sat on the edge of his bed in fresh pajamas, catching his breath, and then Creed spoke to him as his daughter, Ashlee, ran in and out of the room in her beaded pigtails, depositing stuffed animals in her dads lap. Hows your pain on a scale of one to ten? Creed asked. A six, he said. Did you hit the pump? He didnt answer for a moment. Im reluctant, he admitted. Why? Creed asked. It feels like defeat, he said. Defeat? I dont want to become a drug addict, he explained. I dont want to need this. Creed got down on her knees in front of him. Dave, I dont know anyone who can manage this kind of pain without the medication, she said. Its not defeat. Youve got a beautiful wife and daughter, and youre not going to be able to enjoy them with the pain. Youre right about that, he said, looking at Ashlee as she gave him a little horse. And he pressed the button. Dave Galloway died one week laterat home, at peace, and surrounded by family. A week after that, Lee Cox died, too. But, as if to show just how resistant to formula human lives are, Cox had never reconciled herself to the incurability of her illnesses. So when her family found her in cardiac arrest one morning they followed her wishes and called 911 instead of the hospice service. The emergency medical technicians and firefighters and police rushed in. They pulled off her clothes and pumped her chest, put a tube in her airway and forced oxygen into her lungs, and tried to see if they could shock her heart back. But such efforts rarely succeed with terminal patients, and they did not succeed with her. Hospice has tried to offer a new ideal for how we die. Although not everyone has embraced its rituals, those who have are helping to negotiate an ars moriendi for our age. But doing so represents a strugglenot only against suffering but also against the seemingly unstoppable momentum of medical treatment. Just before Thanksgiving of 2007, Sara Monopoli, her husband, Rich, and her mother, Dawn Thomas, met with Dr. Marcoux to discuss the options she had left. By this point, Sara had undergone three rounds of chemotherapy with limited, if any, effect. Perhaps Marcoux could have discussed what she most wanted as death neared and how best to achieve those wishes. But the signal he got from Sara and her family was that they wished to talk only about the next treatment options. They did not want to talk about dying. Recently, I spoke to Saras husband and her parents. Sara knew that her disease was incurable, they pointed out. The week after she was given the diagnosis and delivered her baby, she spelled out her wishes for Vivians upbringing after she was gone. She had told her family on several occasions that she did not want to die in the hospital. She wanted to spend her final moments peacefully at home. But the prospect that those moments might be coming soon, that there might be no way to slow the disease, was not something she or I wanted to discuss, her mother said. Her father, Gary, and her twin sister, Emily, still held out hope for a cure. The doctors simply werent looking hard enough, they felt. I just couldnt believe there wasnt something, Gary said. For Rich, the experience of Saras illness had been disorienting: We had a baby. We were young. And this was so shocking and so odd. We never discussed stopping treatment. Marcoux took the measure of the room. With almost two decades of experience treating lung cancer, he had been through many of these conversations. He has a calm, reassuring air and a native Minnesotans tendency to avoid confrontation or overintimacy. He tries to be scientific about decisions. I know that the vast majority of my patients are going to die of their disease, he told me. The data show that, after failure of second-line chemotherapy, lung-cancer patients rarely get any added survival time from further treatments and often suffer significant side effects. But he, too, has his hopes. He told them that, at some point, supportive care was an option for them to think about. But, he went on, there were also experimental therapies. He told them about several that were under trial. The most promising was a Pfizer drug that targeted one of the mutations found in her cancers cells. Sara and her family instantly pinned their hopes on it. The drug was so new that it didnt even have a name, just a numberPF0231006and this made it all the more enticing. There were a few hovering issues, including the fact that the scientists didnt yet know the safe dose. The drug was only in a Phase I trialthat is, a trial designed to determine the toxicity of a range of doses, not whether the drug worked. Furthermore, a test of the drug against her cancer cells in a petri dish showed no effect. But Marcoux didnt think that these were decisive obstaclesjust negatives. The critical problem was that the rules of the trial excluded Sara because of the pulmonary embolism she had developed that summer. To enroll, she would need to wait two months, in order to get far enough past the episode. In the meantime, he suggested trying another conventional chemotherapy, called Navelbine. Sara began the treatment the Monday after Thanksgiving. Its worth pausing to consider what had just happened. Step by step, Sara ended up on a fourth round of chemotherapy, one with a minuscule likelihood of altering the course of her disease and a great likelihood of causing debilitating side effects. An opportunity to prepare for the inevitable was forgone. And it all happened because of an assuredly normal circumstance: a patient and family unready to confront the reality of her disease. I asked Marcoux what he hopes to accomplish for terminal lung-cancer patients when they first come to see him. Im thinking, Can I get them a pretty good year or two out of this? he said. Those are my expectations. For me, the long tail for a patient like her is

Read this story and answer questions that follows. Thomas Monopoli was pregnant with her first child

Read this story and answer questions that follows.
Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die. It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had collapsed, and her chest was filled with fluid. A sample of the fluid was drawn off with a long needle and sent for testing. Instead of an infection, as everyone had expected, it was lung cancer, and it had already spread to the lining of her chest. Her pregnancy was thirty-nine weeks along, and the obstetrician who had ordered the test broke the news to her as she sat with her husband and her parents. The obstetrician didnt get into the prognosisshe would bring in an oncologist for thatbut Sara was stunned. Her mother, who had lost her best friend to lung cancer, began crying. The doctors wanted to start treatment right away, and that meant inducing labor to get the baby out. For the moment, though, Sara and her husband, Rich, sat by themselves on a quiet terrace off the labor floor. It was a warm Monday in June, 2007. She took Richs hands, and they tried to absorb what they had heard. Monopoli was thirty-four. She had never smoked, or lived with anyone who had. She exercised. She ate well. The diagnosis was bewildering. This is going to be O.K., Rich told her. Were going to work through this. Its going to be hard, yes. But well figure it out. We can find the right treatment. For the moment, though, they had a baby to think about. So Sara and I looked at each other, Rich recalled, and we said, We dont have cancer on Tuesday. Its a cancer-free day. Were having a baby. Its exciting. And were going to enjoy our baby. On Tuesday, at 8:55 P.M., Vivian Monopoli, seven pounds nine ounces, was born. She had wavy brown hair, like her mom, and she was perfectly healthy. The next day, Sara underwent blood tests and body scans. Dr. Paul Marcoux, an oncologist, met with her and her family to discuss the findings. He explained that she had a non-small cell lung cancer that had started in her left lung. Nothing she had done had brought this on. More than fifteen per cent of lung cancersmore than people realizeoccur in non-smokers. Hers was advanced, having metastasized to multiple lymph nodes in her chest and its lining. The cancer was inoperable. But there were chemotherapy options, notably a relatively new drug called Tarceva, which targets a gene mutation commonly found in lung cancers of female non-smokers. Eighty-five per cent respond to this drug, and, Marcoux said, some of these responses can be long-term. Words like respond and long-term provide a reassuring gloss on a dire reality. There is no cure for lung cancer at this stage. Even with chemotherapy, the median survival is about a year. But it seemed harsh and pointless to confront Sara and Rich with this now. Vivian was in a bassinet by the bed. They were working hard to be optimistic. As Sara and Rich later told the social worker who was sent to see them, they did not want to focus on survival statistics. They wanted to focus on aggressively managing this diagnosis. Sara was started on the Tarceva, which produced an itchy, acne-like facial rash and numbing tiredness. She also underwent a surgical procedure to drain the fluid around her lung; when the fluid kept coming back, a thoracic surgeon eventually placed a small, permanent tube in her chest, which she could drain whenever fluid accumulated and interfered with her breathing. Three weeks after the delivery, she was admitted to the hospital with severe shortness of breath from a pulmonary embolisma blood clot in an artery to the lungs, which is dangerous but not uncommon in cancer patients. She was started on a blood thinner. Then test results showed that her tumor cells did not have the mutation that Tarceva targets. When Marcoux told Sara that the drug wasnt going to work, she had an almost violent physical reaction to the news, bolting to the bathroom in mid-discussion with a sudden bout of diarrhea. Dr. Marcoux recommended a different, more standard chemotherapy, with two drugs called carboplatin and paclitaxel. But the paclitaxel triggered an extreme, nearly overwhelming allergic response, so he switched her to a regimen of carboplatin plus gemcitabine. Response rates, he said, were still very good for patients on this therapy. She spent the remainder of the summer at home, with Vivian and her husband and her parents, who had moved in to help. She loved being a mother. Between chemotherapy cycles, she began trying to get her life back. Then, in October, a CT scan showed that the tumor deposits in her left lung and chest and lymph nodes had grown substantially. The chemotherapy had failed. She was switched to a drug called pemetrexed. Studies found that it could produce markedly longer survival in some patients. In reality, however, only a small percentage of patients gained very much. On average, the drug extended survival by only two monthsfrom eleven months to thirteen monthsand that was in patients who, unlike Sara, had responded to first-line chemotherapy. She worked hard to take the setbacks and side effects in stride. She was upbeat by nature, and she managed to maintain her optimism. Little by little, however, she grew sickerincreasingly exhausted and short of breath. By November, she didnt have the wind to walk the length of the hallway from the parking garage to Marcouxs office; Rich had to push her in a wheelchair. A few days before Thanksgiving, she had another CT scan, which showed that the pemetrexedher third drug regimenwasnt working, either. The lung cancer had spread: from the left chest to the right; to the liver; to the lining of her abdomen; and to her spine. Time was running out. This is the moment in Saras story that poses a fundamental question for everyone living in the era of modern medicine: What do we want Sara and her doctors to do now? Or, to put it another way, if you were the one who had metastatic canceror, for that matter, a similarly advanced case of emphysema or congestive heart failurewhat would you want your doctors to do? The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the countrys long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit. Spending on a disease like cancer tends to follow a particular pattern. There are high initial costs as the cancer is treated, and then, if all goes well, these costs taper off. Medical spending for a breast-cancer survivor, for instance, averaged an estimated fifty-four thousand dollars in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy. For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the endto an average of sixty-three thousand dollars during the last six months of life with an incurable breast cancer. Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop. The subject seems to reach national awareness mainly as a question of who should win when the expensive decisions are made: the insurers and the taxpayers footing the bill or the patient battling for his or her life. Budget hawks urge us to face the fact that we cant afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But theyre debating the wrong question. The failure of our system of medical care for people facing the end of their life runs much deeper. To see this, you have to get close enough to grapple with the way decisions about care are actually made. Recently, while seeing a patient in an intensive-care unit at my hospital, I stopped to talk with the critical-care physician on duty, someone Id known since college. Im running a warehouse for the dying, she said bleakly. Out of the ten patients in her unit, she said, only two were likely to leave the hospital for any length of time. More typical was an almost eighty-year-old woman at the end of her life, with irreversible congestive heart failure, who was in the I.C.U. for the second time in three weeks, drugged to oblivion and tubed in most natural orifices and a few artificial ones. Or the seventy-year-old with a cancer that had metastasized to her lungs and bone, and a fungal pneumonia that arises only in the final phase of the illness. She had chosen to forgo treatment, but her oncologist pushed her to change her mind, and she was put on a ventilator and antibiotics. Another woman, in her eighties, with end-stage respiratory and kidney failure, had been in the unit for two weeks. Her husband had died after a long illness, with a feeding tube and a tracheotomy, and she had mentioned that she didnt want to die that way. But her children couldnt let her go, and asked to proceed with the placement of various devices: a permanent tracheotomy, a feeding tube, and a dialysis catheter. So now she just lay there tethered to her pumps, drifting in and out of consciousness. Almost all these patients had known, for some time, that they had a terminal condition. Yet theyalong with their families and doctorswere unprepared for the final stage. We are having more conversation now about what patients want for the end of their life, by far, than they have had in all their lives to this point, my friend said. The problem is thats way too late. In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending ones final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or Its O.K. or Im sorry or I love you. People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this systems expense. It is how we can build a health-care system that will actually help dying patients achieve whats most important to them at the end of their lives. For all but our most recent history, dying was typically a brief process. Whether the cause was childhood infection, difficult childbirth, heart attack, or pneumonia, the interval between recognizing that you had a life-threatening ailment and death was often just a matter of days or weeks. Consider how our Presidents died before the modern era. George Washington developed a throat infection at home on December 13, 1799, that killed him by the next evening. John Quincy Adams, Millard Fillmore, and Andrew Johnson all succumbed to strokes, and died within two days. Rutherford Hayes had a heart attack and died three days later. Some deadly illnesses took a longer course: James Monroe and Andrew Jackson died from the months-long consumptive process of what appears to have been tuberculosis; Ulysses Grants oral cancer took a year to kill him; and James Madison was bedridden for two years before dying of old age. But, as the end-of-life researcher Joanne Lynn has observed, people usually experienced life-threatening illness the way they experienced bad weatheras something that struck with little warningand you either got through it or you didnt. Dying used to be accompanied by a prescribed set of customs. Guides to ars moriendi, the art of dying, were extraordinarily popular; a 1415 medieval Latin text was reprinted in more than a hundred editions across Europe. Reaffirming ones faith, repenting ones sins, and letting go of ones worldly possessions and desires were crucial, and the guides provided families with prayers and questions for the dying in order to put them in the right frame of mind during their final hours. Last words came to hold a particular place of reverence. These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable conditionadvanced cancer, progressive organ failure (usually the heart, kidney, or liver), or the multiple debilities of very old age. In all such cases, death is certain, but the timing isnt. So everyone struggles with this uncertaintywith how, and when, to accept that the battle is lost. As for last words, they hardly seem to exist anymore. Technology sustains our organs until we are well past the point of awareness and coherence. Besides, how do you attend to the thoughts and concerns of the dying when medicine has made it almost impossible to be sure who the dying even are? Is someone with terminal cancer, dementia, incurable congestive heart failure dying, exactly? I once cared for a woman in her sixties who had severe chest and abdominal pain from a bowel obstruction that had ruptured her colon, caused her to have a heart attack, and put her into septic shock and renal failure. I performed an emergency operation to remove the damaged length of colon and give her a colostomy. A cardiologist stented her coronary arteries. We put her on dialysis, a ventilator, and intravenous feeding, and stabilized her. After a couple of weeks, though, it was clear that she was not going to get much better. The septic shock had left her with heart and respiratory failure as well as dry gangrene of her foot, which would have to be amputated. She had a large, open abdominal wound with leaking bowel contents, which would require twice-a-day cleaning and dressing for weeks in order to heal. She would not be able to eat. She would need a tracheotomy. Her kidneys were gone, and she would have to spend three days a week on a dialysis machine for the rest of her life. She was unmarried and without children. So I sat with her sisters in the I.C.U. family room to talk about whether we should proceed with the amputation and the tracheotomy. Is she dying? one of the sisters asked me. I didnt know how to answer the question. I wasnt even sure what the word dying meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die. One Friday morning this spring, I went on patient rounds with Sarah Creed, a nurse with the hospice service that my hospital system operates. I didnt know much about hospice. I knew that it specialized in providing comfort care for the terminally ill, sometimes in special facilities, though nowadays usually at home. I knew that, in order for a patient of mine to be eligible, I had to write a note certifying that he or she had a life expectancy of less than six months. And I knew few patients who had chosen it, except maybe in their very last few days, because they had to sign a form indicating that they understood their disease was incurable and that they were giving up on medical care to stop it. The picture I had of hospice was of a morphine drip. It was not of this brown-haired and blue-eyed former I.C.U. nurse with a stethoscope, knocking on Lee Coxs door on a quiet street in Bostons Mattapan neighborhood. Hi, Lee, Creed said when she entered the house. Hi, Sarah, Cox said. She was seventy-two years old. Shed had several years of declining health due to congestive heart failure from a heart attack and pulmonary fibrosis, a progressive and irreversible lung disease. Doctors tried slowing the disease with steroids, but they didnt work. She had cycled in and out of the hospital, each time in worse shape. Ultimately, she accepted hospice care and moved in with her niece for support. She was dependent on oxygen, and unable to do the most ordinary tasks. Just answering the door, with her thirty-foot length of oxygen tubing trailing after her, had left her winded. She stood resting for a moment, her lips pursed and her chest heaving. Creed took Coxs arm gently as we walked to the kitchen to sit down, asking her how she had been doing. Then she asked a series of questions, targeting issues that tend to arise in patients with terminal illness. Did Cox have pain? How was her appetite, thirst, sleeping? Any trouble with confusion, anxiety, or restlessness? Had her shortness of breath grown worse? Was there chest pain or heart palpitations? Abdominal discomfort? Trouble with bowel movements or urination or walking? She did have some new troubles. When she walked from the bedroom to the bathroom, she said, it now took at least five minutes to catch her breath, and that frightened her. She was also getting chest pain. Creed pulled a stethoscope and a blood-pressure cuff from her medical bag. Coxs blood pressure was acceptable, but her heart rate was high. Creed listened to her heart, which had a normal rhythm, and to her lungs, hearing the fine crackles of her pulmonary fibrosis but also a new wheeze. Her ankles were swollen with fluid, and when Creed asked for her pillbox she saw that Cox was out of her heart medication. She asked to see Coxs oxygen equipment. The liquid-oxygen cylinder at the foot of the neatly made bed was filled and working properly. The nebulizer equipment for her inhaler treatments, however, was broken. Given the lack of heart medication and inhaler treatments, it was no wonder that she had worsened. Creed called Coxs pharmacy to confirm that her refills had been waiting, and had her arrange for her niece to pick up the medicine when she came home from work. Creed also called the nebulizer supplier for same-day emergency service. She then chatted with Cox in the kitchen for a few minutes. Her spirits were low. Creed took her hand. Everything was going to be all right, she said. She reminded her about the good days shed hadthe previous weekend, for example, when shed been able to go out with her portable oxygen cylinder to shop with her niece and get her hair colored. I asked Cox about her previous life. She had made radios in a Boston factory. She and her husband had two children, and several grandchildren. When I asked her why she had chosen hospice care, she looked downcast. The lung doctor and heart doctor said they couldnt help me anymore, she said. Creed glared at me. My questions had made Cox sad again. Its good to have my niece and her husband helping to watch me every day, she said. But its not my home. I feel like Im in the way. Creed gave her a hug before we left, and one last reminder. What do you do if you have chest pain that doesnt go away? she asked. Take a nitro, Cox said, referring to the nitroglycerin pill that she can slip under her tongue. And? Call you. Wheres the number? She pointed to the twenty-four-hour hospice call number that was taped beside her phone. Outside, I confessed that I was confused by what Creed was doing. A lot of it seemed to be about extending Coxs life. Wasnt the goal of hospice to let nature take its course? Thats not the goal, Creed said. The difference between standard medical care and hospice is not the difference between treating and doing nothing, she explained. The difference was in your priorities. In ordinary medicine, the goal is to extend life. Well sacrifice the quality of your existence nowby performing surgery, providing chemotherapy, putting you in intensive carefor the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focussing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists arent much concerned about whether that makes peoples lives longer or shorter. Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer. When Cox was transferred to hospice care, her doctors thought that she wouldnt live much longer than a few weeks. With the supportive hospice therapy she received, she had already lived for a year. Creed enters peoples lives at a strange momentwhen they have understood that they have a fatal illness but have not necessarily acknowledged that they are dying. Id say only about a quarter have accepted their fate when they come into hospice, she said. When she first encounters her patients, many feel that they have simply been abandoned by their doctors. Ninety-nine per cent understand theyre dying, but one hundred per cent hope theyre not, she says. They still want to beat their disease. The initial visit is always tricky, but she has found ways to smooth things over. A nurse has five seconds to make a patient like you and trust you. Its in the whole way you present yourself. I do not come in saying, Im so sorry. Instead, its: Im the hospice nurse, and heres what I have to offer you to make your life better. And I know we dont have a lot of time to waste. That was how she started with Dave Galloway, whom we visited after leaving Lee Coxs home. He was forty-two years old. He and his wife, Sharon, were both Boston firefighters. They had a three-year-old daughter. He had pancreatic cancer, which had spread; his upper abdomen was now solid with tumor. During the past few months, the pain had become unbearable at times, and he was admitted to the hospital several times for pain crises. At his most recent admission, about a week earlier, it was found that the tumor had perforated his intestine. There wasnt even a temporary fix for this problem. The medical team started him on intravenous nutrition and offered him a choice between going to the intensive-care unit and going home with hospice. He chose to go home. I wish wed gotten involved sooner, Creed told me. When she and the hospices supervising doctor, Dr. JoAnne Nowak, evaluated Galloway upon his arrival at home, he appeared to have only a few days left. His eyes were hollow. His breathing was labored. Fluid swelled his entire lower body to the point that his skin blistered and wept. He was almost delirious with abdominal pain. Sometimes I just want to curl up with a good book and burn it. They got to work. They set up a pain pump with a button that let him dispense higher doses of narcotic than he had been allowed. They arranged for an electric hospital bed, so that he could sleep with his back raised. They also taught Sharon how to keep Dave clean, protect his skin from breakdown, and handle the crises to come. Creed told me that part of her job is to take the measure of a patients family, and Sharon struck her as unusually capable. She was determined to take care of her husband to the end, and, perhaps because she was a firefighter, she had the resilience and the competence to do so. She did not want to hire a private-duty nurse. She handled everything, from the I.V. lines and the bed linens to orchestrating family members to lend a hand when she needed help. Creed arranged for a specialized comfort pack to be delivered by FedEx and stored in a mini-refrigerator by Daves bed. It contained a dose of morphine for breakthrough pain or shortness of breath, Ativan for anxiety attacks, Compazine for nausea, Haldol for delirium, Tylenol for fever, and atropine for drying up the upper-airway rattle that people can get in their final hours. If any such problem developed, Sharon was instructed to call the twenty-four-hour hospice nurse on duty, who would provide instructions about which rescue medications to use and, if necessary, come out to help. Dave and Sharon were finally able to sleep through the night at home. Creed or another nurse came to see him every day, sometimes twice a day; three times that week, Sharon used the emergency hospice line to help her deal with Daves pain crises or hallucinations. After a few days, they were even able to go out to a favorite restaurant; he wasnt hungry, but they enjoyed just being there, and the memories it stirred. The hardest part so far, Sharon said, was deciding to forgo the two-litre intravenous feedings that Dave had been receiving each day. Although they were his only source of calories, the hospice staff encouraged discontinuing them because his body did not seem to be absorbing the nutrition. The infusion of sugars, proteins, and fats made the painful swelling of his skin and his shortness of breath worseand for what? The mantra was live for now. Sharon had balked, for fear that shed be starving him. The night before our visit, however, she and Dave decided to try going without the infusion. By morning, the swelling was markedly reduced. He could move more, and with less discomfort. He also began to eat a few morsels of food, just for the taste of it, and that made Sharon feel better about the decision. When we arrived, Dave was making his way back to bed after a shower, his arm around his wifes shoulders and his slippered feet taking one shuffling step at a time. Theres nothing he likes better than a long hot shower, Sharon said. Hed live in the shower if he could. Dave sat on the edge of his bed in fresh pajamas, catching his breath, and then Creed spoke to him as his daughter, Ashlee, ran in and out of the room in her beaded pigtails, depositing stuffed animals in her dads lap. Hows your pain on a scale of one to ten? Creed asked. A six, he said. Did you hit the pump? He didnt answer for a moment. Im reluctant, he admitted. Why? Creed asked. It feels like defeat, he said. Defeat? I dont want to become a drug addict, he explained. I dont want to need this. Creed got down on her knees in front of him. Dave, I dont know anyone who can manage this kind of pain without the medication, she said. Its not defeat. Youve got a beautiful wife and daughter, and youre not going to be able to enjoy them with the pain. Youre right about that, he said, looking at Ashlee as she gave him a little horse. And he pressed the button. Dave Galloway died one week laterat home, at peace, and surrounded by family. A week after that, Lee Cox died, too. But, as if to show just how resistant to formula human lives are, Cox had never reconciled herself to the incurability of her illnesses. So when her family found her in cardiac arrest one morning they followed her wishes and called 911 instead of the hospice service. The emergency medical technicians and firefighters and police rushed in. They pulled off her clothes and pumped her chest, put a tube in her airway and forced oxygen into her lungs, and tried to see if they could shock her heart back. But such efforts rarely succeed with terminal patients, and they did not succeed with her. Hospice has tried to offer a new ideal for how we die. Although not everyone has embraced its rituals, those who have are helping to negotiate an ars moriendi for our age. But doing so represents a strugglenot only against suffering but also against the seemingly unstoppable momentum of medical treatment. Just before Thanksgiving of 2007, Sara Monopoli, her husband, Rich, and her mother, Dawn Thomas, met with Dr. Marcoux to discuss the options she had left. By this point, Sara had undergone three rounds of chemotherapy with limited, if any, effect. Perhaps Marcoux could have discussed what she most wanted as death neared and how best to achieve those wishes. But the signal he got from Sara and her family was that they wished to talk only about the next treatment options. They did not want to talk about dying. Recently, I spoke to Saras husband and her parents. Sara knew that her disease was incurable, they pointed out. The week after she was given the diagnosis and delivered her baby, she spelled out her wishes for Vivians upbringing after she was gone. She had told her family on several occasions that she did not want to die in the hospital. She wanted to spend her final moments peacefully at home. But the prospect that those moments might be coming soon, that there might be no way to slow the disease, was not something she or I wanted to discuss, her mother said. Her father, Gary, and her twin sister, Emily, still held out hope for a cure. The doctors simply werent looking hard enough, they felt. I just couldnt believe there wasnt something, Gary said. For Rich, the experience of Saras illness had been disorienting: We had a baby. We were young. And this was so shocking and so odd. We never discussed stopping treatment. Marcoux took the measure of the room. With almost two decades of experience treating lung cancer, he had been through many of these conversations. He has a calm, reassuring air and a native Minnesotans tendency to avoid confrontation or overintimacy. He tries to be scientific about decisions. I know that the vast majority of my patients are going to die of their disease, he told me. The data show that, after failure of second-line chemotherapy, lung-cancer patients rarely get any added survival time from further treatments and often suffer significant side effects. But he, too, has his hopes. He told them that, at some point, supportive care was an option for them to think about. But, he went on, there were also experimental therapies. He told them about several that were under trial. The most promising was a Pfizer drug that targeted one of the mutations found in her cancers cells. Sara and her family instantly pinned their hopes on it. The drug was so new that it didnt even have a name, just a numberPF0231006and this made it all the more enticing. There were a few hovering issues, including the fact that the scientists didnt yet know the safe dose. The drug was only in a Phase I trialthat is, a trial designed to determine the toxicity of a range of doses, not whether the drug worked. Furthermore, a test of the drug against her cancer cells in a petri dish showed no effect. But Marcoux didnt think that these were decisive obstaclesjust negatives. The critical problem was that the rules of the trial excluded Sara because of the pulmonary embolism she had developed that summer. To enroll, she would need to wait two months, in order to get far enough past the episode. In the meantime, he suggested trying another conventional chemotherapy, called Navelbine. Sara began the treatment the Monday after Thanksgiving. Its worth pausing to consider what had just happened. Step by step, Sara ended up on a fourth round of chemotherapy, one with a minuscule likelihood of altering the course of her disease and a great likelihood of causing debilitating side effects. An opportunity to prepare for the inevitable was forgone. And it all happened because of an assuredly normal circumstance: a patient and family unready to confront the reality of her disease. I asked Marcoux what he hopes to accomplish for terminal lung-cancer patients when they first come to see him. Im thinking, Can I get them a pretty good year or two out of this? he said. Those are my expectations. For me, the long tail for a patient like her is

Read this story and answer questions that follows. Thomas Monopoli was pregnant with her first child

Read this story and answer questions that follows.
Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die. It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had collapsed, and her chest was filled with fluid. A sample of the fluid was drawn off with a long needle and sent for testing. Instead of an infection, as everyone had expected, it was lung cancer, and it had already spread to the lining of her chest. Her pregnancy was thirty-nine weeks along, and the obstetrician who had ordered the test broke the news to her as she sat with her husband and her parents. The obstetrician didnt get into the prognosisshe would bring in an oncologist for thatbut Sara was stunned. Her mother, who had lost her best friend to lung cancer, began crying. The doctors wanted to start treatment right away, and that meant inducing labor to get the baby out. For the moment, though, Sara and her husband, Rich, sat by themselves on a quiet terrace off the labor floor. It was a warm Monday in June, 2007. She took Richs hands, and they tried to absorb what they had heard. Monopoli was thirty-four. She had never smoked, or lived with anyone who had. She exercised. She ate well. The diagnosis was bewildering. This is going to be O.K., Rich told her. Were going to work through this. Its going to be hard, yes. But well figure it out. We can find the right treatment. For the moment, though, they had a baby to think about. So Sara and I looked at each other, Rich recalled, and we said, We dont have cancer on Tuesday. Its a cancer-free day. Were having a baby. Its exciting. And were going to enjoy our baby. On Tuesday, at 8:55 P.M., Vivian Monopoli, seven pounds nine ounces, was born. She had wavy brown hair, like her mom, and she was perfectly healthy. The next day, Sara underwent blood tests and body scans. Dr. Paul Marcoux, an oncologist, met with her and her family to discuss the findings. He explained that she had a non-small cell lung cancer that had started in her left lung. Nothing she had done had brought this on. More than fifteen per cent of lung cancersmore than people realizeoccur in non-smokers. Hers was advanced, having metastasized to multiple lymph nodes in her chest and its lining. The cancer was inoperable. But there were chemotherapy options, notably a relatively new drug called Tarceva, which targets a gene mutation commonly found in lung cancers of female non-smokers. Eighty-five per cent respond to this drug, and, Marcoux said, some of these responses can be long-term. Words like respond and long-term provide a reassuring gloss on a dire reality. There is no cure for lung cancer at this stage. Even with chemotherapy, the median survival is about a year. But it seemed harsh and pointless to confront Sara and Rich with this now. Vivian was in a bassinet by the bed. They were working hard to be optimistic. As Sara and Rich later told the social worker who was sent to see them, they did not want to focus on survival statistics. They wanted to focus on aggressively managing this diagnosis. Sara was started on the Tarceva, which produced an itchy, acne-like facial rash and numbing tiredness. She also underwent a surgical procedure to drain the fluid around her lung; when the fluid kept coming back, a thoracic surgeon eventually placed a small, permanent tube in her chest, which she could drain whenever fluid accumulated and interfered with her breathing. Three weeks after the delivery, she was admitted to the hospital with severe shortness of breath from a pulmonary embolisma blood clot in an artery to the lungs, which is dangerous but not uncommon in cancer patients. She was started on a blood thinner. Then test results showed that her tumor cells did not have the mutation that Tarceva targets. When Marcoux told Sara that the drug wasnt going to work, she had an almost violent physical reaction to the news, bolting to the bathroom in mid-discussion with a sudden bout of diarrhea. Dr. Marcoux recommended a different, more standard chemotherapy, with two drugs called carboplatin and paclitaxel. But the paclitaxel triggered an extreme, nearly overwhelming allergic response, so he switched her to a regimen of carboplatin plus gemcitabine. Response rates, he said, were still very good for patients on this therapy. She spent the remainder of the summer at home, with Vivian and her husband and her parents, who had moved in to help. She loved being a mother. Between chemotherapy cycles, she began trying to get her life back. Then, in October, a CT scan showed that the tumor deposits in her left lung and chest and lymph nodes had grown substantially. The chemotherapy had failed. She was switched to a drug called pemetrexed. Studies found that it could produce markedly longer survival in some patients. In reality, however, only a small percentage of patients gained very much. On average, the drug extended survival by only two monthsfrom eleven months to thirteen monthsand that was in patients who, unlike Sara, had responded to first-line chemotherapy. She worked hard to take the setbacks and side effects in stride. She was upbeat by nature, and she managed to maintain her optimism. Little by little, however, she grew sickerincreasingly exhausted and short of breath. By November, she didnt have the wind to walk the length of the hallway from the parking garage to Marcouxs office; Rich had to push her in a wheelchair. A few days before Thanksgiving, she had another CT scan, which showed that the pemetrexedher third drug regimenwasnt working, either. The lung cancer had spread: from the left chest to the right; to the liver; to the lining of her abdomen; and to her spine. Time was running out. This is the moment in Saras story that poses a fundamental question for everyone living in the era of modern medicine: What do we want Sara and her doctors to do now? Or, to put it another way, if you were the one who had metastatic canceror, for that matter, a similarly advanced case of emphysema or congestive heart failurewhat would you want your doctors to do? The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the countrys long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit. Spending on a disease like cancer tends to follow a particular pattern. There are high initial costs as the cancer is treated, and then, if all goes well, these costs taper off. Medical spending for a breast-cancer survivor, for instance, averaged an estimated fifty-four thousand dollars in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy. For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the endto an average of sixty-three thousand dollars during the last six months of life with an incurable breast cancer. Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop. The subject seems to reach national awareness mainly as a question of who should win when the expensive decisions are made: the insurers and the taxpayers footing the bill or the patient battling for his or her life. Budget hawks urge us to face the fact that we cant afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But theyre debating the wrong question. The failure of our system of medical care for people facing the end of their life runs much deeper. To see this, you have to get close enough to grapple with the way decisions about care are actually made. Recently, while seeing a patient in an intensive-care unit at my hospital, I stopped to talk with the critical-care physician on duty, someone Id known since college. Im running a warehouse for the dying, she said bleakly. Out of the ten patients in her unit, she said, only two were likely to leave the hospital for any length of time. More typical was an almost eighty-year-old woman at the end of her life, with irreversible congestive heart failure, who was in the I.C.U. for the second time in three weeks, drugged to oblivion and tubed in most natural orifices and a few artificial ones. Or the seventy-year-old with a cancer that had metastasized to her lungs and bone, and a fungal pneumonia that arises only in the final phase of the illness. She had chosen to forgo treatment, but her oncologist pushed her to change her mind, and she was put on a ventilator and antibiotics. Another woman, in her eighties, with end-stage respiratory and kidney failure, had been in the unit for two weeks. Her husband had died after a long illness, with a feeding tube and a tracheotomy, and she had mentioned that she didnt want to die that way. But her children couldnt let her go, and asked to proceed with the placement of various devices: a permanent tracheotomy, a feeding tube, and a dialysis catheter. So now she just lay there tethered to her pumps, drifting in and out of consciousness. Almost all these patients had known, for some time, that they had a terminal condition. Yet theyalong with their families and doctorswere unprepared for the final stage. We are having more conversation now about what patients want for the end of their life, by far, than they have had in all their lives to this point, my friend said. The problem is thats way too late. In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending ones final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or Its O.K. or Im sorry or I love you. People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this systems expense. It is how we can build a health-care system that will actually help dying patients achieve whats most important to them at the end of their lives. For all but our most recent history, dying was typically a brief process. Whether the cause was childhood infection, difficult childbirth, heart attack, or pneumonia, the interval between recognizing that you had a life-threatening ailment and death was often just a matter of days or weeks. Consider how our Presidents died before the modern era. George Washington developed a throat infection at home on December 13, 1799, that killed him by the next evening. John Quincy Adams, Millard Fillmore, and Andrew Johnson all succumbed to strokes, and died within two days. Rutherford Hayes had a heart attack and died three days later. Some deadly illnesses took a longer course: James Monroe and Andrew Jackson died from the months-long consumptive process of what appears to have been tuberculosis; Ulysses Grants oral cancer took a year to kill him; and James Madison was bedridden for two years before dying of old age. But, as the end-of-life researcher Joanne Lynn has observed, people usually experienced life-threatening illness the way they experienced bad weatheras something that struck with little warningand you either got through it or you didnt. Dying used to be accompanied by a prescribed set of customs. Guides to ars moriendi, the art of dying, were extraordinarily popular; a 1415 medieval Latin text was reprinted in more than a hundred editions across Europe. Reaffirming ones faith, repenting ones sins, and letting go of ones worldly possessions and desires were crucial, and the guides provided families with prayers and questions for the dying in order to put them in the right frame of mind during their final hours. Last words came to hold a particular place of reverence. These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable conditionadvanced cancer, progressive organ failure (usually the heart, kidney, or liver), or the multiple debilities of very old age. In all such cases, death is certain, but the timing isnt. So everyone struggles with this uncertaintywith how, and when, to accept that the battle is lost. As for last words, they hardly seem to exist anymore. Technology sustains our organs until we are well past the point of awareness and coherence. Besides, how do you attend to the thoughts and concerns of the dying when medicine has made it almost impossible to be sure who the dying even are? Is someone with terminal cancer, dementia, incurable congestive heart failure dying, exactly? I once cared for a woman in her sixties who had severe chest and abdominal pain from a bowel obstruction that had ruptured her colon, caused her to have a heart attack, and put her into septic shock and renal failure. I performed an emergency operation to remove the damaged length of colon and give her a colostomy. A cardiologist stented her coronary arteries. We put her on dialysis, a ventilator, and intravenous feeding, and stabilized her. After a couple of weeks, though, it was clear that she was not going to get much better. The septic shock had left her with heart and respiratory failure as well as dry gangrene of her foot, which would have to be amputated. She had a large, open abdominal wound with leaking bowel contents, which would require twice-a-day cleaning and dressing for weeks in order to heal. She would not be able to eat. She would need a tracheotomy. Her kidneys were gone, and she would have to spend three days a week on a dialysis machine for the rest of her life. She was unmarried and without children. So I sat with her sisters in the I.C.U. family room to talk about whether we should proceed with the amputation and the tracheotomy. Is she dying? one of the sisters asked me. I didnt know how to answer the question. I wasnt even sure what the word dying meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die. One Friday morning this spring, I went on patient rounds with Sarah Creed, a nurse with the hospice service that my hospital system operates. I didnt know much about hospice. I knew that it specialized in providing comfort care for the terminally ill, sometimes in special facilities, though nowadays usually at home. I knew that, in order for a patient of mine to be eligible, I had to write a note certifying that he or she had a life expectancy of less than six months. And I knew few patients who had chosen it, except maybe in their very last few days, because they had to sign a form indicating that they understood their disease was incurable and that they were giving up on medical care to stop it. The picture I had of hospice was of a morphine drip. It was not of this brown-haired and blue-eyed former I.C.U. nurse with a stethoscope, knocking on Lee Coxs door on a quiet street in Bostons Mattapan neighborhood. Hi, Lee, Creed said when she entered the house. Hi, Sarah, Cox said. She was seventy-two years old. Shed had several years of declining health due to congestive heart failure from a heart attack and pulmonary fibrosis, a progressive and irreversible lung disease. Doctors tried slowing the disease with steroids, but they didnt work. She had cycled in and out of the hospital, each time in worse shape. Ultimately, she accepted hospice care and moved in with her niece for support. She was dependent on oxygen, and unable to do the most ordinary tasks. Just answering the door, with her thirty-foot length of oxygen tubing trailing after her, had left her winded. She stood resting for a moment, her lips pursed and her chest heaving. Creed took Coxs arm gently as we walked to the kitchen to sit down, asking her how she had been doing. Then she asked a series of questions, targeting issues that tend to arise in patients with terminal illness. Did Cox have pain? How was her appetite, thirst, sleeping? Any trouble with confusion, anxiety, or restlessness? Had her shortness of breath grown worse? Was there chest pain or heart palpitations? Abdominal discomfort? Trouble with bowel movements or urination or walking? She did have some new troubles. When she walked from the bedroom to the bathroom, she said, it now took at least five minutes to catch her breath, and that frightened her. She was also getting chest pain. Creed pulled a stethoscope and a blood-pressure cuff from her medical bag. Coxs blood pressure was acceptable, but her heart rate was high. Creed listened to her heart, which had a normal rhythm, and to her lungs, hearing the fine crackles of her pulmonary fibrosis but also a new wheeze. Her ankles were swollen with fluid, and when Creed asked for her pillbox she saw that Cox was out of her heart medication. She asked to see Coxs oxygen equipment. The liquid-oxygen cylinder at the foot of the neatly made bed was filled and working properly. The nebulizer equipment for her inhaler treatments, however, was broken. Given the lack of heart medication and inhaler treatments, it was no wonder that she had worsened. Creed called Coxs pharmacy to confirm that her refills had been waiting, and had her arrange for her niece to pick up the medicine when she came home from work. Creed also called the nebulizer supplier for same-day emergency service. She then chatted with Cox in the kitchen for a few minutes. Her spirits were low. Creed took her hand. Everything was going to be all right, she said. She reminded her about the good days shed hadthe previous weekend, for example, when shed been able to go out with her portable oxygen cylinder to shop with her niece and get her hair colored. I asked Cox about her previous life. She had made radios in a Boston factory. She and her husband had two children, and several grandchildren. When I asked her why she had chosen hospice care, she looked downcast. The lung doctor and heart doctor said they couldnt help me anymore, she said. Creed glared at me. My questions had made Cox sad again. Its good to have my niece and her husband helping to watch me every day, she said. But its not my home. I feel like Im in the way. Creed gave her a hug before we left, and one last reminder. What do you do if you have chest pain that doesnt go away? she asked. Take a nitro, Cox said, referring to the nitroglycerin pill that she can slip under her tongue. And? Call you. Wheres the number? She pointed to the twenty-four-hour hospice call number that was taped beside her phone. Outside, I confessed that I was confused by what Creed was doing. A lot of it seemed to be about extending Coxs life. Wasnt the goal of hospice to let nature take its course? Thats not the goal, Creed said. The difference between standard medical care and hospice is not the difference between treating and doing nothing, she explained. The difference was in your priorities. In ordinary medicine, the goal is to extend life. Well sacrifice the quality of your existence nowby performing surgery, providing chemotherapy, putting you in intensive carefor the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focussing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists arent much concerned about whether that makes peoples lives longer or shorter. Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer. When Cox was transferred to hospice care, her doctors thought that she wouldnt live much longer than a few weeks. With the supportive hospice therapy she received, she had already lived for a year. Creed enters peoples lives at a strange momentwhen they have understood that they have a fatal illness but have not necessarily acknowledged that they are dying. Id say only about a quarter have accepted their fate when they come into hospice, she said. When she first encounters her patients, many feel that they have simply been abandoned by their doctors. Ninety-nine per cent understand theyre dying, but one hundred per cent hope theyre not, she says. They still want to beat their disease. The initial visit is always tricky, but she has found ways to smooth things over. A nurse has five seconds to make a patient like you and trust you. Its in the whole way you present yourself. I do not come in saying, Im so sorry. Instead, its: Im the hospice nurse, and heres what I have to offer you to make your life better. And I know we dont have a lot of time to waste. That was how she started with Dave Galloway, whom we visited after leaving Lee Coxs home. He was forty-two years old. He and his wife, Sharon, were both Boston firefighters. They had a three-year-old daughter. He had pancreatic cancer, which had spread; his upper abdomen was now solid with tumor. During the past few months, the pain had become unbearable at times, and he was admitted to the hospital several times for pain crises. At his most recent admission, about a week earlier, it was found that the tumor had perforated his intestine. There wasnt even a temporary fix for this problem. The medical team started him on intravenous nutrition and offered him a choice between going to the intensive-care unit and going home with hospice. He chose to go home. I wish wed gotten involved sooner, Creed told me. When she and the hospices supervising doctor, Dr. JoAnne Nowak, evaluated Galloway upon his arrival at home, he appeared to have only a few days left. His eyes were hollow. His breathing was labored. Fluid swelled his entire lower body to the point that his skin blistered and wept. He was almost delirious with abdominal pain. Sometimes I just want to curl up with a good book and burn it. They got to work. They set up a pain pump with a button that let him dispense higher doses of narcotic than he had been allowed. They arranged for an electric hospital bed, so that he could sleep with his back raised. They also taught Sharon how to keep Dave clean, protect his skin from breakdown, and handle the crises to come. Creed told me that part of her job is to take the measure of a patients family, and Sharon struck her as unusually capable. She was determined to take care of her husband to the end, and, perhaps because she was a firefighter, she had the resilience and the competence to do so. She did not want to hire a private-duty nurse. She handled everything, from the I.V. lines and the bed linens to orchestrating family members to lend a hand when she needed help. Creed arranged for a specialized comfort pack to be delivered by FedEx and stored in a mini-refrigerator by Daves bed. It contained a dose of morphine for breakthrough pain or shortness of breath, Ativan for anxiety attacks, Compazine for nausea, Haldol for delirium, Tylenol for fever, and atropine for drying up the upper-airway rattle that people can get in their final hours. If any such problem developed, Sharon was instructed to call the twenty-four-hour hospice nurse on duty, who would provide instructions about which rescue medications to use and, if necessary, come out to help. Dave and Sharon were finally able to sleep through the night at home. Creed or another nurse came to see him every day, sometimes twice a day; three times that week, Sharon used the emergency hospice line to help her deal with Daves pain crises or hallucinations. After a few days, they were even able to go out to a favorite restaurant; he wasnt hungry, but they enjoyed just being there, and the memories it stirred. The hardest part so far, Sharon said, was deciding to forgo the two-litre intravenous feedings that Dave had been receiving each day. Although they were his only source of calories, the hospice staff encouraged discontinuing them because his body did not seem to be absorbing the nutrition. The infusion of sugars, proteins, and fats made the painful swelling of his skin and his shortness of breath worseand for what? The mantra was live for now. Sharon had balked, for fear that shed be starving him. The night before our visit, however, she and Dave decided to try going without the infusion. By morning, the swelling was markedly reduced. He could move more, and with less discomfort. He also began to eat a few morsels of food, just for the taste of it, and that made Sharon feel better about the decision. When we arrived, Dave was making his way back to bed after a shower, his arm around his wifes shoulders and his slippered feet taking one shuffling step at a time. Theres nothing he likes better than a long hot shower, Sharon said. Hed live in the shower if he could. Dave sat on the edge of his bed in fresh pajamas, catching his breath, and then Creed spoke to him as his daughter, Ashlee, ran in and out of the room in her beaded pigtails, depositing stuffed animals in her dads lap. Hows your pain on a scale of one to ten? Creed asked. A six, he said. Did you hit the pump? He didnt answer for a moment. Im reluctant, he admitted. Why? Creed asked. It feels like defeat, he said. Defeat? I dont want to become a drug addict, he explained. I dont want to need this. Creed got down on her knees in front of him. Dave, I dont know anyone who can manage this kind of pain without the medication, she said. Its not defeat. Youve got a beautiful wife and daughter, and youre not going to be able to enjoy them with the pain. Youre right about that, he said, looking at Ashlee as she gave him a little horse. And he pressed the button. Dave Galloway died one week laterat home, at peace, and surrounded by family. A week after that, Lee Cox died, too. But, as if to show just how resistant to formula human lives are, Cox had never reconciled herself to the incurability of her illnesses. So when her family found her in cardiac arrest one morning they followed her wishes and called 911 instead of the hospice service. The emergency medical technicians and firefighters and police rushed in. They pulled off her clothes and pumped her chest, put a tube in her airway and forced oxygen into her lungs, and tried to see if they could shock her heart back. But such efforts rarely succeed with terminal patients, and they did not succeed with her. Hospice has tried to offer a new ideal for how we die. Although not everyone has embraced its rituals, those who have are helping to negotiate an ars moriendi for our age. But doing so represents a strugglenot only against suffering but also against the seemingly unstoppable momentum of medical treatment. Just before Thanksgiving of 2007, Sara Monopoli, her husband, Rich, and her mother, Dawn Thomas, met with Dr. Marcoux to discuss the options she had left. By this point, Sara had undergone three rounds of chemotherapy with limited, if any, effect. Perhaps Marcoux could have discussed what she most wanted as death neared and how best to achieve those wishes. But the signal he got from Sara and her family was that they wished to talk only about the next treatment options. They did not want to talk about dying. Recently, I spoke to Saras husband and her parents. Sara knew that her disease was incurable, they pointed out. The week after she was given the diagnosis and delivered her baby, she spelled out her wishes for Vivians upbringing after she was gone. She had told her family on several occasions that she did not want to die in the hospital. She wanted to spend her final moments peacefully at home. But the prospect that those moments might be coming soon, that there might be no way to slow the disease, was not something she or I wanted to discuss, her mother said. Her father, Gary, and her twin sister, Emily, still held out hope for a cure. The doctors simply werent looking hard enough, they felt. I just couldnt believe there wasnt something, Gary said. For Rich, the experience of Saras illness had been disorienting: We had a baby. We were young. And this was so shocking and so odd. We never discussed stopping treatment. Marcoux took the measure of the room. With almost two decades of experience treating lung cancer, he had been through many of these conversations. He has a calm, reassuring air and a native Minnesotans tendency to avoid confrontation or overintimacy. He tries to be scientific about decisions. I know that the vast majority of my patients are going to die of their disease, he told me. The data show that, after failure of second-line chemotherapy, lung-cancer patients rarely get any added survival time from further treatments and often suffer significant side effects. But he, too, has his hopes. He told them that, at some point, supportive care was an option for them to think about. But, he went on, there were also experimental therapies. He told them about several that were under trial. The most promising was a Pfizer drug that targeted one of the mutations found in her cancers cells. Sara and her family instantly pinned their hopes on it. The drug was so new that it didnt even have a name, just a numberPF0231006and this made it all the more enticing. There were a few hovering issues, including the fact that the scientists didnt yet know the safe dose. The drug was only in a Phase I trialthat is, a trial designed to determine the toxicity of a range of doses, not whether the drug worked. Furthermore, a test of the drug against her cancer cells in a petri dish showed no effect. But Marcoux didnt think that these were decisive obstaclesjust negatives. The critical problem was that the rules of the trial excluded Sara because of the pulmonary embolism she had developed that summer. To enroll, she would need to wait two months, in order to get far enough past the episode. In the meantime, he suggested trying another conventional chemotherapy, called Navelbine. Sara began the treatment the Monday after Thanksgiving. Its worth pausing to consider what had just happened. Step by step, Sara ended up on a fourth round of chemotherapy, one with a minuscule likelihood of altering the course of her disease and a great likelihood of causing debilitating side effects. An opportunity to prepare for the inevitable was forgone. And it all happened because of an assuredly normal circumstance: a patient and family unready to confront the reality of her disease. I asked Marcoux what he hopes to accomplish for terminal lung-cancer patients when they first come to see him. Im thinking, Can I get them a pretty good year or two out of this? he said. Those are my expectations. For me, the long tail for a patient like her is

Read this story and answer questions that follows. Thomas Monopoli was pregnant with her first child

Read this story and answer questions that follows.
Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die. It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had collapsed, and her chest was filled with fluid. A sample of the fluid was drawn off with a long needle and sent for testing. Instead of an infection, as everyone had expected, it was lung cancer, and it had already spread to the lining of her chest. Her pregnancy was thirty-nine weeks along, and the obstetrician who had ordered the test broke the news to her as she sat with her husband and her parents. The obstetrician didnt get into the prognosisshe would bring in an oncologist for thatbut Sara was stunned. Her mother, who had lost her best friend to lung cancer, began crying. The doctors wanted to start treatment right away, and that meant inducing labor to get the baby out. For the moment, though, Sara and her husband, Rich, sat by themselves on a quiet terrace off the labor floor. It was a warm Monday in June, 2007. She took Richs hands, and they tried to absorb what they had heard. Monopoli was thirty-four. She had never smoked, or lived with anyone who had. She exercised. She ate well. The diagnosis was bewildering. This is going to be O.K., Rich told her. Were going to work through this. Its going to be hard, yes. But well figure it out. We can find the right treatment. For the moment, though, they had a baby to think about. So Sara and I looked at each other, Rich recalled, and we said, We dont have cancer on Tuesday. Its a cancer-free day. Were having a baby. Its exciting. And were going to enjoy our baby. On Tuesday, at 8:55 P.M., Vivian Monopoli, seven pounds nine ounces, was born. She had wavy brown hair, like her mom, and she was perfectly healthy. The next day, Sara underwent blood tests and body scans. Dr. Paul Marcoux, an oncologist, met with her and her family to discuss the findings. He explained that she had a non-small cell lung cancer that had started in her left lung. Nothing she had done had brought this on. More than fifteen per cent of lung cancersmore than people realizeoccur in non-smokers. Hers was advanced, having metastasized to multiple lymph nodes in her chest and its lining. The cancer was inoperable. But there were chemotherapy options, notably a relatively new drug called Tarceva, which targets a gene mutation commonly found in lung cancers of female non-smokers. Eighty-five per cent respond to this drug, and, Marcoux said, some of these responses can be long-term. Words like respond and long-term provide a reassuring gloss on a dire reality. There is no cure for lung cancer at this stage. Even with chemotherapy, the median survival is about a year. But it seemed harsh and pointless to confront Sara and Rich with this now. Vivian was in a bassinet by the bed. They were working hard to be optimistic. As Sara and Rich later told the social worker who was sent to see them, they did not want to focus on survival statistics. They wanted to focus on aggressively managing this diagnosis. Sara was started on the Tarceva, which produced an itchy, acne-like facial rash and numbing tiredness. She also underwent a surgical procedure to drain the fluid around her lung; when the fluid kept coming back, a thoracic surgeon eventually placed a small, permanent tube in her chest, which she could drain whenever fluid accumulated and interfered with her breathing. Three weeks after the delivery, she was admitted to the hospital with severe shortness of breath from a pulmonary embolisma blood clot in an artery to the lungs, which is dangerous but not uncommon in cancer patients. She was started on a blood thinner. Then test results showed that her tumor cells did not have the mutation that Tarceva targets. When Marcoux told Sara that the drug wasnt going to work, she had an almost violent physical reaction to the news, bolting to the bathroom in mid-discussion with a sudden bout of diarrhea. Dr. Marcoux recommended a different, more standard chemotherapy, with two drugs called carboplatin and paclitaxel. But the paclitaxel triggered an extreme, nearly overwhelming allergic response, so he switched her to a regimen of carboplatin plus gemcitabine. Response rates, he said, were still very good for patients on this therapy. She spent the remainder of the summer at home, with Vivian and her husband and her parents, who had moved in to help. She loved being a mother. Between chemotherapy cycles, she began trying to get her life back. Then, in October, a CT scan showed that the tumor deposits in her left lung and chest and lymph nodes had grown substantially. The chemotherapy had failed. She was switched to a drug called pemetrexed. Studies found that it could produce markedly longer survival in some patients. In reality, however, only a small percentage of patients gained very much. On average, the drug extended survival by only two monthsfrom eleven months to thirteen monthsand that was in patients who, unlike Sara, had responded to first-line chemotherapy. She worked hard to take the setbacks and side effects in stride. She was upbeat by nature, and she managed to maintain her optimism. Little by little, however, she grew sickerincreasingly exhausted and short of breath. By November, she didnt have the wind to walk the length of the hallway from the parking garage to Marcouxs office; Rich had to push her in a wheelchair. A few days before Thanksgiving, she had another CT scan, which showed that the pemetrexedher third drug regimenwasnt working, either. The lung cancer had spread: from the left chest to the right; to the liver; to the lining of her abdomen; and to her spine. Time was running out. This is the moment in Saras story that poses a fundamental question for everyone living in the era of modern medicine: What do we want Sara and her doctors to do now? Or, to put it another way, if you were the one who had metastatic canceror, for that matter, a similarly advanced case of emphysema or congestive heart failurewhat would you want your doctors to do? The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the countrys long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit. Spending on a disease like cancer tends to follow a particular pattern. There are high initial costs as the cancer is treated, and then, if all goes well, these costs taper off. Medical spending for a breast-cancer survivor, for instance, averaged an estimated fifty-four thousand dollars in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy. For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the endto an average of sixty-three thousand dollars during the last six months of life with an incurable breast cancer. Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop. The subject seems to reach national awareness mainly as a question of who should win when the expensive decisions are made: the insurers and the taxpayers footing the bill or the patient battling for his or her life. Budget hawks urge us to face the fact that we cant afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But theyre debating the wrong question. The failure of our system of medical care for people facing the end of their life runs much deeper. To see this, you have to get close enough to grapple with the way decisions about care are actually made. Recently, while seeing a patient in an intensive-care unit at my hospital, I stopped to talk with the critical-care physician on duty, someone Id known since college. Im running a warehouse for the dying, she said bleakly. Out of the ten patients in her unit, she said, only two were likely to leave the hospital for any length of time. More typical was an almost eighty-year-old woman at the end of her life, with irreversible congestive heart failure, who was in the I.C.U. for the second time in three weeks, drugged to oblivion and tubed in most natural orifices and a few artificial ones. Or the seventy-year-old with a cancer that had metastasized to her lungs and bone, and a fungal pneumonia that arises only in the final phase of the illness. She had chosen to forgo treatment, but her oncologist pushed her to change her mind, and she was put on a ventilator and antibiotics. Another woman, in her eighties, with end-stage respiratory and kidney failure, had been in the unit for two weeks. Her husband had died after a long illness, with a feeding tube and a tracheotomy, and she had mentioned that she didnt want to die that way. But her children couldnt let her go, and asked to proceed with the placement of various devices: a permanent tracheotomy, a feeding tube, and a dialysis catheter. So now she just lay there tethered to her pumps, drifting in and out of consciousness. Almost all these patients had known, for some time, that they had a terminal condition. Yet theyalong with their families and doctorswere unprepared for the final stage. We are having more conversation now about what patients want for the end of their life, by far, than they have had in all their lives to this point, my friend said. The problem is thats way too late. In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending ones final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or Its O.K. or Im sorry or I love you. People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this systems expense. It is how we can build a health-care system that will actually help dying patients achieve whats most important to them at the end of their lives. For all but our most recent history, dying was typically a brief process. Whether the cause was childhood infection, difficult childbirth, heart attack, or pneumonia, the interval between recognizing that you had a life-threatening ailment and death was often just a matter of days or weeks. Consider how our Presidents died before the modern era. George Washington developed a throat infection at home on December 13, 1799, that killed him by the next evening. John Quincy Adams, Millard Fillmore, and Andrew Johnson all succumbed to strokes, and died within two days. Rutherford Hayes had a heart attack and died three days later. Some deadly illnesses took a longer course: James Monroe and Andrew Jackson died from the months-long consumptive process of what appears to have been tuberculosis; Ulysses Grants oral cancer took a year to kill him; and James Madison was bedridden for two years before dying of old age. But, as the end-of-life researcher Joanne Lynn has observed, people usually experienced life-threatening illness the way they experienced bad weatheras something that struck with little warningand you either got through it or you didnt. Dying used to be accompanied by a prescribed set of customs. Guides to ars moriendi, the art of dying, were extraordinarily popular; a 1415 medieval Latin text was reprinted in more than a hundred editions across Europe. Reaffirming ones faith, repenting ones sins, and letting go of ones worldly possessions and desires were crucial, and the guides provided families with prayers and questions for the dying in order to put them in the right frame of mind during their final hours. Last words came to hold a particular place of reverence. These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable conditionadvanced cancer, progressive organ failure (usually the heart, kidney, or liver), or the multiple debilities of very old age. In all such cases, death is certain, but the timing isnt. So everyone struggles with this uncertaintywith how, and when, to accept that the battle is lost. As for last words, they hardly seem to exist anymore. Technology sustains our organs until we are well past the point of awareness and coherence. Besides, how do you attend to the thoughts and concerns of the dying when medicine has made it almost impossible to be sure who the dying even are? Is someone with terminal cancer, dementia, incurable congestive heart failure dying, exactly? I once cared for a woman in her sixties who had severe chest and abdominal pain from a bowel obstruction that had ruptured her colon, caused her to have a heart attack, and put her into septic shock and renal failure. I performed an emergency operation to remove the damaged length of colon and give her a colostomy. A cardiologist stented her coronary arteries. We put her on dialysis, a ventilator, and intravenous feeding, and stabilized her. After a couple of weeks, though, it was clear that she was not going to get much better. The septic shock had left her with heart and respiratory failure as well as dry gangrene of her foot, which would have to be amputated. She had a large, open abdominal wound with leaking bowel contents, which would require twice-a-day cleaning and dressing for weeks in order to heal. She would not be able to eat. She would need a tracheotomy. Her kidneys were gone, and she would have to spend three days a week on a dialysis machine for the rest of her life. She was unmarried and without children. So I sat with her sisters in the I.C.U. family room to talk about whether we should proceed with the amputation and the tracheotomy. Is she dying? one of the sisters asked me. I didnt know how to answer the question. I wasnt even sure what the word dying meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die. One Friday morning this spring, I went on patient rounds with Sarah Creed, a nurse with the hospice service that my hospital system operates. I didnt know much about hospice. I knew that it specialized in providing comfort care for the terminally ill, sometimes in special facilities, though nowadays usually at home. I knew that, in order for a patient of mine to be eligible, I had to write a note certifying that he or she had a life expectancy of less than six months. And I knew few patients who had chosen it, except maybe in their very last few days, because they had to sign a form indicating that they understood their disease was incurable and that they were giving up on medical care to stop it. The picture I had of hospice was of a morphine drip. It was not of this brown-haired and blue-eyed former I.C.U. nurse with a stethoscope, knocking on Lee Coxs door on a quiet street in Bostons Mattapan neighborhood. Hi, Lee, Creed said when she entered the house. Hi, Sarah, Cox said. She was seventy-two years old. Shed had several years of declining health due to congestive heart failure from a heart attack and pulmonary fibrosis, a progressive and irreversible lung disease. Doctors tried slowing the disease with steroids, but they didnt work. She had cycled in and out of the hospital, each time in worse shape. Ultimately, she accepted hospice care and moved in with her niece for support. She was dependent on oxygen, and unable to do the most ordinary tasks. Just answering the door, with her thirty-foot length of oxygen tubing trailing after her, had left her winded. She stood resting for a moment, her lips pursed and her chest heaving. Creed took Coxs arm gently as we walked to the kitchen to sit down, asking her how she had been doing. Then she asked a series of questions, targeting issues that tend to arise in patients with terminal illness. Did Cox have pain? How was her appetite, thirst, sleeping? Any trouble with confusion, anxiety, or restlessness? Had her shortness of breath grown worse? Was there chest pain or heart palpitations? Abdominal discomfort? Trouble with bowel movements or urination or walking? She did have some new troubles. When she walked from the bedroom to the bathroom, she said, it now took at least five minutes to catch her breath, and that frightened her. She was also getting chest pain. Creed pulled a stethoscope and a blood-pressure cuff from her medical bag. Coxs blood pressure was acceptable, but her heart rate was high. Creed listened to her heart, which had a normal rhythm, and to her lungs, hearing the fine crackles of her pulmonary fibrosis but also a new wheeze. Her ankles were swollen with fluid, and when Creed asked for her pillbox she saw that Cox was out of her heart medication. She asked to see Coxs oxygen equipment. The liquid-oxygen cylinder at the foot of the neatly made bed was filled and working properly. The nebulizer equipment for her inhaler treatments, however, was broken. Given the lack of heart medication and inhaler treatments, it was no wonder that she had worsened. Creed called Coxs pharmacy to confirm that her refills had been waiting, and had her arrange for her niece to pick up the medicine when she came home from work. Creed also called the nebulizer supplier for same-day emergency service. She then chatted with Cox in the kitchen for a few minutes. Her spirits were low. Creed took her hand. Everything was going to be all right, she said. She reminded her about the good days shed hadthe previous weekend, for example, when shed been able to go out with her portable oxygen cylinder to shop with her niece and get her hair colored. I asked Cox about her previous life. She had made radios in a Boston factory. She and her husband had two children, and several grandchildren. When I asked her why she had chosen hospice care, she looked downcast. The lung doctor and heart doctor said they couldnt help me anymore, she said. Creed glared at me. My questions had made Cox sad again. Its good to have my niece and her husband helping to watch me every day, she said. But its not my home. I feel like Im in the way. Creed gave her a hug before we left, and one last reminder. What do you do if you have chest pain that doesnt go away? she asked. Take a nitro, Cox said, referring to the nitroglycerin pill that she can slip under her tongue. And? Call you. Wheres the number? She pointed to the twenty-four-hour hospice call number that was taped beside her phone. Outside, I confessed that I was confused by what Creed was doing. A lot of it seemed to be about extending Coxs life. Wasnt the goal of hospice to let nature take its course? Thats not the goal, Creed said. The difference between standard medical care and hospice is not the difference between treating and doing nothing, she explained. The difference was in your priorities. In ordinary medicine, the goal is to extend life. Well sacrifice the quality of your existence nowby performing surgery, providing chemotherapy, putting you in intensive carefor the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focussing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists arent much concerned about whether that makes peoples lives longer or shorter. Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer. When Cox was transferred to hospice care, her doctors thought that she wouldnt live much longer than a few weeks. With the supportive hospice therapy she received, she had already lived for a year. Creed enters peoples lives at a strange momentwhen they have understood that they have a fatal illness but have not necessarily acknowledged that they are dying. Id say only about a quarter have accepted their fate when they come into hospice, she said. When she first encounters her patients, many feel that they have simply been abandoned by their doctors. Ninety-nine per cent understand theyre dying, but one hundred per cent hope theyre not, she says. They still want to beat their disease. The initial visit is always tricky, but she has found ways to smooth things over. A nurse has five seconds to make a patient like you and trust you. Its in the whole way you present yourself. I do not come in saying, Im so sorry. Instead, its: Im the hospice nurse, and heres what I have to offer you to make your life better. And I know we dont have a lot of time to waste. That was how she started with Dave Galloway, whom we visited after leaving Lee Coxs home. He was forty-two years old. He and his wife, Sharon, were both Boston firefighters. They had a three-year-old daughter. He had pancreatic cancer, which had spread; his upper abdomen was now solid with tumor. During the past few months, the pain had become unbearable at times, and he was admitted to the hospital several times for pain crises. At his most recent admission, about a week earlier, it was found that the tumor had perforated his intestine. There wasnt even a temporary fix for this problem. The medical team started him on intravenous nutrition and offered him a choice between going to the intensive-care unit and going home with hospice. He chose to go home. I wish wed gotten involved sooner, Creed told me. When she and the hospices supervising doctor, Dr. JoAnne Nowak, evaluated Galloway upon his arrival at home, he appeared to have only a few days left. His eyes were hollow. His breathing was labored. Fluid swelled his entire lower body to the point that his skin blistered and wept. He was almost delirious with abdominal pain. Sometimes I just want to curl up with a good book and burn it. They got to work. They set up a pain pump with a button that let him dispense higher doses of narcotic than he had been allowed. They arranged for an electric hospital bed, so that he could sleep with his back raised. They also taught Sharon how to keep Dave clean, protect his skin from breakdown, and handle the crises to come. Creed told me that part of her job is to take the measure of a patients family, and Sharon struck her as unusually capable. She was determined to take care of her husband to the end, and, perhaps because she was a firefighter, she had the resilience and the competence to do so. She did not want to hire a private-duty nurse. She handled everything, from the I.V. lines and the bed linens to orchestrating family members to lend a hand when she needed help. Creed arranged for a specialized comfort pack to be delivered by FedEx and stored in a mini-refrigerator by Daves bed. It contained a dose of morphine for breakthrough pain or shortness of breath, Ativan for anxiety attacks, Compazine for nausea, Haldol for delirium, Tylenol for fever, and atropine for drying up the upper-airway rattle that people can get in their final hours. If any such problem developed, Sharon was instructed to call the twenty-four-hour hospice nurse on duty, who would provide instructions about which rescue medications to use and, if necessary, come out to help. Dave and Sharon were finally able to sleep through the night at home. Creed or another nurse came to see him every day, sometimes twice a day; three times that week, Sharon used the emergency hospice line to help her deal with Daves pain crises or hallucinations. After a few days, they were even able to go out to a favorite restaurant; he wasnt hungry, but they enjoyed just being there, and the memories it stirred. The hardest part so far, Sharon said, was deciding to forgo the two-litre intravenous feedings that Dave had been receiving each day. Although they were his only source of calories, the hospice staff encouraged discontinuing them because his body did not seem to be absorbing the nutrition. The infusion of sugars, proteins, and fats made the painful swelling of his skin and his shortness of breath worseand for what? The mantra was live for now. Sharon had balked, for fear that shed be starving him. The night before our visit, however, she and Dave decided to try going without the infusion. By morning, the swelling was markedly reduced. He could move more, and with less discomfort. He also began to eat a few morsels of food, just for the taste of it, and that made Sharon feel better about the decision. When we arrived, Dave was making his way back to bed after a shower, his arm around his wifes shoulders and his slippered feet taking one shuffling step at a time. Theres nothing he likes better than a long hot shower, Sharon said. Hed live in the shower if he could. Dave sat on the edge of his bed in fresh pajamas, catching his breath, and then Creed spoke to him as his daughter, Ashlee, ran in and out of the room in her beaded pigtails, depositing stuffed animals in her dads lap. Hows your pain on a scale of one to ten? Creed asked. A six, he said. Did you hit the pump? He didnt answer for a moment. Im reluctant, he admitted. Why? Creed asked. It feels like defeat, he said. Defeat? I dont want to become a drug addict, he explained. I dont want to need this. Creed got down on her knees in front of him. Dave, I dont know anyone who can manage this kind of pain without the medication, she said. Its not defeat. Youve got a beautiful wife and daughter, and youre not going to be able to enjoy them with the pain. Youre right about that, he said, looking at Ashlee as she gave him a little horse. And he pressed the button. Dave Galloway died one week laterat home, at peace, and surrounded by family. A week after that, Lee Cox died, too. But, as if to show just how resistant to formula human lives are, Cox had never reconciled herself to the incurability of her illnesses. So when her family found her in cardiac arrest one morning they followed her wishes and called 911 instead of the hospice service. The emergency medical technicians and firefighters and police rushed in. They pulled off her clothes and pumped her chest, put a tube in her airway and forced oxygen into her lungs, and tried to see if they could shock her heart back. But such efforts rarely succeed with terminal patients, and they did not succeed with her. Hospice has tried to offer a new ideal for how we die. Although not everyone has embraced its rituals, those who have are helping to negotiate an ars moriendi for our age. But doing so represents a strugglenot only against suffering but also against the seemingly unstoppable momentum of medical treatment. Just before Thanksgiving of 2007, Sara Monopoli, her husband, Rich, and her mother, Dawn Thomas, met with Dr. Marcoux to discuss the options she had left. By this point, Sara had undergone three rounds of chemotherapy with limited, if any, effect. Perhaps Marcoux could have discussed what she most wanted as death neared and how best to achieve those wishes. But the signal he got from Sara and her family was that they wished to talk only about the next treatment options. They did not want to talk about dying. Recently, I spoke to Saras husband and her parents. Sara knew that her disease was incurable, they pointed out. The week after she was given the diagnosis and delivered her baby, she spelled out her wishes for Vivians upbringing after she was gone. She had told her family on several occasions that she did not want to die in the hospital. She wanted to spend her final moments peacefully at home. But the prospect that those moments might be coming soon, that there might be no way to slow the disease, was not something she or I wanted to discuss, her mother said. Her father, Gary, and her twin sister, Emily, still held out hope for a cure. The doctors simply werent looking hard enough, they felt. I just couldnt believe there wasnt something, Gary said. For Rich, the experience of Saras illness had been disorienting: We had a baby. We were young. And this was so shocking and so odd. We never discussed stopping treatment. Marcoux took the measure of the room. With almost two decades of experience treating lung cancer, he had been through many of these conversations. He has a calm, reassuring air and a native Minnesotans tendency to avoid confrontation or overintimacy. He tries to be scientific about decisions. I know that the vast majority of my patients are going to die of their disease, he told me. The data show that, after failure of second-line chemotherapy, lung-cancer patients rarely get any added survival time from further treatments and often suffer significant side effects. But he, too, has his hopes. He told them that, at some point, supportive care was an option for them to think about. But, he went on, there were also experimental therapies. He told them about several that were under trial. The most promising was a Pfizer drug that targeted one of the mutations found in her cancers cells. Sara and her family instantly pinned their hopes on it. The drug was so new that it didnt even have a name, just a numberPF0231006and this made it all the more enticing. There were a few hovering issues, including the fact that the scientists didnt yet know the safe dose. The drug was only in a Phase I trialthat is, a trial designed to determine the toxicity of a range of doses, not whether the drug worked. Furthermore, a test of the drug against her cancer cells in a petri dish showed no effect. But Marcoux didnt think that these were decisive obstaclesjust negatives. The critical problem was that the rules of the trial excluded Sara because of the pulmonary embolism she had developed that summer. To enroll, she would need to wait two months, in order to get far enough past the episode. In the meantime, he suggested trying another conventional chemotherapy, called Navelbine. Sara began the treatment the Monday after Thanksgiving. Its worth pausing to consider what had just happened. Step by step, Sara ended up on a fourth round of chemotherapy, one with a minuscule likelihood of altering the course of her disease and a great likelihood of causing debilitating side effects. An opportunity to prepare for the inevitable was forgone. And it all happened because of an assuredly normal circumstance: a patient and family unready to confront the reality of her disease. I asked Marcoux what he hopes to accomplish for terminal lung-cancer patients when they first come to see him. Im thinking, Can I get them a pretty good year or two out of this? he said. Those are my expectations. For me, the long tail for a patient like her is

Does the introduction announce the layout of the rest of the paper? What lets you know this?Has the.

Does the introduction announce the layout of the rest of the paper? What lets you know this?Has the writer made you want to learn more? Why or why not?Body:
Underline the topic sentences on the paper. Is there a clear connection between each of the paragraphs and the thesis? If not, where do you see problems?Are points substantiated with evidence? Is the evidence pertinent, reliable, and/or verifiable?Are paragraphs unified (exploring only one idea)? Point out paragraphs that lack unity.Are paragraphs developed (is there enough information in each paragraph)? Point out paragraphs that lack development.Are there in-text citations in MLA style if sources are used?Conclusion:
Is the thesis restated (and, if possible, reworded)? Is the length of the conclusion appropriate? Does it need to be tightened or expanded? Why?What strategies does the paper use to close the discussion (ex: brief summary of points, recommendation)?Are you interested in learning more about (has the author made the topic relevant to you)? Why or why not?Overall Recommendations:
Are there issues related to grammar and punctuation that the author needs to address? If so, what are they?Have sources been quoted correctly, if sources were used?Is the Works Cited formatted correctly, if sources were used?List three strengths (what you feel the author did well) and three weakness (areas that need improvement) of the paper.
PAPER 1
A Bittersweet Hour
The Story of an Hour, written by Kate Chopin displays a common struggle that most women internally encountered during the eighteen-hundreds. There were very few rights that women had during this time period. Chopin often writes based off the feelings of women who are not happy with their love life. As mentioned in the cultural context, Chopin was married in a state where the men were favored both legally and physically. Women were powerless compared to their male counterparts. Due to the lack of respect and authority, married women were imprisoned in marriages. Their body and possessions belonged to their husband. Divorce was uncommon, so everything was done to remain as happy as possible. Even if that means ignoring the dark, negative thoughts that come to mind. Women fall into a pattern of learned helplessness. This means that no matter what intervention is utilized, the same outcome will occur. Therefore, trying to prevent something becomes useless. The term learned helplessness is used to refer to any behavioral or physiological consequence of exposure to an adverse event that is produced not by the event itself but by the organisms lack of behavioral control over the event (Batsching et al. 1). There is no surprise, given the time of events, that Louis Mallard reacted the way she did. Freedom was a new element of her life that she was not used to. Although the story only describes one hour into a womans life, the audience experiences the feelings of what thousands of women during this time period were dealing with.
The plot of the story is linear, narrated in the third person omniscient point of view. This gives the audience the advantage of knowing about the train wreck before Mrs. Mallard is aware and the immediate actions after her death. This also allows the audience to understand Mrs. Mallards actions more. If the story were to be told in first person, Mrs. Mallard may come across as a selfish, spoiled wife. The layout is displayed in chronological order. The storys exposition begins by informing the audience about Mrs. Mallards heart condition. Although, the condition is not named specifically, it is understood that heart breaking news must be delivered to her in a delicate manner. Josephine, Mrs. Mallards sister, is the one in charge of presenting the terrible news. Richards, Mr. Millards friend, was the one who had first discovered the news, but as also there for support.
The main conflict in the story is that a train crash killed Mr. Mallard. It is the job of Richards and Josephine to strategically break the news to the new widow. A difficult task considering that the news can affect her beloved sister physically. Josephine internally fears that the knowledge of her husband passing could kill Mrs. Mallard. As skillfully as possible, given the circumstances, Josephine relays the tragic news to her sister. Grief overcomes Mrs. Mallard immediately as she begins to cry. However, she soon excuses herself to go upstairs alone to ponder the situation. This is where to real climax is reach. Mrs. Mallard is overwhelmed with a growing feeling deep side that is overcoming her. After coming to an abrupt realization, she says, Free, free, free! A reaction the audience was not expecting. The realization that her personal freedom is redeemed is too much for her to stand. The deep feeling that would come across as depression, ends up being utter excitement.
Her pulse beats fast, and the coursing blood warmed and relaxed every inch of her body. This line is foreshadowing her death. An excessive amount of happiness is just as capable of effecting her heart condition as an anxiety attack. Her mind is racing with what is yet to be. A future full of bliss would energize to most dull person. Her reaction to this is completely understandable. She is coming from a marriage she was forced to forever endure. Her feelings are justified when she explains that she will weep about the passing, but the future is so bright that the focus is elsewhere.
A symbol is shown as Mrs. Mallard confesses, internally, her intermitted love for her husband by saying:
And yet she loved him- sometimes. Often she had not. What did it matter! What could love, the unsolved mystery, count for in the face of this possession of self-assertion which she suddenly recognized as the strongest impulse of her being
This symbolizes the distorted way people viewed love in the eight-teen hundreds. Mrs. Mallard confesses that she did not understand the love she had for her husband. That is because it was not love. It was misconstrued with enjoying the presence of another individual, or that absence of loneness. Mrs. Mallards life was not hers to rule, and the idea of a companion kept her sane.
This misunderstanding can still be recognized in todays society in emotionally abusive relationships. Over time, emotional abuse can be as powerful a control tactic as physical abuse (Reed and Enright 805). Women are viewed as something that needs to be constantly under control.
The tone in the beginning of the story is stressful with hints of sadness, transforms to a radiant happiness and closes as ironic. As the story is introduce, the readers are aware of a terrible tragedy. To tell a wife her husband has passed should be a stressful situation. Once the news is delivered grief follows along promptly. After much thinking our main character realizes her newfound freedom. That is when her happiness becomes infectious. It is short live as the irony hits. After praying to live a long life after hearing the news, she passes away. The situational irony does not end there either, because her husband never did die in the crash. This irony is similar to the way women views their lives. Women want to be free so much, but freedom is always out of their grasp. Never truly getting to taste the sweet victory we call freedom.
Figures of speech are implemented in this brief story. Personification is mention when the narrator says, Into this she sank, pressed down by a physical exhaustion that haunted her body and seemed to reach into her soul. Physical exhaustion obviously cannot physically actually haunt her or reach into her soul, but it amplifies the intensity of the feeling she is experiencing. Personification is also mentioned later on Mrs. Mallards fancy is running wild due to the thoughts she was having. The narrator uses a metaphor to describe to amount of joy Mrs. Mallard is in by saying, No; she was drinking in a very elixir of life through that open window. These figures of speech help explain the extent to which the characters are feeling, but the imagery does that as well. Throughout the story, the narrator describes things in fine detail. From Mrs. Mallards face to the life shown outside the window. That piece of detail appeals to the audiences sense of sight. Giving the readers the opportunity to visualize what Mrs. Mallard may look like and what she is seeing outside the second story window.
Louis Mallard is our main character and protagonist. She is closely observed, described and followed throughout this piece of literature. She is a round, dynamic character because of the way she develops throughout the story. Initially she is viewed by the audience for being the stereotypical wife that is about to get news that will paralyze her mentally for the rest of her life. Besides the brief grief she displays, she surprises us with her abundance of happiness. The audience picks up on the critical thinking that she goes through to realize this sense of happiness. In a way, it builds the readers respect for this woman for being so strong. The readers perspective of Mrs. Mallard changes from our trademark version of a wife in the eight-teen hundreds to a liberated woman who finally gets a taste of freedom. Josephine is a flat, static character because she remains the same throughout the context. She is only worried about the well-being of her sister and will remain as part of her support system. Richards is another flat, static character. He is the individual who recognized Brently Mallards name on the list of people killed from the wreck. Potentially, he is to blame for Mrs. Mallards death. It is in the end that we figured out Mr. Mallard was not killed. The odds that someone had the same name as Brently Mallard are slim, yet, they add a dramatic twist. Brently Mallard, only mentioned at the end of the story, is a supporting character. Nothing is known about his character besides that he has a wife. Once the news got out that she died of joy, his reaction is would be unknown for the reader. That is because we have not been able to observe Mr. Mallard at all.
Many themes can be taken away from this short story, but freedom from oppression is the one that stands out the most. Anyone educated on the eight-teen hundreds understands that women were viewed as incompetent. When married, everything that a woman is, becomes her husbands. Womens rights were not even a thing to people back then. A womens job was to cook, clean and to give her husband whatever he wants. Even if it meant their body. Women were stuck in this culture where men were these superior figures who owned them. With little that was able to be done or said, women felt hopeless. Forget about divorce, because that was not positively looked at during that time frame either. Most women would find themselves feeling as Mrs. Mallard did if they were to lose their significant other. How is it possible that all these members of society who come to realize this unequal division of power usually follow and accept the rules of the dominant people (Nociar 78). Society ushers people to act a certain way, so women tended to not go against the grain with this issue. Women would rather sugar coat their lives than to be shunned or viewed terribly. With that being said, Mrs. Mallards reaction was not so surprising. However, to the viewer will interpret her actions based off of the stereotypical responses. To be a woman who can live for herself was something of a dream. Although that may be our reality today, those women did not have that luxury. These ideas will make female readers will reflect and appreciate the luxuries that they have. Works Cited
Reed, Gayle L., and Robert D. Enright. The Effects of Forgiveness Therapy on Depression,
Anxiety, and Posttraumatic Stress For Women After Spousal Emotional Abuse. Journal
of Consulting and Clinical Psychology, vol. 74, no. 5, Oct. 2006, pp. 920929.Nociar, Tomas. Glasberg, Davita Silfen – Shannon, Deric: Political Sociology: Opression,
Resistance and the State. Slovensk Politologick Revue, vol. 12, no. 1, 2012, pp. 7780.
Batsching, Sophie, et al. Inescapable Stress Changes Walking Behavior in Flies – Learned
Helplessness Revisited. Scholarly Journals, vol. 11, no. 11, Nov. 2016, pp. 116.
PAPER 2 Short Story Essay In the short story Gryphon by Charles Baxter, the author writes a short story from the perspective of a fourth-grade student at Garfield-Murray Elementary School in Five Oaks, Michigan. Throughout the course of this story the narrator, who is a fourth-grade student at Garfield-Murray Elementary School, talks about the experience of a normal day in his classroom and the interactions that he has with other students and his teacher as well. The story begins in the narrators classroom, and its where the majority of the story takes place. During a normal day of class, the narrators teacher, whose name is Mr. Hibler, begins to feel ill, and starts to cough. This prompts a substitute to be called in to instruct the narrators class in his absence the next day. The setting in the town where the school is located contributes to many of the things that happen in the story, including one of the most notable and important factors of the story, which is the appearance of a substitute teacher called in to teach the narrators class. The substitute, whose name is Ms. Ferenczi, introduces herself to the entire class, and she leaves a strange initial impression on the class of fourth graders with her eccentric clothing and overall character. Ms. Ferenczi is a woman whose parents are Hungarian and French, and she came to the U.S. because of unknown circumstances. The main characters that are introduced in the beginning of the story play crucial roles to the development of the plot to the story, as well as the progression of the ideas of other characters in regards to how they view the strange new substitute that is taking the place of their normal teacher.
Throughout the length of Gryphon, the story is told through the viewpoint of a fourth-grade student at an elementary school in Michigan, where he is in the process of learning more about Egyptian culture and technology. During one class, his teacher becomes sick with a cold, and he is forced to take a few days off, giving way to a substitute; someone who is difficult to come across in the small community that the narrator lives. The next day, a new strange substitute arrives as cover for the narrators sick teacher. The plot of the story is advanced with every day the substitute, whose name is Ms. Ferenczi, spent teaching the students in the narrators class. Ms. Ferenczi would tell the children stories such as why the Egyptians built the pyramids, and also about how death isnt the end of life and everything itself, but the beginning of another existence for human existence. The narrator in this portion of the story is an observer that offers his thoughts on the things that the strange Ms. Ferenczi would say in class. For the most part, the narrator believes that many of the things that Ms. Ferenczi says are not true, and makes a point of this by jokingly convincing one of his classmates on the bus ride home that a lot of the things Ms. Ferenczi says are true. After Ms. Ferenczi leaves, the other students that are in the narrators class tell their teacher Mr. Hibler about all of the things that Ms. Ferenczi told them about during his absence, but he is indifferent, as most of the work that the students had to complete had been finished. Later on, Ms. Ferenczi returns as a substitute for Mr. Hiblers class, and she is as odd and eccentric as she was before. On this occasion, however, she has a surprise for the students of Mr. Hiblers class, and it is in the form of her telling each of the children their fortunes for the future. Each of the students in the class line up to have Ms. Ferenczi tell their fortune, and some of them are either pleased or frightened by what they are told. In particular, one of the children was told by the substitute that they would soon die, and this made him upset enough to report her to the principal, effectively getting rid of Ms. Ferenczi as their teacher. This demonstrates that the main basis for the plot in the story was a new substitute covering for the narrators sick teacher for a couple of days, and eventually figuring out that the substitute was a very strange women that would have to leave as a result of this.
In the story Gryphon, each one of the main characters in the progress themselves based upon their actions. The narrator is introduced at the start of the story as a normal fourth-grade boy that is simply going through another ordinary day of school. These general characteristics are maintained through the entire story, but eventually, the narrator starts to change how he views things around him and starts to question things that he views as normal occurrences. These changes are in response to others around him, and the largest influencer of these changes is the new substitute that covers the narrators normal teacher, Mr. Hibler. The new substitute, whose name is Ms. Ferenczi, introduces herself to the class of fourth-graders that the narrator is in. Ms. Ferenczi is dress in clothes with vibrant colors and she wears gaudy, gold rimmed glasses. She is an older woman that has some lines running down her face that the narrator says are similar to Pinocchio. During the beginning of the story, the narrator says that Ms. Ferenczi speaks with a strange accent and behaves in a flamboyant manner. The reason that Ms. Ferenczi speaks with a strange accent is because her parents were from Hungary and France, and they came to the U.S. for unknown reasons, according to her. Through the rest of the story, Ms. Ferenczi teaches the students based off of the lesson plan that Mr. Hibler had left for the substitute that covered for him. Despite this, Ms. Ferenczi begins to drift away from the lesson plan, and tells the students stories about things that are slightly related to what they were discussing in class. Ms. Ferenczi told the children about Egyptian myths and she even claimed that she had seen even seen a mythical creature called a Gryphon, which is a hybrid between an eagle and a lion. This caught the interest of all the students in the classroom, including the narrator of the story. They all wondered about all the marvelous stories that Ms. Ferenczi had told them during the time that she was there substitute. The narrator also questioned how legitimate all of the claims that his substitute had made, showing that he had become inquisitive during the time that Ms. Ferenczi had been his substitute. He also knew that some of the things that she had said had a grain of truth to them such as the story about flesh eating plants, which he had seen in a television show about nature. After Ms. Ferenczi leaves, the narrator wonders whether any of the things that she ever said were actually true. This continues up until the strange substitute actually returns to their class, and leaves after she predicted that one of the students would soon meet his end. The events at the end of this story demonstrate the character of both the narrator and of the substitute, Ms. Ferenczi.
The setting in the story Gryphon takes place entirely in a fictional small town called Five Oaks in Michigan. The narrator explains that the town is small enough that nearly everyone in the town knows each other, and that newcomers usually stand out amongst everyone else. This is why when the narrators teacher comes down with a cold, he also mentions that a substitute is hard to come by on such short notice in a small town. A substitute is found for the next day of class, and it is a new female substitute. The students recognize that she is new to town, despite only being in the fourth grade. The substitute explains that she is new in town as well, and that she is of Hungarian and French descent. The impact that the setting has upon the narrator and everyone else in the classroom is that since they live in rural place with a small population, residents that are new are usually very few and far between. This demonstrates that the diversity that is present throughout the entire United States reaches every corner of the country and in every state, county, and city. The effect that this has is shown with the presence of the substitute in the town of Five Oaks.
In conclusion, throughout the short story Gryphon, the main characters progress the ideas and thoughts of other characters that are developed in regards to the substitute, who is also one of the main characters in the story. The plot of the story mainly circles around the narrator that describes the strange substitute, Ms. Ferenczi, being his teacher for several days, and eventually leaving and not coming back after she tells a student that his death was in the immediate future. The characters in the story, which consists of two main characters, which are the narrator and the substitute, Ms. Ferenczi. Both the narrator and the substitute develop over the course of the story in regards to their personalities, interactions with others, and other personal traits as well. The setting throughout the story remains consistently in the same town of Five Oaks in Michigan. Despites this, the setting has a noticeable impact on the emotions that the narrator, students, and other teachers in the story because of the substitutes background, which is something that is unusual and uncommon to the people of the small town. The reason being that everyone in the town knows each other, and having a new resident that is as strange as Ms. Ferenczi is odd even for the children in the fourth-grade class that she is substituting for. These are some of the characteristics from the short story Gryphon in regards to characters, plot, and setting.
PAPER 3 A Bittersweet Hour
The Story of an Hour, written by Kate Chopin displays a common struggle that most women internally encountered during the eighteen-hundreds. There were very few rights that women had during this time period. Chopin often writes based off the feelings of women who are not happy with their love life. As mentioned in the cultural context, Chopin was married in a state where the men were favored both legally and physically. Women were powerless compared to their male counterparts. Due to the lack of respect and authority, married women were imprisoned in marriages. Their body and possessions belonged to their husband. Divorce was uncommon, so everything was done to remain as happy as possible. Even if that means ignoring the dark, negative thoughts that come to mind. Women fall into a pattern of learned helplessness. This means that no matter what intervention is utilized, the same outcome will occur. Therefore, trying to prevent something becomes useless. The term learned helplessness is used to refer to any behavioral or physiological consequence of exposure to an adverse event that is produced not by the event itself but by the organisms lack of behavioral control over the event (Batsching et al. 1). There is no surprise, given the time of events, that Louis Mallard reacted the way she did. Freedom was a new element of her life that she was not used to. Although the story only describes one hour into a womans life, the audience experiences the feelings of what thousands of women during this time period were dealing with.
The plot of the story is linear, narrated in the third person omniscient point of view. This gives the audience the advantage of knowing about the train wreck before Mrs. Mallard is aware and the immediate actions after her death. This also allows the audience to understand Mrs. Mallards actions more. If the story were to be told in first person, Mrs. Mallard may come across as a selfish, spoiled wife. The layout is displayed in chronological order. The storys exposition begins by informing the audience about Mrs. Mallards heart condition. Although, the condition is not named specifically, it is understood that heart breaking news must be delivered to her in a delicate manner. Josephine, Mrs. Mallards sister, is the one in charge of presenting the terrible news. Richards, Mr. Millards friend, was the one who had first discovered the news, but as also there for support.
The main conflict in the story is that a train crash killed Mr. Mallard. It is the job of Richards and Josephine to strategically break the news to the new widow. A difficult task considering that the news can affect her beloved sister physically. Josephine internally fears that the knowledge of her husband passing could kill Mrs. Mallard. As skillfully as possible, given the circumstances, Josephine relays the tragic news to her sister. Grief overcomes Mrs. Mallard immediately as she begins to cry. However, she soon excuses herself to go upstairs alone to ponder the situation. This is where to real climax is reach. Mrs. Mallard is overwhelmed with a growing feeling deep side that is overcoming her. After coming to an abrupt realization, she says, Free, free, free! A reaction the audience was not expecting. The realization that her personal freedom is redeemed is too much for her to stand. The deep feeling that would come across as depression, ends up being utter excitement.
Her pulse beats fast, and the coursing blood warmed and relaxed every inch of her body. This line is foreshadowing her death. An excessive amount of happiness is just as capable of effecting her heart condition as an anxiety attack. Her mind is racing with what is yet to be. A future full of bliss would energize to most dull person. Her reaction to this is completely understandable. She is coming from a marriage she was forced to forever endure. Her feelings are justified when she explains that she will weep about the passing, but the future is so bright that the focus is elsewhere.
A symbol is shown as Mrs. Mallard confesses, internally, her intermitted love for her husband by saying:
And yet she loved him- sometimes. Often she had not. What did it matter! What could love, the unsolved mystery, count for in the face of this possession of self-assertion which she suddenly recognized as the strongest impulse of her being
This symbolizes the distorted way people viewed love in the eight-teen hundreds. Mrs. Mallard confesses that she did not understand the love she had for her husband. That is because it was not love. It was misconstrued with enjoying the presence of another individual, or that absence of loneness. Mrs. Mallards life was not hers to rule, and the idea of a companion kept her sane.
This misunderstanding can still be recognized in todays society in emotionally abusive relationships. Over time, emotional abuse can be as powerful a control tactic as physical abuse (Reed and Enright 805). Women are viewed as something that needs to be constantly under control.
The tone in the beginning of the story is stressful with hints of sadness, transforms to a radiant happiness and closes as ironic. As the story is introduce, the readers are aware of a terrible tragedy. To tell a wife her husband has passed should be a stressful situation. Once the news is delivered grief follows along promptly. After much thinking our main character realizes her newfound freedom. That is when her happiness becomes infectious. It is short live as the irony hits. After praying to live a long life after hearing the news, she passes away. The situational irony does not end there either, because her husband never did die in the crash. This irony is similar to the way women views their lives. Women want to be free so much, but freedom is always out of their grasp. Never truly getting to taste the sweet victory we call freedom.
Figures of speech are implemented in this brief story. Personification is mention when the narrator says, Into this she sank, pressed down by a physical exhaustion that haunted her body and seemed to reach into her soul. Physical exhaustion obviously cannot physically actually haunt her or reach into her soul, but it amplifies the intensity of the feeling she is experiencing. Personification is also mentioned later on Mrs. Mallards fancy is running wild due to the thoughts she was having. The narrator uses a metaphor to describe to amount of joy Mrs. Mallard is in by saying, No; she was drinking in a very elixir of life through that open window. These figures of speech help explain the extent to which the characters are feeling, but the imagery does that as well. Throughout the story, the narrator describes things in fine detail. From Mrs. Mallards face to the life shown outside the window. That piece of detail appeals to the audiences sense of sight. Giving the readers the opportunity to visualize what Mrs. Mallard may look like and what she is seeing outside the second story window.
Louis Mallard is our main character and protagonist. She is closely observed, described and followed throughout this piece of literature. She is a round, dynamic character because of the way she develops throughout the story. Initially she is viewed by the audience for being the stereotypical wife that is about to get news that will paralyze her mentally for the rest of her life. Besides the brief grief she displays, she surprises us with her abundance of happiness. The audience picks up on the critical thinking that she goes through to realize this sense of happiness. In a way, it builds the readers respect for this woman for being so strong. The readers perspective of Mrs. Mallard changes from our trademark version of a wife in the eight-teen hundreds to a liberated woman who finally gets a taste of freedom. Josephine is a flat, static character because she remains the same throughout the context. She is only worried about the well-being of her sister and will remain as part of her support system. Richards is another flat, static character. He is the individual who recognized Brently Mallards name on the list of people killed from the wreck. Potentially, he is to blame for Mrs. Mallards death. It is in the end that we figured out Mr. Mallard was not killed. The odds that someone had the same name as Brently Mallard are slim, yet, they add a dramatic twist. Brently Mallard, only mentioned at the end of the story, is a supporting character. Nothing is known about his character besides that he has a wife. Once the news got out that she died of joy, his reaction is would be unknown for the reader. That is because we have not been able to observe Mr. Mallard at all.
Many themes can be taken away from this short story, but freedom from oppression is the one that stands out the most. Anyone educated on the eight-teen hundreds understands that women were viewed as incompetent. When married, everything that a woman is, becomes her husbands. Womens rights were not even a thing to people back then. A womens job was to cook, clean and to give her husband whatever he wants. Even if it meant their body. Women were stuck in this culture where men were these superior figures who owned them. With little that was able to be done or said, women felt hopeless. Forget about divorce, because that was not positively looked at during that time frame either. Most women would find themselves feeling as Mrs. Mallard did if they were to lose their significant other. How is it possible that all these members of society who come to realize this unequal division of power usually follow and accept the rules of the dominant people (Nociar 78). Society ushers people to act a certain way, so women tended to not go against the grain with this issue. Women would rather sugar coat their lives than to be shunned or viewed terribly. With that being said, Mrs. Mallards reaction was not so surprising. However, to the viewer will interpret her actions based off of the stereotypical responses. To be a woman who can live for herself was something of a dream. Although that may be our reality today, those women did not have that luxury. These ideas will make female readers will reflect and appreciate the luxuries that they have.
Works Cited
Reed, Gayle L., and Robert D. Enright. The Effects of Forgiveness Therapy on Depression,
Anxiety, and Posttraumatic Stress For Women After Spousal Emotional Abuse. Journal
of Consulting and Clinical Psychology, vol. 74, no. 5, Oct. 2006, pp. 920929.Nociar, Tomas. Glasberg, Davita Silfen – Shannon, Deric: Political Sociology: Opression,
Resistance and the State. Slovensk Politologick Revue, vol. 12, no. 1, 2012, pp. 7

Does the introduction announce the layout of the rest of the paper? What lets you know this?Has the.

Does the introduction announce the layout of the rest of the paper? What lets you know this?Has the writer made you want to learn more? Why or why not?Body:
Underline the topic sentences on the paper. Is there a clear connection between each of the paragraphs and the thesis? If not, where do you see problems?Are points substantiated with evidence? Is the evidence pertinent, reliable, and/or verifiable?Are paragraphs unified (exploring only one idea)? Point out paragraphs that lack unity.Are paragraphs developed (is there enough information in each paragraph)? Point out paragraphs that lack development.Are there in-text citations in MLA style if sources are used?Conclusion:
Is the thesis restated (and, if possible, reworded)? Is the length of the conclusion appropriate? Does it need to be tightened or expanded? Why?What strategies does the paper use to close the discussion (ex: brief summary of points, recommendation)?Are you interested in learning more about (has the author made the topic relevant to you)? Why or why not?Overall Recommendations:
Are there issues related to grammar and punctuation that the author needs to address? If so, what are they?Have sources been quoted correctly, if sources were used?Is the Works Cited formatted correctly, if sources were used?List three strengths (what you feel the author did well) and three weakness (areas that need improvement) of the paper.
PAPER 1
A Bittersweet Hour
The Story of an Hour, written by Kate Chopin displays a common struggle that most women internally encountered during the eighteen-hundreds. There were very few rights that women had during this time period. Chopin often writes based off the feelings of women who are not happy with their love life. As mentioned in the cultural context, Chopin was married in a state where the men were favored both legally and physically. Women were powerless compared to their male counterparts. Due to the lack of respect and authority, married women were imprisoned in marriages. Their body and possessions belonged to their husband. Divorce was uncommon, so everything was done to remain as happy as possible. Even if that means ignoring the dark, negative thoughts that come to mind. Women fall into a pattern of learned helplessness. This means that no matter what intervention is utilized, the same outcome will occur. Therefore, trying to prevent something becomes useless. The term learned helplessness is used to refer to any behavioral or physiological consequence of exposure to an adverse event that is produced not by the event itself but by the organisms lack of behavioral control over the event (Batsching et al. 1). There is no surprise, given the time of events, that Louis Mallard reacted the way she did. Freedom was a new element of her life that she was not used to. Although the story only describes one hour into a womans life, the audience experiences the feelings of what thousands of women during this time period were dealing with.
The plot of the story is linear, narrated in the third person omniscient point of view. This gives the audience the advantage of knowing about the train wreck before Mrs. Mallard is aware and the immediate actions after her death. This also allows the audience to understand Mrs. Mallards actions more. If the story were to be told in first person, Mrs. Mallard may come across as a selfish, spoiled wife. The layout is displayed in chronological order. The storys exposition begins by informing the audience about Mrs. Mallards heart condition. Although, the condition is not named specifically, it is understood that heart breaking news must be delivered to her in a delicate manner. Josephine, Mrs. Mallards sister, is the one in charge of presenting the terrible news. Richards, Mr. Millards friend, was the one who had first discovered the news, but as also there for support.
The main conflict in the story is that a train crash killed Mr. Mallard. It is the job of Richards and Josephine to strategically break the news to the new widow. A difficult task considering that the news can affect her beloved sister physically. Josephine internally fears that the knowledge of her husband passing could kill Mrs. Mallard. As skillfully as possible, given the circumstances, Josephine relays the tragic news to her sister. Grief overcomes Mrs. Mallard immediately as she begins to cry. However, she soon excuses herself to go upstairs alone to ponder the situation. This is where to real climax is reach. Mrs. Mallard is overwhelmed with a growing feeling deep side that is overcoming her. After coming to an abrupt realization, she says, Free, free, free! A reaction the audience was not expecting. The realization that her personal freedom is redeemed is too much for her to stand. The deep feeling that would come across as depression, ends up being utter excitement.
Her pulse beats fast, and the coursing blood warmed and relaxed every inch of her body. This line is foreshadowing her death. An excessive amount of happiness is just as capable of effecting her heart condition as an anxiety attack. Her mind is racing with what is yet to be. A future full of bliss would energize to most dull person. Her reaction to this is completely understandable. She is coming from a marriage she was forced to forever endure. Her feelings are justified when she explains that she will weep about the passing, but the future is so bright that the focus is elsewhere.
A symbol is shown as Mrs. Mallard confesses, internally, her intermitted love for her husband by saying:
And yet she loved him- sometimes. Often she had not. What did it matter! What could love, the unsolved mystery, count for in the face of this possession of self-assertion which she suddenly recognized as the strongest impulse of her being
This symbolizes the distorted way people viewed love in the eight-teen hundreds. Mrs. Mallard confesses that she did not understand the love she had for her husband. That is because it was not love. It was misconstrued with enjoying the presence of another individual, or that absence of loneness. Mrs. Mallards life was not hers to rule, and the idea of a companion kept her sane.
This misunderstanding can still be recognized in todays society in emotionally abusive relationships. Over time, emotional abuse can be as powerful a control tactic as physical abuse (Reed and Enright 805). Women are viewed as something that needs to be constantly under control.
The tone in the beginning of the story is stressful with hints of sadness, transforms to a radiant happiness and closes as ironic. As the story is introduce, the readers are aware of a terrible tragedy. To tell a wife her husband has passed should be a stressful situation. Once the news is delivered grief follows along promptly. After much thinking our main character realizes her newfound freedom. That is when her happiness becomes infectious. It is short live as the irony hits. After praying to live a long life after hearing the news, she passes away. The situational irony does not end there either, because her husband never did die in the crash. This irony is similar to the way women views their lives. Women want to be free so much, but freedom is always out of their grasp. Never truly getting to taste the sweet victory we call freedom.
Figures of speech are implemented in this brief story. Personification is mention when the narrator says, Into this she sank, pressed down by a physical exhaustion that haunted her body and seemed to reach into her soul. Physical exhaustion obviously cannot physically actually haunt her or reach into her soul, but it amplifies the intensity of the feeling she is experiencing. Personification is also mentioned later on Mrs. Mallards fancy is running wild due to the thoughts she was having. The narrator uses a metaphor to describe to amount of joy Mrs. Mallard is in by saying, No; she was drinking in a very elixir of life through that open window. These figures of speech help explain the extent to which the characters are feeling, but the imagery does that as well. Throughout the story, the narrator describes things in fine detail. From Mrs. Mallards face to the life shown outside the window. That piece of detail appeals to the audiences sense of sight. Giving the readers the opportunity to visualize what Mrs. Mallard may look like and what she is seeing outside the second story window.
Louis Mallard is our main character and protagonist. She is closely observed, described and followed throughout this piece of literature. She is a round, dynamic character because of the way she develops throughout the story. Initially she is viewed by the audience for being the stereotypical wife that is about to get news that will paralyze her mentally for the rest of her life. Besides the brief grief she displays, she surprises us with her abundance of happiness. The audience picks up on the critical thinking that she goes through to realize this sense of happiness. In a way, it builds the readers respect for this woman for being so strong. The readers perspective of Mrs. Mallard changes from our trademark version of a wife in the eight-teen hundreds to a liberated woman who finally gets a taste of freedom. Josephine is a flat, static character because she remains the same throughout the context. She is only worried about the well-being of her sister and will remain as part of her support system. Richards is another flat, static character. He is the individual who recognized Brently Mallards name on the list of people killed from the wreck. Potentially, he is to blame for Mrs. Mallards death. It is in the end that we figured out Mr. Mallard was not killed. The odds that someone had the same name as Brently Mallard are slim, yet, they add a dramatic twist. Brently Mallard, only mentioned at the end of the story, is a supporting character. Nothing is known about his character besides that he has a wife. Once the news got out that she died of joy, his reaction is would be unknown for the reader. That is because we have not been able to observe Mr. Mallard at all.
Many themes can be taken away from this short story, but freedom from oppression is the one that stands out the most. Anyone educated on the eight-teen hundreds understands that women were viewed as incompetent. When married, everything that a woman is, becomes her husbands. Womens rights were not even a thing to people back then. A womens job was to cook, clean and to give her husband whatever he wants. Even if it meant their body. Women were stuck in this culture where men were these superior figures who owned them. With little that was able to be done or said, women felt hopeless. Forget about divorce, because that was not positively looked at during that time frame either. Most women would find themselves feeling as Mrs. Mallard did if they were to lose their significant other. How is it possible that all these members of society who come to realize this unequal division of power usually follow and accept the rules of the dominant people (Nociar 78). Society ushers people to act a certain way, so women tended to not go against the grain with this issue. Women would rather sugar coat their lives than to be shunned or viewed terribly. With that being said, Mrs. Mallards reaction was not so surprising. However, to the viewer will interpret her actions based off of the stereotypical responses. To be a woman who can live for herself was something of a dream. Although that may be our reality today, those women did not have that luxury. These ideas will make female readers will reflect and appreciate the luxuries that they have. Works Cited
Reed, Gayle L., and Robert D. Enright. The Effects of Forgiveness Therapy on Depression,
Anxiety, and Posttraumatic Stress For Women After Spousal Emotional Abuse. Journal
of Consulting and Clinical Psychology, vol. 74, no. 5, Oct. 2006, pp. 920929.Nociar, Tomas. Glasberg, Davita Silfen – Shannon, Deric: Political Sociology: Opression,
Resistance and the State. Slovensk Politologick Revue, vol. 12, no. 1, 2012, pp. 7780.
Batsching, Sophie, et al. Inescapable Stress Changes Walking Behavior in Flies – Learned
Helplessness Revisited. Scholarly Journals, vol. 11, no. 11, Nov. 2016, pp. 116.
PAPER 2 Short Story Essay In the short story Gryphon by Charles Baxter, the author writes a short story from the perspective of a fourth-grade student at Garfield-Murray Elementary School in Five Oaks, Michigan. Throughout the course of this story the narrator, who is a fourth-grade student at Garfield-Murray Elementary School, talks about the experience of a normal day in his classroom and the interactions that he has with other students and his teacher as well. The story begins in the narrators classroom, and its where the majority of the story takes place. During a normal day of class, the narrators teacher, whose name is Mr. Hibler, begins to feel ill, and starts to cough. This prompts a substitute to be called in to instruct the narrators class in his absence the next day. The setting in the town where the school is located contributes to many of the things that happen in the story, including one of the most notable and important factors of the story, which is the appearance of a substitute teacher called in to teach the narrators class. The substitute, whose name is Ms. Ferenczi, introduces herself to the entire class, and she leaves a strange initial impression on the class of fourth graders with her eccentric clothing and overall character. Ms. Ferenczi is a woman whose parents are Hungarian and French, and she came to the U.S. because of unknown circumstances. The main characters that are introduced in the beginning of the story play crucial roles to the development of the plot to the story, as well as the progression of the ideas of other characters in regards to how they view the strange new substitute that is taking the place of their normal teacher.
Throughout the length of Gryphon, the story is told through the viewpoint of a fourth-grade student at an elementary school in Michigan, where he is in the process of learning more about Egyptian culture and technology. During one class, his teacher becomes sick with a cold, and he is forced to take a few days off, giving way to a substitute; someone who is difficult to come across in the small community that the narrator lives. The next day, a new strange substitute arrives as cover for the narrators sick teacher. The plot of the story is advanced with every day the substitute, whose name is Ms. Ferenczi, spent teaching the students in the narrators class. Ms. Ferenczi would tell the children stories such as why the Egyptians built the pyramids, and also about how death isnt the end of life and everything itself, but the beginning of another existence for human existence. The narrator in this portion of the story is an observer that offers his thoughts on the things that the strange Ms. Ferenczi would say in class. For the most part, the narrator believes that many of the things that Ms. Ferenczi says are not true, and makes a point of this by jokingly convincing one of his classmates on the bus ride home that a lot of the things Ms. Ferenczi says are true. After Ms. Ferenczi leaves, the other students that are in the narrators class tell their teacher Mr. Hibler about all of the things that Ms. Ferenczi told them about during his absence, but he is indifferent, as most of the work that the students had to complete had been finished. Later on, Ms. Ferenczi returns as a substitute for Mr. Hiblers class, and she is as odd and eccentric as she was before. On this occasion, however, she has a surprise for the students of Mr. Hiblers class, and it is in the form of her telling each of the children their fortunes for the future. Each of the students in the class line up to have Ms. Ferenczi tell their fortune, and some of them are either pleased or frightened by what they are told. In particular, one of the children was told by the substitute that they would soon die, and this made him upset enough to report her to the principal, effectively getting rid of Ms. Ferenczi as their teacher. This demonstrates that the main basis for the plot in the story was a new substitute covering for the narrators sick teacher for a couple of days, and eventually figuring out that the substitute was a very strange women that would have to leave as a result of this.
In the story Gryphon, each one of the main characters in the progress themselves based upon their actions. The narrator is introduced at the start of the story as a normal fourth-grade boy that is simply going through another ordinary day of school. These general characteristics are maintained through the entire story, but eventually, the narrator starts to change how he views things around him and starts to question things that he views as normal occurrences. These changes are in response to others around him, and the largest influencer of these changes is the new substitute that covers the narrators normal teacher, Mr. Hibler. The new substitute, whose name is Ms. Ferenczi, introduces herself to the class of fourth-graders that the narrator is in. Ms. Ferenczi is dress in clothes with vibrant colors and she wears gaudy, gold rimmed glasses. She is an older woman that has some lines running down her face that the narrator says are similar to Pinocchio. During the beginning of the story, the narrator says that Ms. Ferenczi speaks with a strange accent and behaves in a flamboyant manner. The reason that Ms. Ferenczi speaks with a strange accent is because her parents were from Hungary and France, and they came to the U.S. for unknown reasons, according to her. Through the rest of the story, Ms. Ferenczi teaches the students based off of the lesson plan that Mr. Hibler had left for the substitute that covered for him. Despite this, Ms. Ferenczi begins to drift away from the lesson plan, and tells the students stories about things that are slightly related to what they were discussing in class. Ms. Ferenczi told the children about Egyptian myths and she even claimed that she had seen even seen a mythical creature called a Gryphon, which is a hybrid between an eagle and a lion. This caught the interest of all the students in the classroom, including the narrator of the story. They all wondered about all the marvelous stories that Ms. Ferenczi had told them during the time that she was there substitute. The narrator also questioned how legitimate all of the claims that his substitute had made, showing that he had become inquisitive during the time that Ms. Ferenczi had been his substitute. He also knew that some of the things that she had said had a grain of truth to them such as the story about flesh eating plants, which he had seen in a television show about nature. After Ms. Ferenczi leaves, the narrator wonders whether any of the things that she ever said were actually true. This continues up until the strange substitute actually returns to their class, and leaves after she predicted that one of the students would soon meet his end. The events at the end of this story demonstrate the character of both the narrator and of the substitute, Ms. Ferenczi.
The setting in the story Gryphon takes place entirely in a fictional small town called Five Oaks in Michigan. The narrator explains that the town is small enough that nearly everyone in the town knows each other, and that newcomers usually stand out amongst everyone else. This is why when the narrators teacher comes down with a cold, he also mentions that a substitute is hard to come by on such short notice in a small town. A substitute is found for the next day of class, and it is a new female substitute. The students recognize that she is new to town, despite only being in the fourth grade. The substitute explains that she is new in town as well, and that she is of Hungarian and French descent. The impact that the setting has upon the narrator and everyone else in the classroom is that since they live in rural place with a small population, residents that are new are usually very few and far between. This demonstrates that the diversity that is present throughout the entire United States reaches every corner of the country and in every state, county, and city. The effect that this has is shown with the presence of the substitute in the town of Five Oaks.
In conclusion, throughout the short story Gryphon, the main characters progress the ideas and thoughts of other characters that are developed in regards to the substitute, who is also one of the main characters in the story. The plot of the story mainly circles around the narrator that describes the strange substitute, Ms. Ferenczi, being his teacher for several days, and eventually leaving and not coming back after she tells a student that his death was in the immediate future. The characters in the story, which consists of two main characters, which are the narrator and the substitute, Ms. Ferenczi. Both the narrator and the substitute develop over the course of the story in regards to their personalities, interactions with others, and other personal traits as well. The setting throughout the story remains consistently in the same town of Five Oaks in Michigan. Despites this, the setting has a noticeable impact on the emotions that the narrator, students, and other teachers in the story because of the substitutes background, which is something that is unusual and uncommon to the people of the small town. The reason being that everyone in the town knows each other, and having a new resident that is as strange as Ms. Ferenczi is odd even for the children in the fourth-grade class that she is substituting for. These are some of the characteristics from the short story Gryphon in regards to characters, plot, and setting.
PAPER 3 A Bittersweet Hour
The Story of an Hour, written by Kate Chopin displays a common struggle that most women internally encountered during the eighteen-hundreds. There were very few rights that women had during this time period. Chopin often writes based off the feelings of women who are not happy with their love life. As mentioned in the cultural context, Chopin was married in a state where the men were favored both legally and physically. Women were powerless compared to their male counterparts. Due to the lack of respect and authority, married women were imprisoned in marriages. Their body and possessions belonged to their husband. Divorce was uncommon, so everything was done to remain as happy as possible. Even if that means ignoring the dark, negative thoughts that come to mind. Women fall into a pattern of learned helplessness. This means that no matter what intervention is utilized, the same outcome will occur. Therefore, trying to prevent something becomes useless. The term learned helplessness is used to refer to any behavioral or physiological consequence of exposure to an adverse event that is produced not by the event itself but by the organisms lack of behavioral control over the event (Batsching et al. 1). There is no surprise, given the time of events, that Louis Mallard reacted the way she did. Freedom was a new element of her life that she was not used to. Although the story only describes one hour into a womans life, the audience experiences the feelings of what thousands of women during this time period were dealing with.
The plot of the story is linear, narrated in the third person omniscient point of view. This gives the audience the advantage of knowing about the train wreck before Mrs. Mallard is aware and the immediate actions after her death. This also allows the audience to understand Mrs. Mallards actions more. If the story were to be told in first person, Mrs. Mallard may come across as a selfish, spoiled wife. The layout is displayed in chronological order. The storys exposition begins by informing the audience about Mrs. Mallards heart condition. Although, the condition is not named specifically, it is understood that heart breaking news must be delivered to her in a delicate manner. Josephine, Mrs. Mallards sister, is the one in charge of presenting the terrible news. Richards, Mr. Millards friend, was the one who had first discovered the news, but as also there for support.
The main conflict in the story is that a train crash killed Mr. Mallard. It is the job of Richards and Josephine to strategically break the news to the new widow. A difficult task considering that the news can affect her beloved sister physically. Josephine internally fears that the knowledge of her husband passing could kill Mrs. Mallard. As skillfully as possible, given the circumstances, Josephine relays the tragic news to her sister. Grief overcomes Mrs. Mallard immediately as she begins to cry. However, she soon excuses herself to go upstairs alone to ponder the situation. This is where to real climax is reach. Mrs. Mallard is overwhelmed with a growing feeling deep side that is overcoming her. After coming to an abrupt realization, she says, Free, free, free! A reaction the audience was not expecting. The realization that her personal freedom is redeemed is too much for her to stand. The deep feeling that would come across as depression, ends up being utter excitement.
Her pulse beats fast, and the coursing blood warmed and relaxed every inch of her body. This line is foreshadowing her death. An excessive amount of happiness is just as capable of effecting her heart condition as an anxiety attack. Her mind is racing with what is yet to be. A future full of bliss would energize to most dull person. Her reaction to this is completely understandable. She is coming from a marriage she was forced to forever endure. Her feelings are justified when she explains that she will weep about the passing, but the future is so bright that the focus is elsewhere.
A symbol is shown as Mrs. Mallard confesses, internally, her intermitted love for her husband by saying:
And yet she loved him- sometimes. Often she had not. What did it matter! What could love, the unsolved mystery, count for in the face of this possession of self-assertion which she suddenly recognized as the strongest impulse of her being
This symbolizes the distorted way people viewed love in the eight-teen hundreds. Mrs. Mallard confesses that she did not understand the love she had for her husband. That is because it was not love. It was misconstrued with enjoying the presence of another individual, or that absence of loneness. Mrs. Mallards life was not hers to rule, and the idea of a companion kept her sane.
This misunderstanding can still be recognized in todays society in emotionally abusive relationships. Over time, emotional abuse can be as powerful a control tactic as physical abuse (Reed and Enright 805). Women are viewed as something that needs to be constantly under control.
The tone in the beginning of the story is stressful with hints of sadness, transforms to a radiant happiness and closes as ironic. As the story is introduce, the readers are aware of a terrible tragedy. To tell a wife her husband has passed should be a stressful situation. Once the news is delivered grief follows along promptly. After much thinking our main character realizes her newfound freedom. That is when her happiness becomes infectious. It is short live as the irony hits. After praying to live a long life after hearing the news, she passes away. The situational irony does not end there either, because her husband never did die in the crash. This irony is similar to the way women views their lives. Women want to be free so much, but freedom is always out of their grasp. Never truly getting to taste the sweet victory we call freedom.
Figures of speech are implemented in this brief story. Personification is mention when the narrator says, Into this she sank, pressed down by a physical exhaustion that haunted her body and seemed to reach into her soul. Physical exhaustion obviously cannot physically actually haunt her or reach into her soul, but it amplifies the intensity of the feeling she is experiencing. Personification is also mentioned later on Mrs. Mallards fancy is running wild due to the thoughts she was having. The narrator uses a metaphor to describe to amount of joy Mrs. Mallard is in by saying, No; she was drinking in a very elixir of life through that open window. These figures of speech help explain the extent to which the characters are feeling, but the imagery does that as well. Throughout the story, the narrator describes things in fine detail. From Mrs. Mallards face to the life shown outside the window. That piece of detail appeals to the audiences sense of sight. Giving the readers the opportunity to visualize what Mrs. Mallard may look like and what she is seeing outside the second story window.
Louis Mallard is our main character and protagonist. She is closely observed, described and followed throughout this piece of literature. She is a round, dynamic character because of the way she develops throughout the story. Initially she is viewed by the audience for being the stereotypical wife that is about to get news that will paralyze her mentally for the rest of her life. Besides the brief grief she displays, she surprises us with her abundance of happiness. The audience picks up on the critical thinking that she goes through to realize this sense of happiness. In a way, it builds the readers respect for this woman for being so strong. The readers perspective of Mrs. Mallard changes from our trademark version of a wife in the eight-teen hundreds to a liberated woman who finally gets a taste of freedom. Josephine is a flat, static character because she remains the same throughout the context. She is only worried about the well-being of her sister and will remain as part of her support system. Richards is another flat, static character. He is the individual who recognized Brently Mallards name on the list of people killed from the wreck. Potentially, he is to blame for Mrs. Mallards death. It is in the end that we figured out Mr. Mallard was not killed. The odds that someone had the same name as Brently Mallard are slim, yet, they add a dramatic twist. Brently Mallard, only mentioned at the end of the story, is a supporting character. Nothing is known about his character besides that he has a wife. Once the news got out that she died of joy, his reaction is would be unknown for the reader. That is because we have not been able to observe Mr. Mallard at all.
Many themes can be taken away from this short story, but freedom from oppression is the one that stands out the most. Anyone educated on the eight-teen hundreds understands that women were viewed as incompetent. When married, everything that a woman is, becomes her husbands. Womens rights were not even a thing to people back then. A womens job was to cook, clean and to give her husband whatever he wants. Even if it meant their body. Women were stuck in this culture where men were these superior figures who owned them. With little that was able to be done or said, women felt hopeless. Forget about divorce, because that was not positively looked at during that time frame either. Most women would find themselves feeling as Mrs. Mallard did if they were to lose their significant other. How is it possible that all these members of society who come to realize this unequal division of power usually follow and accept the rules of the dominant people (Nociar 78). Society ushers people to act a certain way, so women tended to not go against the grain with this issue. Women would rather sugar coat their lives than to be shunned or viewed terribly. With that being said, Mrs. Mallards reaction was not so surprising. However, to the viewer will interpret her actions based off of the stereotypical responses. To be a woman who can live for herself was something of a dream. Although that may be our reality today, those women did not have that luxury. These ideas will make female readers will reflect and appreciate the luxuries that they have.
Works Cited
Reed, Gayle L., and Robert D. Enright. The Effects of Forgiveness Therapy on Depression,
Anxiety, and Posttraumatic Stress For Women After Spousal Emotional Abuse. Journal
of Consulting and Clinical Psychology, vol. 74, no. 5, Oct. 2006, pp. 920929.Nociar, Tomas. Glasberg, Davita Silfen – Shannon, Deric: Political Sociology: Opression,
Resistance and the State. Slovensk Politologick Revue, vol. 12, no. 1, 2012, pp. 7

Does the introduction announce the layout of the rest of the paper? What lets you know this?Has the.

Does the introduction announce the layout of the rest of the paper? What lets you know this?Has the writer made you want to learn more? Why or why not?Body:
Underline the topic sentences on the paper. Is there a clear connection between each of the paragraphs and the thesis? If not, where do you see problems?Are points substantiated with evidence? Is the evidence pertinent, reliable, and/or verifiable?Are paragraphs unified (exploring only one idea)? Point out paragraphs that lack unity.Are paragraphs developed (is there enough information in each paragraph)? Point out paragraphs that lack development.Are there in-text citations in MLA style if sources are used?Conclusion:
Is the thesis restated (and, if possible, reworded)? Is the length of the conclusion appropriate? Does it need to be tightened or expanded? Why?What strategies does the paper use to close the discussion (ex: brief summary of points, recommendation)?Are you interested in learning more about (has the author made the topic relevant to you)? Why or why not?Overall Recommendations:
Are there issues related to grammar and punctuation that the author needs to address? If so, what are they?Have sources been quoted correctly, if sources were used?Is the Works Cited formatted correctly, if sources were used?List three strengths (what you feel the author did well) and three weakness (areas that need improvement) of the paper.
PAPER 1
A Bittersweet Hour
The Story of an Hour, written by Kate Chopin displays a common struggle that most women internally encountered during the eighteen-hundreds. There were very few rights that women had during this time period. Chopin often writes based off the feelings of women who are not happy with their love life. As mentioned in the cultural context, Chopin was married in a state where the men were favored both legally and physically. Women were powerless compared to their male counterparts. Due to the lack of respect and authority, married women were imprisoned in marriages. Their body and possessions belonged to their husband. Divorce was uncommon, so everything was done to remain as happy as possible. Even if that means ignoring the dark, negative thoughts that come to mind. Women fall into a pattern of learned helplessness. This means that no matter what intervention is utilized, the same outcome will occur. Therefore, trying to prevent something becomes useless. The term learned helplessness is used to refer to any behavioral or physiological consequence of exposure to an adverse event that is produced not by the event itself but by the organisms lack of behavioral control over the event (Batsching et al. 1). There is no surprise, given the time of events, that Louis Mallard reacted the way she did. Freedom was a new element of her life that she was not used to. Although the story only describes one hour into a womans life, the audience experiences the feelings of what thousands of women during this time period were dealing with.
The plot of the story is linear, narrated in the third person omniscient point of view. This gives the audience the advantage of knowing about the train wreck before Mrs. Mallard is aware and the immediate actions after her death. This also allows the audience to understand Mrs. Mallards actions more. If the story were to be told in first person, Mrs. Mallard may come across as a selfish, spoiled wife. The layout is displayed in chronological order. The storys exposition begins by informing the audience about Mrs. Mallards heart condition. Although, the condition is not named specifically, it is understood that heart breaking news must be delivered to her in a delicate manner. Josephine, Mrs. Mallards sister, is the one in charge of presenting the terrible news. Richards, Mr. Millards friend, was the one who had first discovered the news, but as also there for support.
The main conflict in the story is that a train crash killed Mr. Mallard. It is the job of Richards and Josephine to strategically break the news to the new widow. A difficult task considering that the news can affect her beloved sister physically. Josephine internally fears that the knowledge of her husband passing could kill Mrs. Mallard. As skillfully as possible, given the circumstances, Josephine relays the tragic news to her sister. Grief overcomes Mrs. Mallard immediately as she begins to cry. However, she soon excuses herself to go upstairs alone to ponder the situation. This is where to real climax is reach. Mrs. Mallard is overwhelmed with a growing feeling deep side that is overcoming her. After coming to an abrupt realization, she says, Free, free, free! A reaction the audience was not expecting. The realization that her personal freedom is redeemed is too much for her to stand. The deep feeling that would come across as depression, ends up being utter excitement.
Her pulse beats fast, and the coursing blood warmed and relaxed every inch of her body. This line is foreshadowing her death. An excessive amount of happiness is just as capable of effecting her heart condition as an anxiety attack. Her mind is racing with what is yet to be. A future full of bliss would energize to most dull person. Her reaction to this is completely understandable. She is coming from a marriage she was forced to forever endure. Her feelings are justified when she explains that she will weep about the passing, but the future is so bright that the focus is elsewhere.
A symbol is shown as Mrs. Mallard confesses, internally, her intermitted love for her husband by saying:
And yet she loved him- sometimes. Often she had not. What did it matter! What could love, the unsolved mystery, count for in the face of this possession of self-assertion which she suddenly recognized as the strongest impulse of her being
This symbolizes the distorted way people viewed love in the eight-teen hundreds. Mrs. Mallard confesses that she did not understand the love she had for her husband. That is because it was not love. It was misconstrued with enjoying the presence of another individual, or that absence of loneness. Mrs. Mallards life was not hers to rule, and the idea of a companion kept her sane.
This misunderstanding can still be recognized in todays society in emotionally abusive relationships. Over time, emotional abuse can be as powerful a control tactic as physical abuse (Reed and Enright 805). Women are viewed as something that needs to be constantly under control.
The tone in the beginning of the story is stressful with hints of sadness, transforms to a radiant happiness and closes as ironic. As the story is introduce, the readers are aware of a terrible tragedy. To tell a wife her husband has passed should be a stressful situation. Once the news is delivered grief follows along promptly. After much thinking our main character realizes her newfound freedom. That is when her happiness becomes infectious. It is short live as the irony hits. After praying to live a long life after hearing the news, she passes away. The situational irony does not end there either, because her husband never did die in the crash. This irony is similar to the way women views their lives. Women want to be free so much, but freedom is always out of their grasp. Never truly getting to taste the sweet victory we call freedom.
Figures of speech are implemented in this brief story. Personification is mention when the narrator says, Into this she sank, pressed down by a physical exhaustion that haunted her body and seemed to reach into her soul. Physical exhaustion obviously cannot physically actually haunt her or reach into her soul, but it amplifies the intensity of the feeling she is experiencing. Personification is also mentioned later on Mrs. Mallards fancy is running wild due to the thoughts she was having. The narrator uses a metaphor to describe to amount of joy Mrs. Mallard is in by saying, No; she was drinking in a very elixir of life through that open window. These figures of speech help explain the extent to which the characters are feeling, but the imagery does that as well. Throughout the story, the narrator describes things in fine detail. From Mrs. Mallards face to the life shown outside the window. That piece of detail appeals to the audiences sense of sight. Giving the readers the opportunity to visualize what Mrs. Mallard may look like and what she is seeing outside the second story window.
Louis Mallard is our main character and protagonist. She is closely observed, described and followed throughout this piece of literature. She is a round, dynamic character because of the way she develops throughout the story. Initially she is viewed by the audience for being the stereotypical wife that is about to get news that will paralyze her mentally for the rest of her life. Besides the brief grief she displays, she surprises us with her abundance of happiness. The audience picks up on the critical thinking that she goes through to realize this sense of happiness. In a way, it builds the readers respect for this woman for being so strong. The readers perspective of Mrs. Mallard changes from our trademark version of a wife in the eight-teen hundreds to a liberated woman who finally gets a taste of freedom. Josephine is a flat, static character because she remains the same throughout the context. She is only worried about the well-being of her sister and will remain as part of her support system. Richards is another flat, static character. He is the individual who recognized Brently Mallards name on the list of people killed from the wreck. Potentially, he is to blame for Mrs. Mallards death. It is in the end that we figured out Mr. Mallard was not killed. The odds that someone had the same name as Brently Mallard are slim, yet, they add a dramatic twist. Brently Mallard, only mentioned at the end of the story, is a supporting character. Nothing is known about his character besides that he has a wife. Once the news got out that she died of joy, his reaction is would be unknown for the reader. That is because we have not been able to observe Mr. Mallard at all.
Many themes can be taken away from this short story, but freedom from oppression is the one that stands out the most. Anyone educated on the eight-teen hundreds understands that women were viewed as incompetent. When married, everything that a woman is, becomes her husbands. Womens rights were not even a thing to people back then. A womens job was to cook, clean and to give her husband whatever he wants. Even if it meant their body. Women were stuck in this culture where men were these superior figures who owned them. With little that was able to be done or said, women felt hopeless. Forget about divorce, because that was not positively looked at during that time frame either. Most women would find themselves feeling as Mrs. Mallard did if they were to lose their significant other. How is it possible that all these members of society who come to realize this unequal division of power usually follow and accept the rules of the dominant people (Nociar 78). Society ushers people to act a certain way, so women tended to not go against the grain with this issue. Women would rather sugar coat their lives than to be shunned or viewed terribly. With that being said, Mrs. Mallards reaction was not so surprising. However, to the viewer will interpret her actions based off of the stereotypical responses. To be a woman who can live for herself was something of a dream. Although that may be our reality today, those women did not have that luxury. These ideas will make female readers will reflect and appreciate the luxuries that they have. Works Cited
Reed, Gayle L., and Robert D. Enright. The Effects of Forgiveness Therapy on Depression,
Anxiety, and Posttraumatic Stress For Women After Spousal Emotional Abuse. Journal
of Consulting and Clinical Psychology, vol. 74, no. 5, Oct. 2006, pp. 920929.Nociar, Tomas. Glasberg, Davita Silfen – Shannon, Deric: Political Sociology: Opression,
Resistance and the State. Slovensk Politologick Revue, vol. 12, no. 1, 2012, pp. 7780.
Batsching, Sophie, et al. Inescapable Stress Changes Walking Behavior in Flies – Learned
Helplessness Revisited. Scholarly Journals, vol. 11, no. 11, Nov. 2016, pp. 116.
PAPER 2 Short Story Essay In the short story Gryphon by Charles Baxter, the author writes a short story from the perspective of a fourth-grade student at Garfield-Murray Elementary School in Five Oaks, Michigan. Throughout the course of this story the narrator, who is a fourth-grade student at Garfield-Murray Elementary School, talks about the experience of a normal day in his classroom and the interactions that he has with other students and his teacher as well. The story begins in the narrators classroom, and its where the majority of the story takes place. During a normal day of class, the narrators teacher, whose name is Mr. Hibler, begins to feel ill, and starts to cough. This prompts a substitute to be called in to instruct the narrators class in his absence the next day. The setting in the town where the school is located contributes to many of the things that happen in the story, including one of the most notable and important factors of the story, which is the appearance of a substitute teacher called in to teach the narrators class. The substitute, whose name is Ms. Ferenczi, introduces herself to the entire class, and she leaves a strange initial impression on the class of fourth graders with her eccentric clothing and overall character. Ms. Ferenczi is a woman whose parents are Hungarian and French, and she came to the U.S. because of unknown circumstances. The main characters that are introduced in the beginning of the story play crucial roles to the development of the plot to the story, as well as the progression of the ideas of other characters in regards to how they view the strange new substitute that is taking the place of their normal teacher.
Throughout the length of Gryphon, the story is told through the viewpoint of a fourth-grade student at an elementary school in Michigan, where he is in the process of learning more about Egyptian culture and technology. During one class, his teacher becomes sick with a cold, and he is forced to take a few days off, giving way to a substitute; someone who is difficult to come across in the small community that the narrator lives. The next day, a new strange substitute arrives as cover for the narrators sick teacher. The plot of the story is advanced with every day the substitute, whose name is Ms. Ferenczi, spent teaching the students in the narrators class. Ms. Ferenczi would tell the children stories such as why the Egyptians built the pyramids, and also about how death isnt the end of life and everything itself, but the beginning of another existence for human existence. The narrator in this portion of the story is an observer that offers his thoughts on the things that the strange Ms. Ferenczi would say in class. For the most part, the narrator believes that many of the things that Ms. Ferenczi says are not true, and makes a point of this by jokingly convincing one of his classmates on the bus ride home that a lot of the things Ms. Ferenczi says are true. After Ms. Ferenczi leaves, the other students that are in the narrators class tell their teacher Mr. Hibler about all of the things that Ms. Ferenczi told them about during his absence, but he is indifferent, as most of the work that the students had to complete had been finished. Later on, Ms. Ferenczi returns as a substitute for Mr. Hiblers class, and she is as odd and eccentric as she was before. On this occasion, however, she has a surprise for the students of Mr. Hiblers class, and it is in the form of her telling each of the children their fortunes for the future. Each of the students in the class line up to have Ms. Ferenczi tell their fortune, and some of them are either pleased or frightened by what they are told. In particular, one of the children was told by the substitute that they would soon die, and this made him upset enough to report her to the principal, effectively getting rid of Ms. Ferenczi as their teacher. This demonstrates that the main basis for the plot in the story was a new substitute covering for the narrators sick teacher for a couple of days, and eventually figuring out that the substitute was a very strange women that would have to leave as a result of this.
In the story Gryphon, each one of the main characters in the progress themselves based upon their actions. The narrator is introduced at the start of the story as a normal fourth-grade boy that is simply going through another ordinary day of school. These general characteristics are maintained through the entire story, but eventually, the narrator starts to change how he views things around him and starts to question things that he views as normal occurrences. These changes are in response to others around him, and the largest influencer of these changes is the new substitute that covers the narrators normal teacher, Mr. Hibler. The new substitute, whose name is Ms. Ferenczi, introduces herself to the class of fourth-graders that the narrator is in. Ms. Ferenczi is dress in clothes with vibrant colors and she wears gaudy, gold rimmed glasses. She is an older woman that has some lines running down her face that the narrator says are similar to Pinocchio. During the beginning of the story, the narrator says that Ms. Ferenczi speaks with a strange accent and behaves in a flamboyant manner. The reason that Ms. Ferenczi speaks with a strange accent is because her parents were from Hungary and France, and they came to the U.S. for unknown reasons, according to her. Through the rest of the story, Ms. Ferenczi teaches the students based off of the lesson plan that Mr. Hibler had left for the substitute that covered for him. Despite this, Ms. Ferenczi begins to drift away from the lesson plan, and tells the students stories about things that are slightly related to what they were discussing in class. Ms. Ferenczi told the children about Egyptian myths and she even claimed that she had seen even seen a mythical creature called a Gryphon, which is a hybrid between an eagle and a lion. This caught the interest of all the students in the classroom, including the narrator of the story. They all wondered about all the marvelous stories that Ms. Ferenczi had told them during the time that she was there substitute. The narrator also questioned how legitimate all of the claims that his substitute had made, showing that he had become inquisitive during the time that Ms. Ferenczi had been his substitute. He also knew that some of the things that she had said had a grain of truth to them such as the story about flesh eating plants, which he had seen in a television show about nature. After Ms. Ferenczi leaves, the narrator wonders whether any of the things that she ever said were actually true. This continues up until the strange substitute actually returns to their class, and leaves after she predicted that one of the students would soon meet his end. The events at the end of this story demonstrate the character of both the narrator and of the substitute, Ms. Ferenczi.
The setting in the story Gryphon takes place entirely in a fictional small town called Five Oaks in Michigan. The narrator explains that the town is small enough that nearly everyone in the town knows each other, and that newcomers usually stand out amongst everyone else. This is why when the narrators teacher comes down with a cold, he also mentions that a substitute is hard to come by on such short notice in a small town. A substitute is found for the next day of class, and it is a new female substitute. The students recognize that she is new to town, despite only being in the fourth grade. The substitute explains that she is new in town as well, and that she is of Hungarian and French descent. The impact that the setting has upon the narrator and everyone else in the classroom is that since they live in rural place with a small population, residents that are new are usually very few and far between. This demonstrates that the diversity that is present throughout the entire United States reaches every corner of the country and in every state, county, and city. The effect that this has is shown with the presence of the substitute in the town of Five Oaks.
In conclusion, throughout the short story Gryphon, the main characters progress the ideas and thoughts of other characters that are developed in regards to the substitute, who is also one of the main characters in the story. The plot of the story mainly circles around the narrator that describes the strange substitute, Ms. Ferenczi, being his teacher for several days, and eventually leaving and not coming back after she tells a student that his death was in the immediate future. The characters in the story, which consists of two main characters, which are the narrator and the substitute, Ms. Ferenczi. Both the narrator and the substitute develop over the course of the story in regards to their personalities, interactions with others, and other personal traits as well. The setting throughout the story remains consistently in the same town of Five Oaks in Michigan. Despites this, the setting has a noticeable impact on the emotions that the narrator, students, and other teachers in the story because of the substitutes background, which is something that is unusual and uncommon to the people of the small town. The reason being that everyone in the town knows each other, and having a new resident that is as strange as Ms. Ferenczi is odd even for the children in the fourth-grade class that she is substituting for. These are some of the characteristics from the short story Gryphon in regards to characters, plot, and setting.
PAPER 3 A Bittersweet Hour
The Story of an Hour, written by Kate Chopin displays a common struggle that most women internally encountered during the eighteen-hundreds. There were very few rights that women had during this time period. Chopin often writes based off the feelings of women who are not happy with their love life. As mentioned in the cultural context, Chopin was married in a state where the men were favored both legally and physically. Women were powerless compared to their male counterparts. Due to the lack of respect and authority, married women were imprisoned in marriages. Their body and possessions belonged to their husband. Divorce was uncommon, so everything was done to remain as happy as possible. Even if that means ignoring the dark, negative thoughts that come to mind. Women fall into a pattern of learned helplessness. This means that no matter what intervention is utilized, the same outcome will occur. Therefore, trying to prevent something becomes useless. The term learned helplessness is used to refer to any behavioral or physiological consequence of exposure to an adverse event that is produced not by the event itself but by the organisms lack of behavioral control over the event (Batsching et al. 1). There is no surprise, given the time of events, that Louis Mallard reacted the way she did. Freedom was a new element of her life that she was not used to. Although the story only describes one hour into a womans life, the audience experiences the feelings of what thousands of women during this time period were dealing with.
The plot of the story is linear, narrated in the third person omniscient point of view. This gives the audience the advantage of knowing about the train wreck before Mrs. Mallard is aware and the immediate actions after her death. This also allows the audience to understand Mrs. Mallards actions more. If the story were to be told in first person, Mrs. Mallard may come across as a selfish, spoiled wife. The layout is displayed in chronological order. The storys exposition begins by informing the audience about Mrs. Mallards heart condition. Although, the condition is not named specifically, it is understood that heart breaking news must be delivered to her in a delicate manner. Josephine, Mrs. Mallards sister, is the one in charge of presenting the terrible news. Richards, Mr. Millards friend, was the one who had first discovered the news, but as also there for support.
The main conflict in the story is that a train crash killed Mr. Mallard. It is the job of Richards and Josephine to strategically break the news to the new widow. A difficult task considering that the news can affect her beloved sister physically. Josephine internally fears that the knowledge of her husband passing could kill Mrs. Mallard. As skillfully as possible, given the circumstances, Josephine relays the tragic news to her sister. Grief overcomes Mrs. Mallard immediately as she begins to cry. However, she soon excuses herself to go upstairs alone to ponder the situation. This is where to real climax is reach. Mrs. Mallard is overwhelmed with a growing feeling deep side that is overcoming her. After coming to an abrupt realization, she says, Free, free, free! A reaction the audience was not expecting. The realization that her personal freedom is redeemed is too much for her to stand. The deep feeling that would come across as depression, ends up being utter excitement.
Her pulse beats fast, and the coursing blood warmed and relaxed every inch of her body. This line is foreshadowing her death. An excessive amount of happiness is just as capable of effecting her heart condition as an anxiety attack. Her mind is racing with what is yet to be. A future full of bliss would energize to most dull person. Her reaction to this is completely understandable. She is coming from a marriage she was forced to forever endure. Her feelings are justified when she explains that she will weep about the passing, but the future is so bright that the focus is elsewhere.
A symbol is shown as Mrs. Mallard confesses, internally, her intermitted love for her husband by saying:
And yet she loved him- sometimes. Often she had not. What did it matter! What could love, the unsolved mystery, count for in the face of this possession of self-assertion which she suddenly recognized as the strongest impulse of her being
This symbolizes the distorted way people viewed love in the eight-teen hundreds. Mrs. Mallard confesses that she did not understand the love she had for her husband. That is because it was not love. It was misconstrued with enjoying the presence of another individual, or that absence of loneness. Mrs. Mallards life was not hers to rule, and the idea of a companion kept her sane.
This misunderstanding can still be recognized in todays society in emotionally abusive relationships. Over time, emotional abuse can be as powerful a control tactic as physical abuse (Reed and Enright 805). Women are viewed as something that needs to be constantly under control.
The tone in the beginning of the story is stressful with hints of sadness, transforms to a radiant happiness and closes as ironic. As the story is introduce, the readers are aware of a terrible tragedy. To tell a wife her husband has passed should be a stressful situation. Once the news is delivered grief follows along promptly. After much thinking our main character realizes her newfound freedom. That is when her happiness becomes infectious. It is short live as the irony hits. After praying to live a long life after hearing the news, she passes away. The situational irony does not end there either, because her husband never did die in the crash. This irony is similar to the way women views their lives. Women want to be free so much, but freedom is always out of their grasp. Never truly getting to taste the sweet victory we call freedom.
Figures of speech are implemented in this brief story. Personification is mention when the narrator says, Into this she sank, pressed down by a physical exhaustion that haunted her body and seemed to reach into her soul. Physical exhaustion obviously cannot physically actually haunt her or reach into her soul, but it amplifies the intensity of the feeling she is experiencing. Personification is also mentioned later on Mrs. Mallards fancy is running wild due to the thoughts she was having. The narrator uses a metaphor to describe to amount of joy Mrs. Mallard is in by saying, No; she was drinking in a very elixir of life through that open window. These figures of speech help explain the extent to which the characters are feeling, but the imagery does that as well. Throughout the story, the narrator describes things in fine detail. From Mrs. Mallards face to the life shown outside the window. That piece of detail appeals to the audiences sense of sight. Giving the readers the opportunity to visualize what Mrs. Mallard may look like and what she is seeing outside the second story window.
Louis Mallard is our main character and protagonist. She is closely observed, described and followed throughout this piece of literature. She is a round, dynamic character because of the way she develops throughout the story. Initially she is viewed by the audience for being the stereotypical wife that is about to get news that will paralyze her mentally for the rest of her life. Besides the brief grief she displays, she surprises us with her abundance of happiness. The audience picks up on the critical thinking that she goes through to realize this sense of happiness. In a way, it builds the readers respect for this woman for being so strong. The readers perspective of Mrs. Mallard changes from our trademark version of a wife in the eight-teen hundreds to a liberated woman who finally gets a taste of freedom. Josephine is a flat, static character because she remains the same throughout the context. She is only worried about the well-being of her sister and will remain as part of her support system. Richards is another flat, static character. He is the individual who recognized Brently Mallards name on the list of people killed from the wreck. Potentially, he is to blame for Mrs. Mallards death. It is in the end that we figured out Mr. Mallard was not killed. The odds that someone had the same name as Brently Mallard are slim, yet, they add a dramatic twist. Brently Mallard, only mentioned at the end of the story, is a supporting character. Nothing is known about his character besides that he has a wife. Once the news got out that she died of joy, his reaction is would be unknown for the reader. That is because we have not been able to observe Mr. Mallard at all.
Many themes can be taken away from this short story, but freedom from oppression is the one that stands out the most. Anyone educated on the eight-teen hundreds understands that women were viewed as incompetent. When married, everything that a woman is, becomes her husbands. Womens rights were not even a thing to people back then. A womens job was to cook, clean and to give her husband whatever he wants. Even if it meant their body. Women were stuck in this culture where men were these superior figures who owned them. With little that was able to be done or said, women felt hopeless. Forget about divorce, because that was not positively looked at during that time frame either. Most women would find themselves feeling as Mrs. Mallard did if they were to lose their significant other. How is it possible that all these members of society who come to realize this unequal division of power usually follow and accept the rules of the dominant people (Nociar 78). Society ushers people to act a certain way, so women tended to not go against the grain with this issue. Women would rather sugar coat their lives than to be shunned or viewed terribly. With that being said, Mrs. Mallards reaction was not so surprising. However, to the viewer will interpret her actions based off of the stereotypical responses. To be a woman who can live for herself was something of a dream. Although that may be our reality today, those women did not have that luxury. These ideas will make female readers will reflect and appreciate the luxuries that they have.
Works Cited
Reed, Gayle L., and Robert D. Enright. The Effects of Forgiveness Therapy on Depression,
Anxiety, and Posttraumatic Stress For Women After Spousal Emotional Abuse. Journal
of Consulting and Clinical Psychology, vol. 74, no. 5, Oct. 2006, pp. 920929.Nociar, Tomas. Glasberg, Davita Silfen – Shannon, Deric: Political Sociology: Opression,
Resistance and the State. Slovensk Politologick Revue, vol. 12, no. 1, 2012, pp. 7

Differentiate between a problem and a crisis. Table 8-3 in your textbook will help you with this discussion.

A Problem or a Crisis?

For this discussion question, perform the following:

  • Differentiate between a problem and a crisis. Table 8-3 in your textbook will help you with this discussion.
  • Examine a project that you are familiar with and consider one of the metrics/KPIs used to find something that is either a problem or crisis.
  • Explain your reasoning.

Support your statements and conclusions using at least one of this week’s required readings and one current, peer-reviewed scholarly article. Current means that the article was published in the most recent five years. Be sure to include your citation/reference pair in accordance with APA  format. Be sure to post a substantive initial post of at least 350 words.

Subject: Ethical Decision Making for Business

Subject: Ethical Decision Making for Business

– Recommended textbook for the subject: Weiss, J., Business Ethics: A Stakeholder and Issues Management Approach, 6th edition (CHAPTER 7)

– Answer the following essay questions:

1. What are some changes that have occurred as a result of the Civil Rights Act of 1991?

2. What does the term legal and moral entitlement mean to you as an employee or future employee? Give an example. Do you agree that employees have legal and moral entitlements in the workplace? Explain.

3. Select an employee right in the workplace from the module. Give an example, based on your own outside reading or experience, of a situation involving this right. Was it violated? How? What was the outcome? What should the outcome have been? Why? Explain.

4. Think of three people you know from the different generations discussed in the module. Of these people, who is and is not satisfied with their work and jobs? Explain why they are or are not satisfied. Refer back to the generational differences and values in the chapter. To what extent did “generational differences” contribute in your analysis of the individuals’ work satisfaction? To what extent did “ethical reasons” affect their work satisfaction? Explain.

5. Do you believe dating should be permitted among employees? Do you think formal policies setting boundaries will keep this from happening? Why or why not?