{"id":1344,"date":"2013-10-11T06:33:44","date_gmt":"2013-10-11T06:33:44","guid":{"rendered":"http:\/\/jacobimed.org\/NS\/?page_id=1344"},"modified":"2013-10-11T06:33:44","modified_gmt":"2013-10-11T06:33:44","slug":"care-of-dying-patients","status":"publish","type":"page","link":"https:\/\/jacobimed.org\/old\/ambulatory\/intern-ambulatory-block\/spring\/end-of-life\/care-of-dying-patients\/","title":{"rendered":"Care of Dying Patients"},"content":{"rendered":"

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\n<\/span><\/p>\n

EDITORIAL<\/span><\/span><\/span><\/span><\/h4>\n

The Care of Dying Patients <\/span><\/span><\/span><\/h2>\n

\"\"<\/a> Arthur W. Feinberg, MD <\/span><\/a><\/p>\n

<\/span><\/span><\/span><\/p>\n

15 January 1997 | Volume 126 Issue 2 | Pages
\n164-165<\/strong><\/span>
\n<\/span><\/span><\/span><\/p>\n

 <\/p>\n

\n

Ann Intern Med.
\n1997;126:164-165.
\n<\/span><\/span><\/span><\/span><\/p>\n

In our world of increasingly sophisticated medical technology,
\n<\/sup>there is growing concern that the care of persons facing death
\n<\/sup>is wanting and that many patients are dying in physical and
\n<\/sup>mental anguish. This deficiency in care at the end of life is
\n<\/sup>highlighted in the recent report from SUPPORT (the Study to
\n<\/sup>Understand Prognoses and Preferences for Outcomes and Risksof
\nTreatments) [1]<\/a>,
\none phase of which is described in thisissue [2]<\/a>.
\nThis study was a 5-year project designed to identifyand correct
\nproblems in the care of patients approaching death.The project was
\ndone at five hospitals across the United Statesand was funded by the
\nRobert Wood Johnson Foundation in theamount of $28 million.
\n<\/sup>
\n<\/span><\/span><\/span><\/span><\/p>\n

Despite intense effort and dedicated input from many professionals,
\n<\/sup>the results of SUPPORT have been disappointing. Proposed
\ninterventionshave had no clear effect on improving patient-physician
\ncommunication,facilitating the documentation of appropriate
\ndo-not-resuscitateorders, decreasing the number of days spent in
\nintensive careunits, relieving pain, or reducing the use of hospital
\nresources.As Lynn and associates report [2]<\/a>,
\nfamily members of patientsin SUPPORT and HELP (the Hospitalized
\nElderly Longitudinal Project)have confirmed that dying patients are
\noften left with a greatdeal of pain, anxiety, and dysphoria.
\n<\/sup>
\n<\/span><\/span><\/span><\/span><\/p>\n

Why, despite our honest efforts, are we doing such an inadequate
\n<\/sup>job with end-of-life care? Why did SUPPORT fail even to begin
\n<\/sup>to alleviate the problems it set out to address? What are the
\n<\/sup>implications of the public’s perception that care is frequently
\n<\/sup>impersonal and mechanical? And, finally, what can be done about
\n<\/sup>this perception?
\n<\/span><\/span><\/span><\/span><\/p>\n

We must look beyond conventional explanations. There is no doubt
\n<\/sup>that many physicians lack good communication skills, do not
\n<\/sup>explain situations well, are trained to see death as failure,
\n<\/sup>and may be too aggressive in treating dying patients. It is
\n<\/sup>equally true that patients and families often have unrealistic
\n<\/sup>expectations and false hopes. But the problems go deeper than
\n<\/sup>that. There is a wide gap between what the public believes technology
\n<\/sup>is capable of doing and what technology actually accomplishes.
\n<\/sup>Only when serious illness strikes do families begin to realize
\n<\/sup>that physicians can often do little to change outcomes. It is
\n<\/sup>certainly not well appreciated that large gaps in medical knowledge
\n<\/sup>remain and that many diseases elude treatment. For patientsand
\nfamilies who have so little knowledge of our failings, thetruth
\ncomes as a shock. For example, no one has publicized thedismal
\nstatistics about recovery from cardiopulmonary resuscitationin
\nelderly patients; the results are far different from whatis seen on
\ntelevision [3]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/span><\/span><\/p>\n

Many patients and families are ambivalent about what to do when
\n<\/sup>serious illness strikes and death becomes a real possibility.
\n<\/sup>Despite the Patient Self Determination Act of 1990 and campaigns
\n<\/sup>to encourage written advance directives, only about 15% of persons
\n<\/sup>in the United States have executed such documents. Patientsare
\nconfused about having to make life and death decisions farin
\nadvance. How can one be sure about how much pain one wouldtolerate
\nto see a grandchild’s wedding or to spend a few moredays or weeks
\nwith a loved one? This ambivalence also extendsto the hospice
\nmovement. Hospice offers humane care with anemphasis on the relief
\nof both physical and mental pain. Butonly a small percentage of
\npatients avail themselves of thisopportunity, perhaps because
\nentering hospice means acceptingdeath and “defeat.”
\n<\/span><\/span><\/span><\/span><\/p>\n

Faced with overwhelmingly complex technology, patients in the
\n<\/sup>United States fear loss of autonomy. They may wish to be saved
\n<\/sup>by technology, but they fear that it will cause them to lose
\n<\/sup>control over their lives and experience a lonely and impersonal
\n<\/sup>death. Fear of losing control has led to increasing interestin
\nthe “right-to-die” movement. Physician-assisted suicide,the
\nlegalization of euthanasia, medical futility, and the activitiesof
\nDr. Jack Kevorkian are discussed and debated throughout theUnited
\nStates. The growing interest in alternative medicineis at least
\npartly due to a deep distrust of medical science.
\n<\/span><\/span><\/span><\/span><\/p>\n

Where will all of this lead? What can we do to resolve the justified
\n<\/sup>concerns of our patients? We cannot turn the clock back like
\n<\/sup>modern-day Luddites. Technology will not disappear. On the contrary,
\n<\/sup>it is more likely to become more sophisticated and make these
\n<\/sup>problems even more difficult to solve.
\n<\/span><\/span><\/span><\/span><\/p>\n

Because more than 50% of Americans die in hospitals [4]<\/a>,
\nithas been suggested that special hospital units be established
\n<\/sup>to separate dying persons from other hospitalized patients [5]<\/a>.
\n<\/sup>Trained nurses and physicians could provide humane and dignified
\n<\/sup>care in such settings. However, although the proposal seemsto
\nmake sense, it raises the specter of transferring seriouslyill
\npatients to the back room-the dying room-of the ward, aswas done
\nyears ago.
\n<\/span><\/span><\/span><\/span><\/p>\n

Another option is to keep the dying patient out of the high-technology
\n<\/sup>milieu of the hospital. Most patients do not stay home when
\n<\/sup>death is approaching, even though they may initially have intended
\n<\/sup>to do so. Whether because of the panic of family members or
\n<\/sup>because of an inability to face the finality of death, most
\n<\/sup>patients find themselves in a hospital at the end. However,
\n<\/sup>other, more appropriate facilities, including extended care
\n<\/sup>centers, nursing homes, and hospice, provide end-of-life care.
\n<\/sup>Personal observations in a geriatric long-term care facility
\n<\/sup>have suggested that dying in such a setting may be much morein
\nkeeping with the desires of patients and their families.
\n<\/span><\/span><\/span><\/span><\/p>\n

Significant change in the way we approach end-of-life care will
\n<\/sup>require at least two difficult adjustments. First, we must change
\n<\/sup>our cultural attitudes and accept death as a natural phenomenon.
\n<\/sup>This will not be easy to do and will not happen quickly. The
\n<\/sup>current debate over the right to die may help to focus society’s
\n<\/sup>viewpoints in this regard. Second, despite the apparent failure
\n<\/sup>of SUPPORT, our health care institutions must commit more resources
\n<\/sup>to improving end-of-life care. Hospitals will continue to have
\n<\/sup>little interest in altering their approach to the dying patient
\n<\/sup>unless public pressure for change increases.
\n<\/span><\/span><\/span><\/span><\/p>\n

Our society has not yet accepted the inevitability of death.We
\nare impressed by the steady extension of life expectancy,but we
\nforget that we have not extended, and probably cannotextend, our
\nlifespan much beyond 100 years. How we deal withthe final years of
\nlife does much to define the kind of societywe have. We must provide
\nour patients with a peaceful and dignifieddeath, without pain and
\nwith as little anguish and anxiety aspossible. We may finally
\nconsider SUPPORT (a valiant attemptto correct a serious shortcoming)
\na success if it is the beginning-andnot the end-of our
\ncommitment.
\n<\/span><\/span><\/span><\/span><\/p>\n

Requests for Reprints: Arthur W. Feinberg, MD, Center for Extended
\n<\/sup>Care and Rehabilitation, North Shore University Hospital, 330
\n<\/sup>Community Drive, Manhasset, NY 11030.
\n<\/span><\/span><\/span><\/span><\/p>\n

<\/a><\/span><\/span><\/span><\/p>\n\n\n\n
Author
\nand Article Information <\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
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\n<\/a>\"\"Author & Article
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<\/a>North Shore University
\nHospital, Manhasset, NY 11030
\nRequests for Reprints: Arthur W. Feinberg, MD,
\nCenter for Extended Care and Rehabilitation, North Shore University Hospital,
\n330 Community Drive, Manhasset, NY 11030. <\/span>
\n<\/span><\/p>\n

<\/a><\/span><\/span><\/span><\/p>\n\n\n\n
References <\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"Top<\/span>
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<\/a>
\n<\/span><\/p>\n

1.<\/strong> A controlled trial to improve care for seriously ill hospitalized
\npatients. The study to understand prognoses and preferences for outcomes and
\nrisks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA.
\n1995;274:1591-8.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

2.<\/strong> Lynn J, Teno JM, Phillips RS, Wu AW, Desbiens N, Harrold J, et al.
\nPerceptions by family members of the dying experience of older and seriously ill
\npatients. Ann Intern Med. 1997;126:97-106.[Abstract\/Free<\/span> Full\u00a0Text]<\/a><\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

3.<\/strong> Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on
\ntelevision. Miracles and misinformation. N Engl J Med. 1996;334:1578-82.[Abstract\/Free<\/span> Full\u00a0Text]<\/a><\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

4.<\/strong> National Center for Health Statistics. Vital Statistics of the
\nUnited States, 1991. v. 2. Mortality. Part A, section 1. Washington, D.C.: US
\nGov Pr Office; 1996:380-1; DHHS publication no. (PHS) 96-1101.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

5.<\/strong> Miller FG, Fins JJ. A proposal to restructure hospital care for
\ndying patients. N Engl J Med.
\n1996;334:1740-2.[Free<\/span> Full\u00a0Text]<\/a><\/span>
\n<\/span>
\n<\/a>
\n<\/span><\/span><\/p>\n

Related
\narticles in Annals:<\/span><\/strong>
\n<\/span><\/span><\/p>\n

 <\/p>\n

Articles
\nPerceptions by Family Members of the Dying Experience
\nof Older and Seriously Ill Patients<\/strong>Joanne Lynn, Joan M. Teno, Russell S. Phillips, Albert W. Wu, Norman
\nDesbiens, Joan Harrold, Michael T. Claessens, Neil Wenger, Barbara Kreling,
\nand Alfred F. Connors, Jr.<\/span><\/span><\/span><\/span><\/p>\n

Annals 1997 126: 97-106. (in ) [Abstract]<\/a>
\n[Full
\nText]<\/a><\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

<\/a><\/p>\n

This article has been cited by other
\narticles:<\/strong><\/span>
\n<\/span><\/span><\/span><\/p>\n\n\n\n\n
\"\"<\/td>\n\"\"<\/td>\n\"Home<\/a><\/td>\n\"\"<\/td>\n\"Ann\"Home<\/a>
\nN. S.
\nKnudsen
\nDoing Everything<\/strong>
\nAnn Intern Med,
\nJanuary\u00a019,\u00a01999; 130(2): 165 – 165.
\n[Full
\nText]<\/a> [PDF]<\/a><\/p>\n

\"\" <\/span><\/td>\n

\"\"<\/td>\n<\/tr>\n
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\"\"<\/td>\n\"\"<\/td>\n\"Home<\/a><\/td>\n\"\"<\/td>\n\"Arch\"Home<\/a>
\nL. M.
\nCohen
\nSuicide, Hastening Death, and
\nPsychiatry<\/strong>
\nArchives of Internal Medicine,
\nOctober\u00a012,\u00a01998; 158(18): 1973 – 1976.
\n[Full
\nText]<\/a> [PDF]<\/a><\/p>\n

\"\" <\/span><\/td>\n

\"\"<\/td>\n<\/tr>\n
\n
\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n\n
\"\"<\/td>\n\"\"<\/td>\n\"Home<\/a><\/td>\n\"\"<\/td>\n\"Arch\"Home<\/a>
\nL. M. Cohen,
\nM. J. Germain, D. M. Poppel, A. L. Woods, P. S. Pekow, and C. M.
\nKjellstrand
\nDying Well After Discontinuing the Life-Support
\nTreatment of Dialysis<\/strong>
\nArchives of Internal Medicine,
\nSeptember\u00a011,\u00a02000; 160(16): 2513 – 2518.
\n[Abstract]<\/a>
\n[Full
\nText]<\/a>
\n\"\" <\/span><\/td>\n		\"\"<\/td>\n<\/tr>\n
\n
\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n\n
\"\"<\/td>\n\"\"<\/td>\n\"Home<\/a><\/td>\n\"\"<\/td>\n\"Psychosomatics\"\"Home<\/a>
\nL. M. Cohen,
\nM. D. Steinberg, K. C. Hails, S. K. Dobscha, and S. V.
\nFischel
\nPsychiatric Evaluation of Death-Hastening Requests:
\nLessons From Dialysis Discontinuation<\/strong>
\nPsychosomatics,
\nJune\u00a01,\u00a02000; 41(3): 195 – 203.
\n[Abstract]<\/a>
\n[Full
\nText]<\/a>
\n\"\" <\/span><\/td>\n		\"\"<\/td>\n<\/tr>\n
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\nCopyright \u00a9 1997 by the American College of
\nPhysicians.<\/a><\/span><\/span><\/span><\/span><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Search Annals: Advanced search \u00a0Home | Current Issue | Past Issues | Search | Collections | CME | PDA Services | Subscribe | Contact Us | Help | ACP Online\u00a0 Institution: Albert Einstein Coll Med \u00a0 Sign In as Member or Subscriber \u00a0 \u00a0 \u00a0Article \u00a0 Table of Contents \u00a0 Related articles in Annals \u00a0….<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1341,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-1344","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1344","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=1344"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1344\/revisions"}],"predecessor-version":[{"id":1346,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1344\/revisions\/1346"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1341"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=1344"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}