{"id":1347,"date":"2013-10-11T06:34:36","date_gmt":"2013-10-11T06:34:36","guid":{"rendered":"http:\/\/jacobimed.org\/NS\/?page_id=1347"},"modified":"2013-10-11T06:34:36","modified_gmt":"2013-10-11T06:34:36","slug":"whose-death-is-it-anyway","status":"publish","type":"page","link":"https:\/\/jacobimed.org\/old\/ambulatory\/intern-ambulatory-block\/spring\/end-of-life\/whose-death-is-it-anyway\/","title":{"rendered":"Whose Death Is It Anyway"},"content":{"rendered":"

<\/a><\/p>\n\n\n\n
\n\n\n\n\n
\"Annals\"<\/a><\/td>\n<\/tr>\n
\"Established<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n\n
Search Annals:
\n
\nAdvanced
\nsearch<\/a> <\/span><\/form>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Institution: Albert Einstein
\nColl Med <\/strong>\u00a0 Sign In as Member or Subscriber<\/a><\/strong> \u00a0 \u00a0
\n<\/span><\/p>\n\n\n\n
\n\n\n\n\n
\"\"\u00a0Article<\/strong><\/span><\/td>\n<\/tr>\n
\n\n\n\n\n\n\n\n\n\n\n
\u00a0\"\"<\/td>\nTable
\nof
\nContents<\/a>
\n<\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nAbstract
\nof this article<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nArticles
\nciting this article<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n
\"\"\u00a0Services<\/strong><\/span><\/td>\n<\/tr>\n
\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\u00a0\"\"<\/td>\nSend
\ncomment\/rapid response letter<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nNotify
\na friend about this article<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nAlert
\nme when this article is cited<\/a><\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nAdd
\nto Personal Archive<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nDownload
\nto Citation Manager<\/a><\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nACP
\nSearch<\/a><\/p>\n

<\/span><\/td>\n<\/tr>\n

\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n
\"\"\u00a0PubMed<\/strong><\/span><\/td>\n<\/tr>\n
\n\n\n\n
Articles in PubMed by Author:<\/strong><\/span><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n
\u00a0\"\"\"\"<\/td>\nGilligan, T.<\/a><\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"\"\"<\/td>\nRaffin, T. A.<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nRelated Articles in PubMed<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nPubMed Citation<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nPubMed<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n


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

PERSPECTIVE<\/span><\/span><\/span><\/span><\/h4>\n

Whose Death Is It, Anyway? <\/span><\/span><\/span><\/h2>\n

\"\"<\/a> Timothy Gilligan, MD and Thomas
\nA. Raffin, MD <\/span><\/a><\/p>\n

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

15 July 1996 | Volume 125 Issue 2 | Pages
\n137-141<\/strong><\/span>
\n<\/span><\/span><\/span><\/p>\n

As medicine has increasingly gained the power to prolong
\nlifein the face of devastating illness, patients have
\nincreasinglybecome concerned about maintaining some control over how
\nandwhen death arrives.Competent patients have the legal right
\ntorefuse treatment, but critically ill patients are frequently
\n<\/sup>unable to participate in decision making. Advance directives
\n<\/sup>were designed to help patients establish the level of care they
\n<\/sup>would receive if they were to be rendered incompetent; yet,as
\nthe case discussed in this essay shows, even a valid advance
\n<\/sup>directive does not guarantee that unwanted medical interventions
\n<\/sup>will not be forced on us. The problem of physicians ignoring
\n<\/sup>their patients’ wishes goes beyond issues of communication and
\n<\/sup>reflects an ongoing ambivalence about power and control in the
\n<\/sup>physician-patient relationship. Unfortunately, many physicians
\n<\/sup>find it easier to define success in terms of life and death
\n<\/sup>than to try to determine what sort of existence is meaningful
\n<\/sup>to an individual patient.
\n<\/span><\/span><\/span><\/span><\/p>\n


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

\n

As medicine has
\nincreasingly gained the power to prolong lifein the face of
\ndevastating illness and injury, physicians, patients,and patients’
\nloved ones have had to confront the difficultand delicate question
\nof when to stop trying to save a life.When is a dignified death the
\nbest achievable outcome? Thisproblem is complicated by the fact that
\ncritically ill patientsare frequently unable to communicate their
\nwishes, forcing theirphysicians and family members to make decisions
\nfor them thatare among the most personal decisions one can ever
\nmake. Toprotect the right of patients to choose the level of life
\nsupportand medical care they would want if they were to become
\ncriticallyor terminally ill, all 50 states have adopted legally
\nrecognizedways for persons to leave written testimony of their
\nwishes.These documents take the form of advance directives and
\nincludeliving wills and durable powers of attorney for health
\ncare.Unfortunately, as shown in the essay by Hansot in this
\nissue[1]<\/a>,
\na durable power of attorney for health care is no guaranteethat
\nunwanted medical interventions will not be forced on uswhen we are
\nat our most helpless.
\n<\/span><\/span><\/span><\/span><\/p>\n

We believe that the case of Ms. Hansot illuminates several difficult
\n<\/sup>and important problems in medicine: patient autonomy, communication
\n<\/sup>between physicians and patients, the need for emotional as well
\n<\/sup>as physiologic care, and the role of death as a colleague. In
\n<\/sup>addition, this case highlights the limitations of durable powers
\n<\/sup>of attorney for health care.
\n<\/span><\/span><\/span><\/span><\/p>\n

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

Patient
\nautonomy is, in principle, a cornerstone of the legitimacyof Western
\nmedicine. Legally, a person’s right to control hisor her body is
\nsacrosanct, and forcing medical care on an unwillingpatient is akin
\nto battery. Although patients do not have theright to demand
\ninterventions that are clearly futile, physiciansdo not have the
\nright to impose interventions, even if medicallyindicated, contrary
\nto the patient’s wishes. The legal historyestablishing a competent
\npatient’s right to refuse medical interventionshas been well
\ndocumented elsewhere [2]<\/a>.
\nAlthough we appreciatethe concern that Ms. Hansot’s physicians
\nshowed for the preservationof life, the actions of these physicians
\nviolated the patient’sright to decide for herself what quality of
\nlife was acceptable[1]<\/a>.
\nThe hospital was legally required to ascertain whetherMs. Hansot had
\ncompleted an advance directive or similar documentbut failed to do
\nso. Then, the physicians put a tube down thepatient’s throat,
\nconnected her to a mechanical ventilator,and placed her in physical
\nrestraints so that she could notemancipate herself. Despite clear
\nevidence from the patientand the patient’s legally designated agent
\nthat Ms. Hansot didnot want her life prolonged in this manner, it
\ntook 5 days forthe physicians to relent and bring their
\ninterventions intoaccord with the patient’s desires. That these
\nphysicians actedwith the best of intentions makes Ms. Hansot’s
\nexperience noless painful.<\/p>\n

Withholding and withdrawing life support from patients has gained
\n<\/sup>widespread acceptance in the medical community [3,4]<\/a>
\nand thelegal system [2]<\/a>,
\nbut we still see far too many patients tryingdesperately to cut
\nshort the process of dying, only to havetheir best efforts rebuffed
\nby physicians. This unwanted medicineis an arrogant usurpation of
\npatients’ rights and serves neitherthe interests of the patient nor
\nthose of medicine as a profession.In ancient Greece, the Hippocratic
\nCorpus stated that one ofthe primary roles of medicine was to
\nrefrain from treating hopelesslyill persons, lest physicians be
\nthought of as charlatans [5]<\/a>.
\n<\/sup>This caveat still applies today.
\n<\/span><\/span><\/span><\/span><\/p>\n

One of the major ways that patients exercise their autonomyis
\nthrough consent. Physicians have an ethical and legal responsibility
\n<\/sup>to ensure that the patient has consented to the treatment they
\n<\/sup>are providing. This involves talking to the patient. For hospitalized
\n<\/sup>patients, physicians should determine, at a minimum, whether
\n<\/sup>the patients wish to be designated as
\ndo-not-resuscitate\/do-not-intubateand whether the patients have
\nprovided an advance directiveor durable power of attorney for health
\ncare. When patientscannot speak (because of intubation, for
\nexample), they maybe able to communicate by nodding and shaking
\ntheir heads. Ifa physician believes that meaningful communication is
\nimpossible,a patient’s agent, designated by a durable power of
\nattorneyfor health care, can speak and decide for the patient. Dr.
\nHansot’sperception that her mother’s physicians did not concern
\nthemselveswith the wishes of their patient is disturbing.
\n<\/sup>
\n<\/span><\/span><\/span><\/span><\/p>\n

In an emergency, patients who are not designated as
\ndo-not-resuscitate\/do-not-intubateare presumed to have given consent
\nfor cardiopulmonary resuscitation.However, once a patient’s
\ncondition has stabilized, consentfor continuing treatment is
\nmandatory. Admittedly, obtainingmeaningful consent from critically
\nill, ventilator-dependentpatients presents a difficult challenge and
\nis often made impossibleby the patient’s mental state. Patients
\nreceiving mechanicalventilation often appear to become depressed
\nand, if not heavilysedated, may become desperate in their desire to
\nbe extubated.Acutely ill, ventilator-dependent patients in intensive
\ncareunits regularly demand to be extubated despite having an
\nexcellentchance of returning to an independent life. Assessing the
\ncompetencyof these patients is critical because, although physicians
\nhaveno right to force unwanted care on patients, allowing a
\npatientin an altered mental state to make grave medical decisions
\ncanclearly be wrong. In such circumstances, carefully
\nevaluatingthe patient’s mental status, consulting with the patient’s
\nfamilyand loved ones, and waiting to see whether the patient’s
\nwishesremain stable over time can all help physicians determine
\nwhethera patient’s requests are consistent with the patient’s
\nknownvalues and goals. Such an assessment is generally easier
\ntomake when the physician has had a long-term relationship with
\n<\/sup>the patient.
\n<\/span><\/span><\/span><\/span><\/p>\n

For Ms. Hansot, the best-case scenario was not a return to her
\n<\/sup>former state but rather was a hemiparetic life in a nursing
\n<\/sup>home. The physicians not only lacked Ms. Hansot’s consent but
\n<\/sup>had evidence, supplied by her legally designated agent, that
\n<\/sup>she did not want to live the life for which they were saving
\n<\/sup>her. In such a scenario, we do not understand what could give
\n<\/sup>physicians the authority to force a patient to undergo undesired
\n<\/sup>medical interventions.
\n<\/span><\/span><\/span><\/span><\/p>\n

<\/a><\/span><\/span><\/span><\/span><\/p>\n\n\n\n
Communication, Listening, and Caring <\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

Communication
\nand listening skills are prerequisites for goodphysician-patient
\nrelationships, and they give the physiciana chance to learn what an
\nillness means to the patient and thepatient’s family. Good
\ncommunication skills make patients feelless lost in the hospital
\nenvironment and more cared for bytheir physicians. Effective
\ncommunication is particularly importantin the intensive care unit,
\nwhich is an alien environment forpatients and their loved ones. It
\nis filled with monitors andunfamiliar sounds, and the patients are
\noften obscured by asea of wires and tubing. Visitors may find
\nthemselves overwhelmednot only by the gravity of the patient’s
\nmalady but also bythe foreign stimuli. If the patient’s loved ones
\nmust make life-and-deathdecisions on the patient’s behalf, they will
\nprobably have feelingsof grief, guilt, and confusion. Caring
\nphysicians who take thetime to make emotional, human contact with
\npatients and theirfamilies can greatly ease the burden that these
\npersons feelat times of crisis [3,6]<\/a>.
\n<\/sup><\/p>\n

Reading Dr. Hansot’s account of her mother’s last days of life,we
\nask ourselves what happened to the humanistic aspect of medicinein
\nthis case. One of the roles of physicians is to give solaceand
\nsupport to patients’ families during times of serious illness.That
\nthe pulmonologist accused Dr. Hansot of being an ageistpreoccupied
\nwith abstract principles when she was trying torealize her mother’s
\nwishes is to us a double violation of theprinciple of
\nnonmaleficence: The physician not only did harmto the patient by
\nprolonging her suffering but did harm to thepatient’s daughter by
\ngratuitously insulting her and causingher anguish. We believe that
\nmuch of Dr. Hansot’s and Ms. Hansot’sdistress could have been
\navoided if the physicians had madea greater effort to listen to
\ntheir patient and her daughter.
\n<\/span><\/span><\/span><\/span><\/p>\n

As Dr. Hansot implies, their is a difference between takingcare
\nof a patient and simply maintaining a patient’s vital signs.
\n<\/sup>Providing emotional support, understanding, and empathy are
\n<\/sup>important aspects of medical care. Dr. Hansot clearly felt that
\n<\/sup>she and her mother had been abandoned by the team of physicians,
\n<\/sup>a feeling that was only exacerbated by the absence of the physicians
\n<\/sup>at the time of death.
\n<\/span><\/span><\/span><\/span><\/p>\n

<\/a><\/span><\/span><\/span><\/span><\/p>\n\n\n\n
Beyond
\nBetter Communication <\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

Physicians’
\nneglect of their patients’ wishes about criticalcare and code status
\nis disturbingly widespread. The recent,large, multicenter SUPPORT
\n(Study to Understand Prognoses andPreferences for Outcomes and Risks
\nof Treatments) trial [7]<\/a>
\n<\/sup>found that physicians largely ignored or were unaware of the
\n<\/sup>desire of terminally ill patients to be designated as
\ndo-not-resuscitate\/do-not-intubate.And although poor communication
\nis a problem in itself, it isalso a symptom of deeper problems in
\nthe culture and climateof hospital-based medicine that must be
\naddressed. Indeed, thesecond phase of the SUPPORT study found that
\nhaving nurses facilitatecommunication between physicians and
\npatients improved neitherphysicians’ awareness of patients’ wishes
\nabout medical carenor the incidence or timing of written
\ndo-not-resuscitate orders.The deeper problems are related to
\nphysicians’ attitudes towardlife and death and toward medical
\ninterventions and technology.Physicians’ daily work with advanced
\nmedical technology mayengender a familiarity that makes it difficult
\nfor them to understandwhy patients often view ventilators and
\nfeeding tubes with anxietyand aversion. Similarly, medicine’s focus
\non pathology and physiology,on vital signs and diagnostic tests, may
\nobscure the human contextof the illness. Correcting electrolyte
\nimbalances may seem tobe more urgent than discovering what the
\npatient wants. Thisis especially true in the critical care setting,
\nin which thepatient may be intubated and sedated and in which the
\nphysician-patientrelationship may be reduced to a daily 2-minute
\nphysical examination.This elevation of the science of medicine above
\nthe humanityof the patient is a serious problem that probably cannot
\nberesolved without changes in the organization and culture of
\n<\/sup>the hospital and the active support of hospital leaders [8]<\/a>.
\n<\/sup><\/p>\n

The problem of poor communication also reflects ongoing ambivalence
\n<\/sup>and uncertainties about power and control in the physician-patient
\n<\/sup>relationship. As the physician has gradually taken on a less
\n<\/sup>paternalistic role in Western medicine, more emphasis has been
\n<\/sup>placed on patient autonomy. This shift in emphasis has moved
\n<\/sup>the balance of power in the direction of the patient. Educating
\n<\/sup>patients about their diseases and available therapeutic options
\n<\/sup>empowers them to participate more fully in medical decision
\n<\/sup>making, but it also may threaten the physician’s sense of authority.
\n<\/sup>Physicians may feel that they, with their greater medical knowledge
\n<\/sup>and experience, are in a better position to make decisions about
\n<\/sup>health care. Moreover, when it comes to difficult decisions
\n<\/sup>about end-of-life care, physicians may believe that they can
\n<\/sup>relieve the patient’s family of guilt, regret, and confusionby
\nmaking tough choices on their own. However, treatment decisionsare
\ninfluenced not only by outcome probabilities but also byphysicians’
\npersonal values and priorities [9-11]<\/a>.
\nBecause itis the patient’s life that is at stake, we believe that
\nthepatient’s voice must be heard and the patient’s values must
\n<\/sup>be honored.
\n<\/span><\/span><\/span><\/span><\/p>\n

The case of Ms. Hansot raises an additional question about power:
\n<\/sup>Was the physicians’ disregard for their patient’s wishes influenced
\n<\/sup>by the fact that Ms. Hansot and her daughter were women? We
\n<\/sup>will never know the answer, but it is an important questionto
\nask. In the legal world, for example, a study of appellatecourt
\ndecisions in right-to-die cases found that the courtsconsistently
\nportrayed female patients as less capable of rationaldecision making
\nthan male patients [12]<\/a>.
\nAnd the issue is notjust that men devalue women’s voices; it is much
\nmore complicated.Feminist psychologists have observed that women are
\noften moreinterested in the truths of relationships than in the
\ndictatesof abstract principles, in the knowledge derived from
\nhumanconnections rather than the knowledge derived from
\nimpersonalreasoning [13,14]<\/a>.
\nWhen Dr. Hansot confronted her mother’s physicians,a series of power
\ndynamics were put into play. Dr. Hansot wasa non-medical person
\nquestioning medical professionals; shewas a woman questioning men;
\nand she was posing the facts ofher relationship with her mother
\nagainst the facts of medicinepresented by the physicians. The
\npulmonologist accused Dr. Hansotof preoccupation with abstract
\nprinciples, but it seems to usthat just the opposite was true. It
\nwas the pulmonologist himselfwho was preoccupied with the general
\nmedical principle thatlife is good and death is bad. Dr. Hansot was
\npreoccupied withthe knowledge of her mother’s wishes, which she had
\nobtainedthrough a close, lifelong relationship. We are arguing not
\nthatone perspective is superior to the other but that the power
\n<\/sup>differential in the physician-patient relationship can represent
\n<\/sup>a deeper problem that impedes communication and interferes with
\n<\/sup>optimal medical care. If Dr. Hansot’s sex, her nonphysician
\n<\/sup>status, and her focus on her mother’s wishes rather than onher
\nmother’s physiology combined to make it difficult for thephysicians
\nto listen to her, then we can only recommend thatphysicians practice
\ntaking off their white coats. To understandand empathize with those
\nwho are sick or dying, we physiciansmust learn to talk to patients
\nand families as regular personsand must avoid raising the barrier of
\nmedical authority. Thepractice of medicine should not depend on
\noverpowering patientsand their families.
\n<\/span><\/span><\/span><\/span><\/p>\n

<\/a><\/span><\/span><\/span><\/span><\/p>\n\n\n\n
Other
\nObstacles to Communication <\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

Physicians
\nmay also fail to communicate with patients or ignoretheir requests
\nto limit care because of the stress and emotionaldiscomfort
\nassociated with confronting death. Physicians maybe uncomfortable
\nwith their own mortality and hence may avoidspending much time with
\ndying patients. Moreover, having beentrained to prolong life and
\novercome disease, they may feellike failures when they allow a
\npatient to die if that patient’slife could have been prolonged with
\nlife support. In this regard,withholding or withdrawing
\nlife-sustaining care can be one ofthe most difficult actions that a
\nphysician has to take. Physicianswho feel that they are unable to
\ntake such action probably shouldnot work in critical care.
\n<\/sup><\/p>\n

Discomfort with death may also explain one of the more disturbing
\n<\/sup>aspects of Ms. Hansot’s case: the feelings of abandonment experienced
\n<\/sup>by the patient and her daughter. Why did the physician of record
\n<\/sup>leave it to Dr. Hansot to determine that it was indeed possible
\n<\/sup>to communicate with the intubated patient? Why were none ofMs.
\nHansot’s physicians present at the time of death? Thereis an
\nunfortunate tendency in hospitals to avoid engaging thehumanity of
\ncritically ill patients near the end of life. Thefocus of
\nintensive-care-unit rounds can quickly turn from thepatient to the
\nflow sheet of vital signs and laboratory values.When this happens,
\nthe patient is denied some of the most importantbenefits that
\nmedicine has to offer, and the physicians aredenied one of their
\nmost meaningful roles, that of bedside caregiver.
\n<\/span><\/span><\/span><\/span><\/p>\n

Finally, physicians may fear the legal ramifications of withholding
\n<\/sup>or withdrawing life support. These ramifications are complicated
\n<\/sup>and still evolving, and they vary from state to state; we cannot
\n<\/sup>explore them in detail in this context. What is clear is that
\n<\/sup>physicians have no legal right to provide health care contrary
\n<\/sup>to the wishes of the legally competent patient. In the specific
\n<\/sup>area of cardiopulmonary resuscitation, case law indicates that
\n<\/sup>physicians face greater liability when they provide futile
\nresuscitationthan when they withhold resuscitation [15,16]<\/a>.
\nWithholding orwithdrawing care from incompetent patients contrary to
\nthe wishesof the family is a more complicated area that is beyond
\nthescope of this discussion. Dr. Hansot was the only family
\nmemberinvolved in her mother’s medical care, and she wanted life
\nsupportto be withdrawn.
\n<\/span><\/span><\/span><\/span><\/p>\n

<\/a><\/span><\/span><\/span><\/span><\/p>\n\n\n\n
Death
\nas a Colleague <\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

The
\nfailure to determine and respect the end-of-life wishesof patients
\nis an obstacle to improving the quality of medicalcare, an obstacle
\nthat will require doctors to come to termswith death and adjust
\ntheir vision of their role in patients’lives. It was not so long ago
\nthat physicians accepted tendingto and comforting the dying as one
\nof their responsibilities.Even with all of our advanced technology
\ntoday, a good deathis sometimes the best we can offer. Sadly, modern
\nmedicine frequentlydoes the opposite, denying patients a peaceful
\nand dignifiedexit from this world.<\/p>\n

Dr. Hansot’s account of her interactions with her mother’s pulmonologist
\n<\/sup>suggests problems encountered all too often in medicine: Itis
\neasier to keep patients alive on ventilators than to grapplewith
\nwithdrawing support, and it is easier to define successin terms of
\nlife and death than to try to determine the qualityof life that is
\nmeaningful to an individual patient. To thephysicians attending Ms.
\nHansot, sending a hemiparetic patientwith a tracheostoma out of the
\nhospital to live in a nursinghome counted as success. Ms. Hansot,
\nhowever, had indicatedthat she wanted to be allowed to die. The
\npatient in this caserecognized death as a friend; her physicians
\nwere unable toaccept death as a colleague.
\n<\/span><\/span><\/span><\/span><\/p>\n

<\/a><\/span><\/span><\/span><\/span><\/p>\n\n\n\n
Conclusion <\/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>
\n<\/a>\"\"Conclusion<\/span>
\n\"\"Author & Article
\nInfo<\/span>
\n<\/a>\"\"References<\/span>
\n<\/a><\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

Dr. Hansot
\npresents a troubling picture of medicine. She portraysphysicians who
\nare so preoccupied with the preservation of lifethat they can no
\nlonger see the broader human context of theirwork, physicians who
\nhave lost sight of one of the privilegesand responsibilities of
\nmedicine: to offer some humanity atmoments of suffering and loss.
\nMost disturbing, the physiciansfelt that they had the right to force
\na sick, elderly womanto undergo the frightening and uncomfortable
\nexperience of mechanicalventilation when she clearly wished to be
\nallowed to die.<\/p>\n

Requests for Reprints: Thomas A. Raffin, MD, Division of Pulmonary
\n<\/sup>and Critical Care Medicine, Stanford University Medical Center,
\n<\/sup>MC 5236, 300 Pasteur Drive, Room H3151, Stanford, CA 94305-5236.
\n<\/sup>
\n<\/span><\/span><\/span><\/span><\/p>\n

Current Author Addresses: Dr. Gilligan: Department of Internal
\n<\/sup>Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston,
\n<\/sup>MA 02115.
\n<\/span><\/span><\/span><\/span><\/p>\n

Dr. Raffin: Division of Pulmonary and Critical Care Medicine,
\n<\/sup>Stanford University Medical Center, MC 5236, 300 Pasteur Drive,
\n<\/sup>Room H3151, Stanford, CA 94305-5236.
\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
\"\"Top<\/span>
\n<\/a>\"\"Conclusion<\/span>
\n<\/a>\"\"Author & Article Info<\/span>
\n\"\"References<\/span>
\n<\/a><\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/a>From Stanford University
\nCenter for Biomedical Ethics and Stanford University Medical Center, Stanford,
\nCalifornia. <\/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>
\n<\/a>\"\"Conclusion<\/span>
\n<\/a>\"\"Author & Article
\nInfo<\/span>
\n<\/a>\"\"References<\/span>
\n<\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

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

1.<\/strong> Hansot E. A letter from a patient’s daughter. Ann Intern Med.
\n1996;125:149-151.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

2.<\/strong> Ruark JE, Raffin TA. Initiating and withdrawing life support.
\nPrinciples and practice in adult medicine. N Engl J Med. 1988;318:25-30.[Medline]<\/a><\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

3.<\/strong> Consensus report on the ethics of foregoing life-sustaining
\ntreatments in the critically ill. Task Force on Ethics of the Society of
\nCritical Care Medicine. Crit Care Med. 1990;18:1435-9.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

4.<\/strong> Reines HD. Attitudes of critical care medicine professionals
\nconcerning forgoing life-sustaining treatments [Editorial]. Crit Care Med.
\n1992;20:320-6.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

5.<\/strong> Cowley LT, Young E, Raffin TA. Care of the dying: an ethical and
\nhistorical perspective. Crit Care Med. 1992; 20:1473-82.[Medline]<\/a><\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

6.<\/strong> Gilligan T, Raffin TA. Rapid withdrawal of life support. Chest.
\n1996;108:1047-8.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

7.<\/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. 1995;
\n274:1591-8.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

8.<\/strong> Lo B. Improving care near the end of life. Why is it so hard? JAMA.
\n1995; 274:1634-6.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

9.<\/strong> Raffin TA. Withdrawing life support. How is the decision made?
\n[Editorial] JAMA. 1995;273:738-9.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

10.<\/strong> Cook DJ, Guyatt GH, Jaeschke R, Reeve J, Spanier A, King D, et al.
\nDeterminants in Canadian health care workers of the decision to withdraw life
\nsupport from the critically ill. Canadian Critical Care Trials Group. JAMA.
\n1995;273:703-8.[Abstract]<\/a><\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

11.<\/strong> Christakis NA, Asch DA. Physician characteristics associated with
\ndecisions to withdraw life support. Am J Public Health. 1995;85:367-72.[Abstract]<\/a><\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

12.<\/strong> Miles SH, August A. Courts, gender and the right to die. Law Med
\nHealth Care. 1990;18:85-95.[Medline]<\/a><\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

13.<\/strong> Gilligan C. In a Different Voice: Psychological Theory and Women’s
\nDevelopment. Cambridge, MA: Harvard Univ Pr; 1982.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

14.<\/strong> Belenky MF, Clinchy BM, Goldberger NR, Tarule JM. Women’s Ways of
\nKnowing: The Development of Self, Voice, and Mind. New York: Basic Books;
\n1986:100-52.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

15.<\/strong> Marsh FA. Physician authority for unilateral DNR orders. In: Wecht
\nCH, ed. Legal Medicine 1993. Salem, NH: Butterworth Legal Publishers; 1994:
\n283-98.<\/a>
\n<\/span><\/span><\/span><\/span><\/p>\n

16.<\/strong> Paola FA, Anderson JA. The process of dying. In: American College
\nof Legal Medicine. Legal Medicine: Legal Dynamics of Medical Encounters. 3d ed.
\nSt. Louis: Mosby; 1995: 404-23.<\/span> <\/span><\/span><\/span><\/p>\n

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

This article has been cited by other
\narticles:<\/strong><\/span>
\n<\/span><\/span><\/p>\n\n\n\n\n
\"\"<\/td>\n\"\"<\/td>\n\"Home<\/a><\/td>\n\"\"<\/td>\n\"Ann\"Home<\/a>
\nB. Lo, L.
\nSnyder, and H. C. Sox
\nCare at the End of Life:Guiding Practice
\nWhere There Are No Easy Answers<\/strong>
\nAnn Intern Med,
\nMay\u00a04,\u00a01999; 130(9): 772 – 774.
\n[Full
\nText]<\/a> [PDF]<\/a><\/p>\n

\"\"
\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>
\nJ. D. McCue
\nand L. M. Cohen
\nFreud’s Physician-Assisted
\nDeath<\/strong>
\nArchives of Internal Medicine, July\u00a026,\u00a01999;
\n159(14): 1521 – 1525.
\n[Full
\nText]<\/a> [PDF]<\/a><\/p>\n

\"\"
\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\"Chest\"\"Home<\/a>
\nA. M.
\nKarnik
\nEnd-of-Life Issues and the Do-Not-Resuscitate Order :
\nWho Gives The Order and What Influences the Decision?<\/strong>
\nChest,
\nMarch\u00a01,\u00a02002; 121(3): 683 – 686.
\n[Full
\nText]<\/a> [PDF]<\/a><\/p>\n

\"\"
\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\"Chest\"\"Home<\/a>
\nG. W. Ruhnke,
\nS. R. Wilson, T. Akamatsu, T. Kinoue, Y. Takashima, M. K. Goldstein, B. A.
\nKoenig, J. C. Hornberger, and T. A. Raffin
\nEthical Decision
\nMaking and Patient Autonomy : A Comparison of Physicians and Patients in
\nJapan and the United States<\/strong>
\nChest, October\u00a01,\u00a02000;
\n118(4): 1172 – 1182.
\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\"J\"Home<\/a>
\nA. R. Perry,
\nM. M. Rivlin, and A. H. Goldstone
\nBone Marrow Transplant
\nPatients With Life-Threatening Organ Failure: When Should Treatment
\nStop?<\/strong>
\nJ. Clin. Oncol., January\u00a01,\u00a01999; 17(1): 298 –
\n298.
\n[Abstract]<\/a>
\n[Full
\nText]<\/a> [PDF]<\/a><\/p>\n

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

\"\"<\/td>\n<\/tr>\n
\n
\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n
\n\n\n\n\n
\"\"\u00a0Article<\/strong><\/span><\/td>\n<\/tr>\n
\n\n\n\n\n\n\n\n\n\n\n
\u00a0\"\"<\/td>\nTable
\nof
\nContents<\/a>
\n<\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nAbstract
\nof this article<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nArticles
\nciting this article<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n
\"\"\u00a0Services<\/strong><\/span><\/td>\n<\/tr>\n
\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\u00a0\"\"<\/td>\nSend
\ncomment\/rapid response letter<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nNotify
\na friend about this article<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nAlert
\nme when this article is cited<\/a><\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nAdd
\nto Personal Archive<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nDownload
\nto Citation Manager<\/a><\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nACP
\nSearch<\/a><\/p>\n

<\/span><\/td>\n<\/tr>\n

\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n
\"\"\u00a0PubMed<\/strong><\/span><\/td>\n<\/tr>\n
\n\n\n\n
Articles in PubMed by Author:<\/strong><\/span><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n
\u00a0\"\"\"\"<\/td>\nGilligan, T.<\/a><\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"\"\"<\/td>\nRaffin, T. A.<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nRelated Articles in PubMed<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nPubMed Citation<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n
\u00a0\"\"<\/td>\nPubMed<\/a> <\/span><\/td>\n<\/tr>\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/p>\n

 <\/p>\n

\n
\n\n\n\n
\u00a0Home <\/a>| Current Issue <\/a>| Past Issues <\/a>| Search <\/a>| Collections <\/a>| CME <\/a>| PDA Services <\/a>| Subscribe <\/a>| Contact Us <\/a>| Help <\/a>| ACP Online\u00a0<\/a>
\n<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n


\nCopyright \u00a9 1996 by the American College of
\nPhysicians.<\/a><\/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 Abstract of this article \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-1347","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1347","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=1347"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1347\/revisions"}],"predecessor-version":[{"id":1349,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1347\/revisions\/1349"}],"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=1347"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}