American College of Physicians: Internal Medicine — Doctors for Adults ®


Dying patients deserve to live final days with dignity

Physicians should be consensus builders, laying out the available options and working with family members

From the June ACP Observer, copyright 2005 by the American College of Physicians.

By Janet Colwell

SAN FRANCISCO—A 25-year-old female athlete arrives in the emergency room after a severe asthma attack. En route to intensive care, she asks her physician to promise not to put her on a breathing machine if her condition deteriorates. Does the doctor make that promise and write out a "do not resuscitate order"? Or should he or she try to talk her out of her DNR request as she gasps for air?

Most physicians attending this year's "Doctors, Death and Dignity" presentation at Annual Session decided against ordering the DNR because the patient was young, otherwise healthy and suffering from a treatable disease. But how does a physician handle the actual request?

Steven A. Levy, FACP, tells session attendees that physicians shouldn't present treatment as a viable option if they think it's futile.

Such ethical questions are on many physicians' minds in the wake of the Terri Schiavo "right-to-die" case. How should physicians handle family wishes that run counter to their best medical judgment? What role should physicians play in final end-of-life decisions? And should they help patients die comfortably or keep them alive through extraordinary interventions?

As difficult as these situations are, said session leader Steven A. Levy, FACP, associate clinical professor at Lake Erie College of Osteopathic Medicine in Erie, Pa., physicians' effective communication skills and empathy can minimize conflict. Learning what the family is truly concerned about can also dissipate anger and ease confusion.

Focus on goals

According to Dr. Levy, there has been a shift in how physicians think about dying patients: Instead of focusing on interventions, they are now focused on real treatment goals.

Physicians, he said, should be consensus builders as they lay out the available options and work with family members to arrive at informed decisions.

Dr. Levy's advice: "Never ask someone, 'What do you want us to do?' or 'Do you want us to do everything?' Most families will say 'yes' out of guilt without thinking about the implications," he said. Instead, tell families that you will do everything possible "that will help--because what most people are really saying when they ask for 'everything' is 'please take good care of my mom.' " (For your patients with low literacy, see "New advance directive geared to patients with low literacy.")

Facing the inevitable

Dr. Levy presented another case—an 84-year-old woman with a large intracerebral bleed who arrived at the emergency room comatose and unresponsive. Most physicians in the audience agreed that a DNR order would be appropriate—but what if the family disagreed?

Again, talk and listen to the family, Dr. Levy said. "We often throw cold, dispassionate logic at an emotionally distraught family when what we really need to do is listen and to let them clear their heads."

Using the example of that elderly woman, Dr. Levy said you shouldn't present treatment as a viable option if you think it's futile. Instead, you might want to say, "I could jumpstart her heart, but I don't think that's going to help your mother."

With so many health care advances, people often expect that death can be avoided, noted Dr. Levy. But when death is inevitable in the absence of extraordinary measures, physicians should shift gears and help people die with dignity.

"Palliative care is the most important thing we can do for a dying person," he said. "But too often it is dismissed as not doing enough."

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.


New advance directive geared to patients with low literacy

A California nonprofit has created a new advance directive form designed specifically for low-literacy Americans.

The document is being distributed free online by the nonprofit Institute for Healthcare Advancement (IHA). The directive has a simple fill-in-the-blank format with illustrations and easy-to-read bullet points. The directive allows low-literacy patients to make their health care wishes known, choose an agent to make medical decisions for them and provide the necessary signatures to make the document legally binding.

Geared to the 90 million American adults who read below a fifth-grade level, the directive was developed jointly by the University of California at San Francisco, San Francisco General Hospital and the San Francisco Department of Public Health.

Instructions for downloading the document or for ordering copies in bulk are online. For more information on health literacy, see the ACP Foundation Web site. Also, ACP's end-of-life care resource page is online.


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