In the United States, death is a taboo
subject for many, and most people avoid preparing for it until late in their
own lives, and some not even then. Many attend to last wills and testaments,
estate planning, and taxes, but less than 15% of the adult population is
prepared to make advance decisions about restrictions on life-supporting
measures. Yet surveys consistently show a strong preference for a dignified,
comfortable, and peaceful death at home and a strong wish to avoid dying in a
hospital, particularly in an ICU.
The quandary about what to do is particularly vexing when it concerns a
surgical patient who sought relief from symptoms, improved functional-ity, and
a better quality of life, but who ends up with a bad outcome requiring ongoing
life-supporting measures with little prospect of achieving the goals of the
A substantial number of physicians cannot
discuss such difficult situations in a humane, non-adversarial manner or deal
with the anger, despair, and other emotions of family members and friends whose
expectations have not been met. Good com-munication skills are the essential
foundation. Communications with the family, friends, and all caregivers must be
timely, consistent (having only one physician serve as the spokesman has great
advantages), accurate, clear to laypersons, advisory without being dictatorial,
focused on what is best for the patient, and aligned with the patientâ€™s wishes.
A gradual stepwise approach over time allows family members and friends time to
digest the information; get beyond their normal, initial reactions to the bad
news; and make the difficult decision to withdraw intensive support.
Finally, it is important to recognize two
ethi-cal principles that are relevant here. The first is the principle of
double effect. All medical interventions have potential benefits as well as
burdens and risks. If the doses of morphine or sedative drug required to
relieve pain and agitation result in unintended side effects, we accept them,
even if the result is death. Thisis not
euthanasia. The second principle is that with-drawal of medical therapies
and interventions is no different from withholding them: both may be done to
respect the patientâ€™s autonomy. There is a broad religious consensus that
heroic measures are not mandated to support a heartbeat at the end of life.