"Time to Talk About Death"

I agree a lot with this article. Another problem is that doctors don't always discuss end of life care with patients-partly out of discomfort of that they perceive they are "giving up" on the patient-and the patient doesn't even know that there are choices to be had.

And, as the article states, families insist on going against patient wishes and demand expensive futile treatments. Courts need to take a firmer hand in upholding living wills and other documentation that a person may write up before they become incompetent.

Even more important than a living will is the choice of MPOA. Advanced directives and living wills are fine but an MPOA can legally choose other options for care.

There is no question that our society has a "problem" with death. Too many people, including doctors and nurses, have a difficult time talking about death as a natural outcome to our lives. I have dealt with many, many families who are insistent that no one mention death, dying, or hospice to the elderly person who is dying from their disease. They apparently believe that a dying person has no sense of what is happening to them if it is not spoken about. These families are often afraid that discussion of death somehow translates into "giving up" or "no hope". Physicians often promote this misconception when they have the "there is nothing more we can do..." talk with patients and families. First, there IS more that they can do. The traditional medical focus is rarely on symptom management, they CAN be less afraid and more proactive in treating the symptoms of the incurable diseases. Secondly, why do healthcare providers avoid speaking with patients who have terminal illnesses about their death until (in many cases) death is imminent...often within days or weeks? Do they allow their personal prejudices or fears to interfere with their ability to educate their clients appropriately? Or are the providers poorly informed as well? We can see that people are fearful of death...recent shouting about "death panels" and informational pamphlets for veterans is evidence that people are quick to believe that discussion about options is tantamount to advocating euthanasia.
The bottom line is this...we are all born (one way or another), we all live and breathe for a period of time, and we all die (one way or another). As long as we continue to avoid discussion of death we will continue to have a system which promotes and provides painful, invasive, expensive, and futile treatments and procedures for people who will have no improved quality of life because of them. As long as we continue to view death as defeat in the medical arena we will waste resources whilst chasing after immortality. And, by the way, the most valuable resource we waste in that chase is the very valuable TIME that the terminally ill person has remaining in their life.
Too many people die in pain, in anxiety, in fear, in the hospital. Every day I encounter people who are afraid of the death of a loved one, people who begin to realize that they ARE capable of providing the needed care, that dying does not equate to suffering, that there is such a thing as a "good death", that there is great value in openly discussing life and death allowing Mom or grandma to "take care of business" and say the things that they long to say before they embark on the greatest adventure...that of eternity. I find that those doctors, nurses, and families who allow honest discussion about the inevitability of death are enriched by the relationships and dialogs that are grown out of that honesty.

There are worse things in this world than the natural process of dying. The pain and suffering some patients have to go through just to keep them alive can be akin to torture. Quality of life should be more important than the quantity of life. There are things I see families do to their loved ones that I guarantee they wouldn't do to their pet dog. Why is it ok to do it to grandma if you wouldn't do it to your elderly dog?

Death is a natural part of life, and I agree that our society has a problem with this. Doctors are hesitant to discuss DNR/DNI options with families. I've even seen doctors who think a DNR means the same thing as "comfort cares" Medical schools and nursing schools need to do better jobs at educating docs and nurses about death and how to help patients plan for end of life cares. As a society, we spend more money "saving" people who should never be saved (i.e. out of hospital codes with no signs of life on scene), than on preventing illness in the first place.

For people who think I'm being crude with the above statement, please consider this article on the use of capnography in cardiac arrest patients: http://www.rtmagazine.com/issues/art...2008-01_05.asp

" ETCO2 measurement during CPR can both assess effectiveness of the CPR and predict survivability as well. Levels of ETCO2 have a predictive correlation to cardiac output. As pulmonary bloodflow decreases during cardiac arrest, CO2 levels in the bloodstream are decreased, which can be evaluated using a capnograph waveform. Studies have shown that, without a return to ETCO2 levels of 10 mm Hg or more after 20 minutes of CPR, there is a 100% mortality rate."

Other countries use capnography to determine whether or not resuscitation will be futile. Generally speaking, we in the United States do not. We have to "save" everyone!

We see this issue popping up all the time. This is why EDUCATION is the key. Clinicians should always provide continued education.......

Thanks for the article. One thing pops into my head--it's not just patients that are afraid of death. While clinicians may understand the physiology of death better, or see death more often, that doesn't make them any less afraid of it. In fact, since part of the occupational creed of healthcare professionals is to AVOID death, it makes accepting a natural course all the more difficult.

What hospital nurse has not seen a very sick patient who is still a full code, maybe has little family support or ability to communicate, or other socially complex situations, have test after test/consult after consult done before either the patient DOES code and die, or someone (usually family or a nurse) takes the reigns in talking about end of life care?

It's sad to watch.

I am apppalled at the number of people who come through my doors not realizing that their loved ones will die in the next 2 days or so. The doctors simpley do tell families that the patient is dying. They use words like, nothing more can be done, comfort care only, end of life care. But to flat out say, your mom is dying, just is NOT done. I get the deer in the headlight look when I say that word. 100 years ago when we took care of our loved ones at home, we knew what to look for in the dying patient. Now what is so very obvious to me I practically have to hit over the family's head. It is very sad.

I am having a difficult time with this article. Back in the 1980's there was a huge court case about euthanasia. It sparked a national debate. Then, a few years back there was that Dr. Kavorkian who played God. Everybody has some fear regarding death. For me, I am not afraid of dying, just of the pain involved. But I do not want to die. None of us do--unless we are clinically depressed anyway. Who gets to make that "BIG DECISION" about who shall live or die? I can empathise with that daughter who let her Mother go because she thought it was the best thing. I took care of my Mother. We had the living will and all the necessary paperwork. But, when it came down to those final moments, I said "no" to that second IM of morphine. It was a selfish and stupid thing to do. I know better. I just could not let go--I was not ready. Was I wrong, yes. I sat there holding my Mom's hands and crying and singing to her. She did pass a few hours later. I have always asked myself: Was she in more pain because of that decision? Would she have wanted to die sooner (with that morphine injection) ? It is such an emotional area. And the emotions at that time are anything but rational. Yet, I do not want someone else making those decisions for me except me or my family. Third parties should stay out of it. Medicare monies are spent so very foolishly anyway. I doubt if that will ever stop. Hope, finding that right diagnosis, comfort--if you want these things, no government, judge, panel of death or whoever else has no right to decide if you get that blood work, MRI or even pet scan. Give people the dignity of dieing on their terms--yes--do not let them go without because it costs too much to keep them alive.

Very interesting discussion.

We are also discussing this article in the staff blog entitled

Discussing End of Life Issues Part 2 - Living to a Ripe Old Age

More discussion about end of life issues can be found in the following threads:

Who is Responsible for Discussing End-of-Life Treatment Options?

Spiritual Beliefs and End of Life Care

Self-Assessment of Your Beliefs About Death and Dying