HOUSTON--In the current health care environment, peaceful deaths are seriously threatened as clinicians attempt technological brinkmanship and patients and families demand that "everything be done" to extend life, said Rebecca Pentz, PhD, a clinical ethicist at The University of Texas M.D. Anderson Cancer Center.
"Calls for CPR have replaced last rites; the ICU has become the dying room; and critical care nurses, tubes, and machines have become the patient's bedside companions," Dr. Pentz said at an M.D. Anderson-sponsored symposium on cancer and the central nervous system
Dr. Pentz calls this approach to end-of-life care "high-tech" dying. She suggests that although the scientific goals of this approach may be well founded, significant ethical, emotional, and economic factors have been compromised.
Hospice physicians define a peaceful death as one in which the patient is alert, pain free, and surrounded by family and friends. In the report from the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT), an undesirable death was described as occurring in an intensive care unit with the patient either receiving mechanical ventilation or in a comatose state.
Dr. Pentz says deaths in America are drifting more toward this scenario, which Daniel Callahan refers to as "wild deaths" in his 1993 book The Troubled Dream of Life: Living With Mortality.
A Two-Step Approach
One way to avoid "wild" deaths and to ensure that the patient's ethical and emotional needs are satisfied is to provide patients and family members with the information they need to make informed decisions.
Dr. Pentz has proposed a two-step solution in which the medical staff consults with appropriate decision-makers at specific time points during end-of-life care.
Her approach, which is aimed at promoting a more "low-tech" scenario, would involve the medical team and decision-makers in two consults: a frank discussion and a "do not resuscitate" (DNR) discussion.
The frank discussion should take place when the patient's prognosis dims and survival is most probably less than six months. The goals of the frank discussion, Dr. Pentz said, are to produce advance directives and specify a Durable Power of Attorney for Health Care, and to explain the patient's care options at this point: aggressive treatment or palliative care.
"We rob the patient of an important choice," Dr. Pentz argued, "if both options are not described."
The DNR discussion may immediately follow the frank discussion or occur months later. Dr. Pentz believes strongly that the DNR discussion should be held with the patient when possible.
A More Formalized Approach
"About 87% of resuscitation consults are held with the family because the patient is incapacitated," she said. "It is important that the DNR option be discussed with the patient as soon as there is an indication that it might be necessary because the patient has the ultimate right to decide how he or she wants to die."
Although such consults are already held in many instances, Dr. Pentz is proposing a more formalized approach in an open, reciprocal environment.
"Both discussions will be difficult, and the medical team should be prepared to address the patient's ethical and emotional concerns as well as medical questions," she said. "A team consultation, in which an ethicist, a clergyman, and a psychologist are available if needed, is the best approach."
What role does economics play in ensuring peaceful deaths? "At one level, very little," Dr. Pentz said. "The goal of low-tech deaths is not to save money but rather to provide a more natural, supportive environment for the patient to spend his or her final days."
The Cost of a Low-Tech Death
Dr. Pentz said that it makes sense that low-tech deaths would cost less because the requirements for special equipment and technology, and, likewise, the expertise to operate the devices and execute the procedures, would be less; however, she said, there are no data to support this claim.
"Clinicians have forgotten that one of the explicit goals of medicine is ensuring the patient a peaceful death," Dr. Pentz said. "Although the science of medicine is a priority, the ethical aspects of patient care must be recognized, and, foremost, the patient's right to participate in care decisions must be respected."