End of Life

What Should We Do for Those Who Are Dying?

Jeff Menzise

• Publisher: National Issues Forums Institute
• Year: 2016
• ISBN:
  9781946206008
• Topic: Médecine
• Subtopic: Politique de santé

What ought to be done at the end of life is both a personal and public decision. As our population ages, it is becoming a matter of great concern for the entire nation. Diseases that would have been death sentences a few decades ago are now often treatable.This guide explores end-of-life decisions and examines options and trade-offs inherent in this sensitive and universal issue. Medical advances make it more likely that we will care for relatives in their final days, facing decisions regarding their illnesses or death—as well as our own. Even those who never face such choices will pay for them through tax dollars and the cost of insurance premiums. And as more states consider passing "right-to-die" laws similar to the one that took effect in Oregon in 1997, this debate may become a local one.Under most circumstances, end-of-life decisions remain difficult and uncomfortable. A Consumer Reports survey found that 86 percent of those polled wanted to die at home. But fewer than half of the respondents over age 65 had living wills detailing their dying wishes, leaving them at the mercy of hospitals and stressed-out families forced to decide on their behalf. In 1990, the US Supreme Court affirmed an individual's "right to die." Later, in 1997, the court upheld New York and Washington state laws banning physician-assisted death, leaving it for individual states to decide their legality. These rulings established legal precedence for a national conversation.This issue guide asks: What should society allow, and support, at the end of life? It presents three different ways of looking at the problem and suggests possible actions appropriate to each.OPTION 1: Maintain Quality of Life. That means when continued efforts to keep terminally ill patients alive a few more days or weeks result in needless pain and suffering, life-support treatment should be discontinued. At that point, caregiving efforts should be devoted to keeping patients comfortable and pain free.'OPTION 2: 'Preserve Life at All Costs. Do everything we can to prevent death. This means sparing no expense to extend the lives of those who are sick. It should be difficult for doctors to give up on patients, and the end must not be brought about by deliberate medical neglect or intervention. Right-to-die laws must be repealed.OPTION 3: 'My Right, My Choice. The freedoms we value so highly in choosing how we live should not be taken away from us at the end of our lives. People should have the right to end their own lives and to enlist their doctors in helping them to die when a terminal illness leaves nothing to look forward to but higher levels of pain and suffering.

Option 1:

Maintain
Quality of Life

MEDICAL ADVANCES CAN KEEP PEOPLE ALIVE almost indefinitely. While these technologies work to increase life span, they sometimes do nothing beneficial for quality of life. A diminished quality of life is the reason most Americans would choose to die without further medical intervention.

One-third of US adults have written down their desires regarding end-of-life care. These advance directives (or living wills) tell doctors what to do in cases in which patients are unable to communicate their wishes. People may opt for cessation of treatment when they are chronically ill, in severe pain, or totally helpless.

Living pain free, with relative independence and with full mental capacity, is universally desired, according to this option. Improving and maintaining people’s quality of life as long as possible should be our priority. But some treatments for the terminally ill are unlikely to prolong their lives for more than a few days or weeks while degrading their quality of life by causing more pain and suffering.

Avoid Painful and Debilitating Treatments

In this view, we should require doctors to use only the least invasive treatments for the terminally ill. Unnecessary medical procedures expose patients to physical ordeals and inflict both financial and emotional pain on them and their families.

“Avoiding unnecessary medical care is important because care that is not needed can be harmful to patients, and unnecessary care raises health-care costs for everyone,” according to Richard J. Baron, MD, president and CEO of the ABIM Foundation, which advocates for advancing medical professionalism. Yet, in America, most doctors are paid by the services they give and the tests they order, often with little regard to cost. Left alone, the system itself rewards doctors for ordering more medical services, not fewer.

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By restricting medical professionals from using certain painful, debilitating, and noncurative procedures, we can at least eliminate a major contributor to end-of-life suffering. Surgeries that do not cure, chemotherapy and radiation that create sicker patients, and unnecessary, invasive tests should only be used on those patients with a positive prognosis—those who are physically and emotionally strong enough to handle the side effects and results.

Standardize Quality-of-Life Definitions

We also need medical organizations to come up with a standard definition of “quality of life.” Medical doctors should have a uniform understanding of “quality of life” and should be required to work within those boundaries. If a procedure would reduce a terminal patient’s quality of life, it should not occur.

Many physicians struggle with making decisions about performing debilitating procedures. In the presence of a sick and dying patient, it can be difficult to convey the risks, especially when the patient insists that something be done.

“Post-diagnosis is a hard time to begin that conversation, because the patient is scared,” Daniel Barocas, an assistant professor of urology at Vanderbilt University Medical Center, told Scientific American. “If you tell someone they have what they perceive as a lethal disease, they’re going to seek treatment. This effort encourages discussions where doctors and patients can let data and evidence run the show a little instead of emotionality and fear.”

Defining a good quality of life will not be easy. Setting standards will require a variety of voices. For most people the definition would include living pain-free, maintaining independence, and retaining a sound mind. But it will vary greatly among individuals and, in particular, among those with disabilities—some of whom live with conditions that make them less able to live independently or more prone to pain. For those people and for patients with serious illnesses, consideration will have to be given to matters of degree. In any case, in the last months or weeks of a terminal patient’s life, this option holds that treatments that risk decreasing the present quality of life should not be undertaken.

Require Living Wills

Citizens should develop living wills. Doing so alleviates the emotional burden that loved ones experience when forced to make end-of-life decisions for a relative. Dying people should be strongly encouraged to develop living wills immediately following diagnosis.

The Caring Advocates organization has adopted a Plan Now, Die Later model for addressing end-of-life issues. They provide Advance Care Planning, a program designed to reduce suffering during the final stages of life. Surprisingly, it often leads people to choose to live longer.

Employers could require employees of a certain age to formulate a living will as part of their insurance policies. “What if, to be eligible for Medicare, you had to give someone power of attorney and sign a living will?” asked Ezra Klein in the Washington Post. This would surely cut down on much of the confusion and hardship faced by dying persons and their families. It could beco...