What Care for the Terminally Ill?
IN RECENT times people’s approach to death and dying has been undergoing change in many parts of the world.
In times past physicians accepted death as the inevitable end of their ministrations for some patients—an end to be eased, and often to be handled at home.
More recently, with the emphasis on technology and cure, medical personnel have come to regard death as a failure or a defeat. So the primary goal of medical practice has become that of preventing death at all costs. With this change came the development of a whole new technology to keep people alive longer than would previously have been possible.
Medical technology has brought undeniable advances in many lands; nevertheless, it has given rise to some serious misgivings. One doctor commented: “Most physicians have lost the pearl that was once an intimate part of medicine, and that is humanism. Machinery, efficiency and precision have driven from the heart warmth, compassion, sympathy and concern for the individual. Medicine is now an icy science; its charm belongs to another age. The dying man can get little comfort from the mechanical doctor.”
That is just one person’s opinion, and it certainly is not a universal indictment of the medical profession. Yet, you have probably seen that many people have developed a fear of being kept alive on machines.
Gradually another view began to be heard. It was that in some cases people should be allowed to die naturally, with dignity, and without being subjected to the intervention of heartless technology. A poll recently conducted for Time magazine revealed that over three quarters of those contacted felt that a doctor should be allowed to withdraw life-sustaining treatment for a terminally ill patient. The study reached this conclusion: “Once reconciled to the inevitable, [people] want to die with dignity, not tethered to a battery of machines in an intensive-care unit like a laboratory specimen under glass.” Do you agree? How does that compare with your view on the subject?
Depending on one’s culture or social background, there is great variation in approaches to the subject of death and dying. Yet, people in many countries are showing increased interest in the plight of the hopelessly ill. In the last few years, ethicists, doctors, and the public in general have promoted efforts to adjust the care for such unfortunate ones.
Among the many measures being explored to address this issue, the one most commonly implemented in some hospitals is the policy “Do Not Resuscitate,” or DNR. Do you know what this involves? After extensive discussions with the patient’s family, and preferably also with the patient, specific advance plans are made, and these are noted on the patient’s chart. This focuses on what limitations will be imposed on efforts to revive, or resuscitate, the hopelessly ill patient should his or her condition worsen.
Nearly everyone recognizes that the overriding consideration in such difficult decisions should be “What would the patient want done?” What makes it a serious problem, though, is that often the patient is unconscious or otherwise incompetent to make informed personal decisions. This has given rise to a document that may be called a living will. It is designed to allow people to specify in advance what treatment they would desire in their last days. For example, such a will might read:
“If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain.” Such documents may even specify what sort of therapies the individual does or does not want applied in a terminal situation.
Such living wills, though not legally binding under all circumstances, are recognized in many places. An estimated five million people in the United States have drawn up medical living wills. Many authorities in that land consider this to be the best means available to ensure that one’s wishes are respected and followed.
What Type of Treatment or Care?
What about the actual care of the terminally ill? Perhaps the most significant innovation has been the concept called hospice, increasingly recognized worldwide. Just what is “hospice”?
Rather than meaning a place or a building, hospice in this sense refers really to a philosophy or program of care for the terminally ill. It is derived from a medieval French word for a place of rest for pilgrims. Hospice concentrates on a team approach (doctors, nurses, and volunteers) that works to ensure that a terminally ill patient is kept comfortable and relatively pain free, preferably in the patient’s own home.
Though some hospices are based within hospitals, many are independent. Most avail themselves of community resources, such as visiting nurses, nutritionists, ministers, and chiropractors. Rather than employing heroic medical measures, hospice care emphasizes heroic compassion. Rather than aggressive treatment of the patient’s disease, it focuses on aggressive treatment of the patient’s discomfort. One doctor put it this way: “Hospice isn’t less care or no care or cheap care. It’s just a totally different kind of care.”
What is your reaction to this concept? Does this approach seem like one that you feel should be discussed with any of your loved ones who might be diagnosed as facing a terminal condition, and perhaps with the physician involved?
Even though hospice care may not be available in your area now, chances are it will be in the future, as the hospice movement is growing worldwide. Originally viewed as an antiestablishment effort, hospice care has gradually entered the mainstream of medicine, and it is now considered an accepted alternative for the terminally ill. Through its techniques, especially proper use of painkillers, hospice has contributed some notable advances to health care.
In a letter to the New England Journal of Medicine, Dr. Gloria Werth described the death of her sister in a hospice: “At no time was medication, food, or liquid forced on my sister. She was free to eat, drink, . . . or take medication as she wished . . . But the best thing about the hospice is that our memories of Virginia’s death are unusually reassuring and happy. How often can this be said after death in an intensive-care unit?”
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“Medicine is now an icy science; its charm belongs to another age. The dying man can get little comfort from the mechanical doctor”
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Hospices focus on aggressive treatment of the patient’s discomfort rather than aggressive treatment of the disease itself