Two-Step Approach Urged to Avoid High Tech, Wild Death

HOUSTON--In the current health care environment, peaceful deaths areseriously threatened as clinicians attempt technological brinkmanship andpatients and families demand that "everything be done" to extendlife, said Rebecca Pentz, PhD, a clinical ethicist at The University ofTexas M.D. Anderson Cancer Center.

"Calls for CPR have replaced last rites; the ICU has become thedying room; and critical care nurses, tubes, and machines have become thepatient's bedside companions," Dr. Pentz said at an M.D. Anderson-sponsoredsymposium 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 approachmay be well founded, significant ethical, emotional, and economic factorshave been compromised.

Hospice physicians define a peaceful death as one in which the patientis alert, pain free, and surrounded by family and friends. In the reportfrom the Study to Understand Prognosis and Preferences for Outcomes andRisks of Treatment (SUPPORT), an undesirable death was described as occurringin an intensive care unit with the patient either receiving mechanicalventilation 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 1993book The Troubled Dream of Life: Living With Mortality.

A Two-Step Approach

One way to avoid "wild" deaths and to ensure that the patient'sethical and emotional needs are satisfied is to provide patients and familymembers with the information they need to make informed decisions.

Dr. Pentz has proposed a two-step solution in which the medical staffconsults with appropriate decision-makers at specific time points duringend-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 prognosisdims and survival is most probably less than six months. The goals of thefrank discussion, Dr. Pentz said, are to produce advance directives andspecify a Durable Power of Attorney for Health Care, and to explain thepatient's care options at this point: aggressive treatment or palliativecare.

"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 occurmonths later. Dr. Pentz believes strongly that the DNR discussion shouldbe held with the patient when possible.

A More Formalized Approach

"About 87% of resuscitation consults are held with the family becausethe patient is incapacitated," she said. "It is important thatthe DNR option be discussed with the patient as soon as there is an indicationthat it might be necessary because the patient has the ultimate right todecide how he or she wants to die."

Although such consults are already held in many instances, Dr. Pentzis proposing a more formalized approach in an open, reciprocal environment.

"Both discussions will be difficult, and the medical team shouldbe prepared to address the patient's ethical and emotional concerns aswell as medical questions," she said. "A team consultation, inwhich an ethicist, a clergyman, and a psychologist are available if needed,is the best approach."

What role does economics play in ensuring peaceful deaths? "Atone level, very little," Dr. Pentz said. "The goal of low-techdeaths is not to save money but rather to provide a more natural, supportiveenvironment 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 lessbecause the requirements for special equipment and technology, and, likewise,the expertise to operate the devices and execute the procedures, wouldbe less; however, she said, there are no data to support this claim.

"Clinicians have forgotten that one of the explicit goals of medicineis ensuring the patient a peaceful death," Dr. Pentz said. "Althoughthe science of medicine is a priority, the ethical aspects of patient caremust be recognized, and, foremost, the patient's right to participate incare decisions must be respected."