As much as medicine revolves around preventing and treating illnesses, and sometimes defying death, death is as sure as that which is born. There are patients that are accepting towards the prospect of dying, while some raise the white flag and others fight for their lives.

Modern technology and treatment while being able to prolong and save lives, can also mean prolonging death to some - one person’s salvation may be another’s living hell.

Must doctors save their patients?

End of life decisions can become very difficult if a patient’s personal wishes conflicts with the professional views of the doctor, or if a patient leaves such decisions up to their doctor. Should doctors be a judge as to what is an acceptable quality of life for a given individual?

Furthermore, different treating physicians may have conflicting views on a patient’s prognosis. For example, an intensivist monitoring minute-to-minute changes in a patient may have a different viewpoint from the patient’s surgeon.

For many terminal illnesses, physicians are not able to reliably predict a patient’s remaining life expectancy. Diseases can follow unexpected courses and patients can end up surviving for many years.

According to Michael Belkin, chief of vascular and endovascular surgery at Boston’s Brigham and Women’s Hospital, prognostic scoring systems have little predictive value in the care of the individual patient.

“Those population-based scores break down when applied to individuals. Renal failure in one patient is not the same as renal failure in another,” Belkin said.

“On the one hand, we want to do our very best to pull the patient through to recovery. On the other hand, we have to be able to recognise when it’s time to “let go” and allow the patient to pass with comfort and dignity,” Belkin said.

Present the facts and then respect their decision

Patients with terminal illnesses should be led to frank discussions about inevitable death and given full respect to choose their destiny.

“It is your life. As your doctor, my job is to guide, not order or command. It is about you, not me. You are the patient. I am the teacher and healer,” said oncologist James C. Salwitz.

While young patients may choose to fight their illness aggressively, a 2008 study by Boston researchers showed that when told honestly about their prognosis and risk-benefit ratio of treatment, terminally ill patients tend to choose comfort care rather than pursue treatment.

The first author of the study, Dr. Alexi A. Wright, a medical oncologist at the Dana-Farber Cancer Institute, concluded that there was “a need to increase the frequency” of end-of-life conversations.

According to Dr. Diane E. Meier, director of the Hertzberg Palliative Care Institute, regardless of how near or far death may be, patients should be told about and receive palliative care whether or not they are treated for their underlying disease.

The patient’s wishes come above all else

When faced with the critically sick, doctors must understand the limits of their role, respect the choices of their patients, and embrace that sometimes, stopping care is the best care.

“The majority of families depend on us to educate them as they make difficult decisions about their loved ones in the ICU. They are often heavily swayed by what we tell them,” said Belkin.

“If the best outcome we can expect for a patient is to be bedridden, institutionalised and dependent for all activities, we need to be certain that that is an outcome acceptable to that person. The important priority is the patient’s values and preferences,” said Nicholas Sadovnikoff, co-director of Boston’s Brigham and Women’s Hospital’s surgical intensive care unit (ICU).

When patients are unable to speak for themselves, family meetings are important to understand the patient’s goals and values, so that medical decisions can be tailored to do best by the patient. MIMS

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