Chapter contents

The Physician's Attitude

The Physician's Attitude

The "Right Time" to Die

54

Communication

55

When to Tell the Patient

55

How to Tell the Patient

56

Prognosticating

57

Conspiracy of Silence

57

Denial

57

"Watch with Me"

58

Patient Control

58

The Importance of Hope

59

Discussing Religious and Spiritual Issues

59

Prolonging Living or Prolonging Dying?

59

Management of Symptoms

59

Pain Control

60

Visceral Pain and Smooth Muscle Spasm

65

Anxiety and Depression

65

Dyspnea

65

Constipation

66

Nausea and Vomiting

67

Hiccup

67

Subcutaneous Route

67

Nutrition

67

Where to Die

68

Hospice Care

68

Support for the Family

69

Selecting a Hospice

69

Advance Directives

69

Medical education and our professional attitude regarding patient care are oriented primarily toward sustaining life and curing disease. This is reasonable, because not long ago the major causes of death were the infectious diseases, which usually attacked young people, who died before experiencing life. With the advent of antibiotics, it was possible to triumph over these diseases and prevent untimely death. Patients had a high probability of complete recovery. It is no surprise, therefore, that the medical profession emphasized preserving life at all costs and became preoccupied with the advancing technology that made such triumphs possible. Today, people no longer die of acute illness, but rather from chronic disease for which there is no cure. This calls for medicine to focus on improving the quality rather than the quantity of life and to recognize that the relief of suffering is superior to attempts to cure when there is limited likelihood of success. Patients with chronic diseases and those who are terminally ill will benefit most from supportive therapy.

In previous centuries, it was assumed that life should be lived so that one would be able to "die well," but contemporary American culture has refused to accept death as a normal occurrence. Children and young adults have been conditioned to consider death from the viewpoint of the observer or disinterested third party. An individual's attitude toward his or her own death depends largely on experiences in dealing with the deaths of relatives or friends. Rather than a time of despair, sickness may be used as an opportunity for reflection. For some patients, it may be the first time they have faced their own mortality. Too often, however, this natural personal encounter has been depersonalized by removing the dying patient to an institutional setting.

Care of a terminally ill patient typically focuses on the disease, neglecting the patient as a whole person. The value of treatment must be interpreted on the basis of its net value to the individual. When additional treatments no longer provide benefits, the patient needs someone who provides personalized care with attention to the patient's emotional as well as physical comfort. The dying person often is isolated physically and emotionally from familiar surroundings and placed in a social setting that gives very low priority to an individual's personality, fears, and past experiences. Informed physicians, family, and friends can do much to help the terminal patient die with integrity and with dignity. However, if dying is really to be accepted as a normal component of the life cycle, reintegration of the dying patient into the routine course of living is necessary.

The concept of quality care does not always demand that death be regarded as an enemy to be fought with every weapon at a physician's disposal. An obsession with quantity of life can adversely affect its quality; at times, a graceful death with dignity is preferable to lingering torment (LORAN Commission, 1989, p. 27). Many people consider

©2011 Elsevier Ltd, Inc, BV

DOI: 10.1016/B978-1-4377-1160-8.10005-3

quality of life more important than quantity and want to leave while they still have something to say about it. Today, it is possible to keep people alive indefinitely, often without consideration for the quality of life.

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