End-of-life care: What’s the physician role in healthy dying?

There is a growing awareness of the incongruence between the way Americans say they want to die and how they actually do. Most agree that this reality is not the ideal that physicians or patients strive for. Less agreed upon, though, is what the roles of patients and physicians should be in defining what actually constitutes dying, and good care of those who are dying.

What patients and physicians need to know about dying and care at the end of life is an important set of questions explored in the August issue of AMA Journal of Ethics® (@JournalofEthics).

Articles include:

“How Do Medicalization and Rescue Fantasy Prevent Healthy Dying?” Before antibiotics, cardiopulmonary resuscitation and life-sustaining technologies, people had little choice about the timing and manner of their deaths. Today, the medicalization of death has enabled patients to delay death, prolonging their living and dying.

New technology, media influence, and medical professionals seem to have transformed dying from a natural part of the human experience into a medical crisis from which a patient must be rescued. This article examines problematic forms of rescue medicine. It also suggests the need to rethink medicalized dying within the context of medicine’s orientation to health and wholeness.

“For People Dying to Talk, It Finally Pays to Listen with Reimbursable Advanced Care Planning.” Whether at the beginning, middle or end of life, there are numerous health care delivery choices. Yet only recently have conversations specifically regarding preferences for care at the end of life become a reimbursable intervention, deemed equivalent in importance to a medical procedure.

Quite distinct from other procedures, in which expectations for outcomes are explicit and measurable, outcomes have been left intentionally vague for advanced care planning conversations. This article explores challenges of and opportunities for developing formalized outcomes, methods of measurement and training to ensure excellence in advance care planning conversations.

“Clinical Momentum as One Reason Dying Patients Are Underserved in Acute Care Settings.”  Clinical momentum refers to the curious expansion of interventions applied to patients in the intensive care units without pause or design, leading to care that can violate patient wishes and distress physicians.

This article places clinical momentum in a wider context that includes ritual, reimbursement patterns and actor network theory. These contextual features help motivate understanding of one way in which dying patients are underserved in intensive care settings.

“How Should Physicians Manage Organ Donation after the Circulatory Determination of Death in Patients with Extremely Poor Neurological Prognosis?” Organ donation after the circulatory determination of death (DCDD) accounts for a growing percentage of deceased organ donations. Although hospital DCDD protocols stipulate donor death determination, some do not adhere to national guidelines that require mechanical, not electrical, asystole.

Surrogate decisions to withdraw life-sustaining care should be separated from decisions to donate organs. Donor families should be given sufficient information about the DCDD protocol and its impact on a patient’s dying process to provide informed consent, and donors should be given proper palliative care during dying.

In the journal’s August podcast, Helen Chapple, PhD, RN, a professor at Creighton University and expert in end-of-life issues, and Caitlin Doughty, a mortician and author, discuss what it might mean for clinicians and health care systems to fully acknowledge dying as something that can be done in a healthy way. Listen to previous episodes of the podcast, “Ethics Talk,” or subscribe in iTunes or other services.

The Conley Art of Medicine and Conley Ethics Essay contests for medical students, residents, and fellows are now open through Sept. 25. Each has a $5,000 prize for the winning entry.

The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. Submit a manuscript for publication. The journal also invites original photographs, graphics, cartoons, drawings and paintings that explore the ethical dimensions of health or health care.

The AMA Journal of Ethics call for papers is now open. The journal invites original submissions for peer review consideration on themes that will be explored in 2019 issues.

A call for theme issue editors is also now open through Oct. 1, 2018. The journal invites medical students, residents and fellows (MDs or DOs) in United States-based programs to apply to serve as theme issue editors for monthly issues to be published from December 2019 through November 2020.

Upcoming issues of the AMA Journal of Ethics will focus on ethics in precision health, and health and food ethics. Sign up to receive email alerts when new issues are published.