LETTER
Whose Death Is It, Anyway
Valery A. Portnoi, MD
1 April 1997 | Volume 126 Issue 7 | Pages 587-588
TO THE EDITOR:
Gilligan and Raffin draw a picture of intensive hospital care at the end of life as nothing short of medical abuse, "akin to battery" [1]. A neurologist, cardiologist, and pulmonologist were called to patient's bedside. However, this is an established medical practice that allows ascertainment of a patient's potential for survival and the reversibility of nonterminal conditions. The authors see these attempts as a reflection of an anachronistic medical culture and cite SUPPORT (Study to Understand Prognosis and Preferences for Outcome and Risk of Treatments) [2] to buttress their view. Indeed, in the culture of death, dying might be preferable to living with such a disability as hemiparesis.
Is this belief a true reflection of the patient's view? We may never know. The patient may have had a good potential for survival. In general, elderly patients resuscitated in the hospital have the highest rate of survival [3]. Patients who have had a stroke have a good chance of rehabilitation [4]. The patient discussed by Gilligan and Raffin had a chance for life and fulfillment even if disability could not have been avoided, but she was not given this chance by caregivers. She was a victim not only of the disease but also of the culture of death.
This culture, however, does not reflect traditional western or eastern culture. As a physician who has practiced medicine in Kasachstan, Russia; Israel; and the United States, I have first-hand knowledge and experience of those cultures. Values of all cultures command physicians to battle against the death of their patients as if their own lives are at stake. Gilligan and Raffin got it wrong: The Hippocratic Corpus of ancient Greece prescribes "to learn how to forecast" diseases and to forego treatment of only patients "who are over-mastered by their diseases, realizing that in such cases, medicine is powerless" [5]. The authors should accept that this was not the case in the patient they described. There is no culture in which physicians are expected to take off their white coats and put on mortuary coats.
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Author and Article Information
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Genesis Physician Services, Inc., Washington, DC 20037
1. Gilligan T, Raffin T. Whose death is it, anyway? Ann Intern Med. 1996; 125:137-41.
2. A controlled trial to improve care for seriously ill hospitalized patients. The Study to Understand Prognosis and Preferences for Outcome and Risks of Treatments (SUPPORT). The SUPPORT principal investigators. JAMA. 1995; 274:1591-8.
3. Bergner L, Bergner M, Hallstrom AP, Eisenberg M, Cobb LA. Health status of survivors of out-of-hospital cardiac arrest six months later. Am J Public Health. 1984; 74:508-10.
4. Lai SM, Alter M, Friday G, Sobel E. Prognosis for survival after initial stroke. Stroke. 1995; 26:2011-5.
5. Cowley LT, Young E, Raffin JA. Care of the dying: an ethical and historical perspective. Crit Care Med. 1992; 20:1473-82.
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