Care at the End of Life: Guiding Practice Where There Are No Easy Answers

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Throughout the ages, people have sought a “good death” in which they are physically as comfortable as possible, are treated with compassion and respect, and find closure in their lives. In the United States at the end of the 20th century, this quest remains elusive. Many people fear that they will have unrelieved symptoms, will undergo unwanted life-prolonging interventions, or will be abandoned by their health care providers.

This editorial announces a new series of articles on end-of-life care in Annals whose goal is to provide practical advice and other guidance to clinicians who are not specialists in palliative care and for whom the care of dying patients is not an every- day aspect of their practice. These papers supplement the ethics and policy positions articulated in the fourth edition of American College of Physicians Ethics Manual(1).

Recent research documents serious problems in medical care at the end of life. Many patients suffer significant pain in their final days (2, 3). Physicians commonly do not know their patients' preferences for life-sustaining interventions or fail to carry out those preferences (2). Communication often is poor; many seriously ill patients and physicians do not discuss care at the end of life (3). When conversations do occur, physicians miss opportunities to address patients' concerns and fears (4). Relatives of patients have written eloquently of the problems they encountered with the care of a dying patient (5).

Improving care at the end of life is particularly important in light of ongoing public discussions about managed care and physician-assisted suicide. Appropriate palliative care may be as costly as disease-oriented care (6). Some people fear that capitated reimbursement creates an incentive to restrict appropriate care at the end of life in order to save money (7).

Physician-assisted …