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Unformatted text preview: MR1.VOL1:Nejm:NEJM:Layout:Tweek_040513:Tweeklayout0513 Thu Apr 22 04 12:49:19 n engl j med 350;20 www.nejm.org may 13, 2004 2029 PERSPECTIVE I recently helped my father to die. He was an engi- neer, independent, always on the go and in charge. He began to deteriorate rapidly from an ill-defined dementing illness, and his confusion and intermit- tent agitation did not respond to the standard treatments that were tried. He had made his wishes clear about avoiding any prolongation of his dying, but now he had lost the capacity to make decisions for himself. Furthermore, we did not know wheth- er his remaining life span was measured in months or years. He was unable to sleep or relax at night, despite trials of neuroleptics, antidepressants, and antianxiety agents. My mother was exhausted, but neither of them wanted their home to be invaded by strangers. How were we to honor his wishes and values and help him to find dignity and peace in the last phase of his life? In the 13 years that have passed since I wrote a Sounding Board article about helping a patient to die, 1 there have been substantial improvements in palliative care for severely ill patients, particularly in acute care hospitals. Providers of palliative care attempt to relieve uncomfortable symptoms and improve the quality of life for severely ill patients and their families. Unlike hospice care, palliative care is offered alongside the active treatment of a patients underlying disease, regardless of the prog- nosis. Palliative care consultation services, faculty development programs, and a base of evidence- based knowledge have grown exponentially during this period, facilitated enormously by generous fi- nancial support from private foundations such as Robert Wood Johnson, Soros, Nathan Cummings, Greenwall, and Gerbode. Unfortunately, much of this funding is drying up, and the reimbursement systems that support clinical consultation services as well as ongoing academic activities may be too fragile to sustain these remarkable gains. My father was initially a perfect candidate for palliative care. Given his progressive loss of mem- ory and poor prognosis, he consented to do-not- resuscitate status but wanted to receive all other potentially effective treatments. Every effort was made to improve his quality of life with the use of retrospective Dying and Decision Making Evolution of End-of-Life Options Timothy E. Quill, M.D. MR1.VOL1:Nejm:NEJM:Layout:Tweek_040513:Tweeklayout0513 Thu Apr 22 04 12:49:19 n engl j med 350;20 www.nejm.org may 13, 2004 2030 PERSPECTIVE modern treatments for dementia, as well as symp- tomatic treatments for his agitation and insomnia. But each of these treatments made his symptoms worse, rather than better. I began to wonder if he would be an acceptable candidate for hospice care....
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This note was uploaded on 05/12/2008 for the course PHIL 389 taught by Professor Griffin during the Spring '07 term at NMT.
- Spring '07