End-of-Life Decisions: Five Pressing Areas in Need of Change
Posted Feb 19 2009 5:11pm
In the latest issue of theJournal of Palliative Medicine, Muriel Gillick identifies five pressing problems in end-of-life decision-making:
1. The need to discuss underlying health status with patients
2. The overburdening of patients and families with too many choices
3. Lack of appreciation of the importance of symbolism in end-of-life care 4. Confusion between cultural beliefs and scientific facts 5. Difficulties with making decisions because of rapid shifts by the medical team from advocating cure to comfort.
Regarding problem 1, Gillick rightly endorses using videos to educate patients about their health status, so that they can make more informed decisions about interentions that might further their goals.
Regarding problem 2, Gillick argues that we should "flip the default medical choice in selected situations." For example, for patients with very advanced diseases, the default would be DNR. But Gillick's proposals are very deferential to patient autonomy. Gillick's flip the default rule implies that she is willing to accede to a decision to opt-out. Indeed, Gillick specifically endorses providing requested ineffective treatment, so long as it is harmless to the patient (e.g. where the patient is unconscious).
4. Confusion between cultural beliefs and scientific facts
5. Difficulties with making decisions because of rapid shifts by the medical team from advocating cure to comfort.