End of Life Concerns–continued

It would clearly be an understatement to emphasize that these are extremely complex and controversial issues. And just as clearly, each case should be evaluated on an individual basis.

Still, there are additional aspects of this topic which cry out for exposure–one is the attitude of ‘health-care providers’. In the past we were often known as ‘physicians’ or ‘doctors’ but HMOs/managed care have ‘managed’ to lump us together with everyone who contributes to the entire system. This is not to demean the role of nurses, assistants, technicians, podiatrists, chiropractors etc. But it is a subtle way of diminishing the role that the physician traditionally assumed in the world of healing .

My point is that families at these difficult times will often turn for guidance to physicians who, infortunately, are often woefully incapable of dealing with them. The reasons are multi-factorial:  1] physicians are not trained to deal with such issues, 2] physicians are personally conflicted over their own beliefs regarding end of life care, 3] some physicians feel obligated to impose their own personal beliefs on families, and 4] sadly, some physicians only see the possibility of ordering or performing procedures on the elderly which will provide them with additional income.

It is extremely unfortunate that physicians are frequently incapable of dealing with these powerful emotional, medical and ethical issues. We receive almost no training regarding these issues in our medical education. There is an implicit assumption that we will somehow gather ‘wisdom’ in this area over years of clinical practice.  I have seen little evidence for this assumption.

There is another essential point I would like to make regarding feeding tubes [PEG] in the elderly.  Families are under the mistaken impression that to withhold tube feedings is to ‘starve’ their loved-ones. I don’t believe that this is the case at all. In fact I believe that the dying patient does not eat because they have no desire to do so. The actual process of dying is poorly understood by medical science, but I do believe that we can approximate an understanding of this loss of appetite [anorexia] by recalling how we felt during a severe viral syndrome.  Most can remember how impossible it would have been to even force ourselves to eat.  I believe that a dying individual has no appetite whatsoever. Furthermore, instituting tube feedings may actually cause discomfort, nausea and suffering!

I often will emphasize to conflicted families  that they attempt to regard the best interest of their loved-one rather than their own inability to  cope with the stress of their death.

My suggestion is that each and every family member expresses an opinion in the matter to attempt to keep in mind the best interest of their loved-ones and to allow them to die peacefully and with ‘dignity’. This is an often used but rarely discussed concept. I can only express my own opinion that having a confused loved-one struggling with their tubes and iv’s and having to be sedated or restrained in order to offer them these end of life ‘services’ is hardly dignified or compassionate.

I first suggest that society as a whole, develop a deep an awareness of what should be obvious, but is not—the inevitability of physical death, in the impermanence of all things.

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