Band 101, Heft 10

Physicians have a unique role in supporting patients and families throughout their lives; their expertise is called on not only in life, but also at its end. This study was designed to determine the effect of an individual's age, gender, and attachment to the decision maker with regard to life support choices. A total of 151 subjects completed the researcher-developed instrument. Results suggest that the age of patients is significantly related to the life support options chosen. Specifically, the greater the age of the patient, the more likely a less vigorous life support alternative was chosen. Gender and attachment had no effect on the level of care chosen. Study participants also identified reasons for selecting a particular life support choice for each case. The most common reasons given for a close relative centered around quality-of-life issues. In situations involving a nonrelative, life support decisions were likely to be made using the principle of best interest. The primary care physician has a unique opportunity to initiate discussions about life support issues with patients and families. These decisions must be framed in the context of individual patient expectations and desires throughout the life span.

Chronic heart failure is one of the most serious medical problems in the United States, affecting some 4 million persons. In spite of its common occurrence, and comprehensive literature regarding this condition, no unifying hypothesis has been accepted to explain the signs and symptoms of chronic heart failure. The cardiocirculatory and neurohormonal models place an emphasis on left ventricular ejection fraction and cardiac output and do not provide appropriate explanations for the symptoms of breathlessness and fatigue. The muscle hypothesis supplements these conventional models. It proposes that abnormal skeletal muscle in heart failure results in activation of muscle ergoreceptors, leading to an increase in ventilation and sensation of breathlessness, the perception of fatigue, and sympathetic activation. At least one fourth of patients with chronic heart failure are limited by skeletal muscle abnormalities rather than cardiac output. Cardiac rehabilitation exercise can lead to an increase in exercise capacity that is superior to that gained from digitalis or angiotensin-converting enzyme inhibitors. Exercise tends to reverse the skeletal muscle myopathy of chronic heart failure and reduces the abnormal ergoreflex. Other interventions that have been shown to have a favorable outcome include localized muscle group training, respiratory muscle training, and dietary approaches. The possibility that osteopathic manipulative treatment might be of benefit is an attractive, but untested, possibility.

At no other time in any patient's life is the team approach to care more important than at the end of life. The demands and challenges of end-of-life care (ELC) tax all physicians at some point. There is no other profession that is charged with this ultimate responsibility. No discipline in medicine is immune to the issues of end-of-life care except perhaps, ironically, pathology. This presentation addresses the issues, options, and challenges of providing optimal care at the end of life. It looks at the principles of ELC, barriers to good ELC, and what patients and families expect from ELC. Barriers to ELC include financial restrictions, inadequate care-givers, community support, legal issues, legislative issues, training needs, coordination of care, hospice care, and transitions for the patients and families. The legal aspects of physician-assisted suicide is presented as well as the approach of the American Osteopathic Association to ensure better education for physicians in the principles of ELC.

A majority of patients and families are interested in discussing end-of-life issues with their physicians. End of life conversations can be difficult and challenging for physicians. Several barriers hamper effective communication between physicians and their patients and families. Physicians have received little training to acquire needed interpersonal skills to address end-of-life issues. This article reviews practical approaches for conducting end-of-life discussions. These general guidelines can be used in situations such as advanced care planning, do not resuscitate orders, artificial hydration, and nutrition, and implementation of palliative/hospice care.

Pain is a common finding in dying patients. Most patients who experience pain at the end of their lives can have their pain effectively treated by their primary care physicians. The key to pain management is good pain assessment and a working familiarity with pain medications. Opioids are particularly important, and primary care physicians should be comfortable in prescribing these medications and should be familiar with appropriate dosing regimens. Clinical and ethical concerns regarding the use of opioids are overestimated, and opioids can be used safely in most pain management situations.

Numerous, well-defined symptoms are associated with end of life when death is caused by a chronic or debilitating illness (or both) such as cancer, HIV/AIDS, Alzheimer's dementia, and congestive heart failure. These symptoms, if unrelieved, are distressing to both the patients and their families and preclude any possibility of relieving psychological, social, and spiritual suffering, improving quality of life, or completing life closure. Therefore, the objective of this article is to identify some common symptoms at end of life and various management strategies for each.

Providing good care for dying patients requires that physicians be knowledgeable of ethical issues pertinent to end-of-life care. Effective advance care planning can assure patient autonomy at the end of life even when the patient has lost decision-making capacity. Medical futility is difficult to identify in the clinical setting but may be described as an intervention that will not allow the intended goal of therapy to be achieved. Medical interventions, including artificial nutrition and hydration, can be withheld or withdrawn if this measure is consistent with the dying patient's wishes. Physicians caring for terminally ill patients receive requests for physician-assisted suicide. The physician should establish the basis for the request and work with the healthcare team to provide support and comfort for the patient. Physician-assisted suicide could negate the traditional patient-physician relationship and place vulnerable populations at risk. Physicians need to incorporate spiritual issues into the management of patients at the end of life. The integrity of the physician as a moral agent in the clinical setting needs to be recognized and honored. The physician has a moral imperative to assure good care for dying patients.