In November 20001 Timothy Quill, MD,
discussed the case of Mr B, an 81-year-old father of 6 with advanced pulmonary
fibrosis, type 2 diabetes mellitus, atrial fibrillation complicated by a stroke,
and chronic renal insufficiency. Drawing on excerpts of interviews conducted
in February 2000 with Mr B, his son, and his primary care physician, Dr Quill
discussed the obligation of, and rewards to, physicians in opening end-of-life
discussions with seriously ill patients, as well as specific strategies for
doing so. At the time of the interview Mr B had completed an advance directive
indicating that he did not want to be resusitated in the event of cardiopulmonary
arrest, stopped anticoagulation and immunosuppressants, and was clear about
his wishes to forgo interventions aimed at prolonging his life. Dr G, his
primary care physician, described her initial hesitation about broaching the
topic of end-of-life care, and her ultimate relief and satisfaction at having
done it in a timely manner. Shortly after the interview, Mr B was admitted
to a nursing home because of intractable weakness, shortness of breath, and
dependence on others for his activities of daily living. Mr B's son was reinterviewed
by Amy J. Markowitz, JD, on November 6, 2000. Dr G was reinterviewed by Michael
W. Rabow, MD, on November 30, 2000.