0
April 5, 1995, Vol 273, No. 13 >
ARTICLE | April 5, 1995

The Naturalness of Dying FREE

Jack D. McCue, MD
[+] Author Affiliations

Corresponding author: Jack D. McCue, MD, Berkshire Medical Center, 725 North St, Pittsfield, MA 01201.


JAMA. 1995;273(13):1039-1043. doi:10.1001/jama.1995.03520370081041
Text Size: A A A
Published online
Article
References

Evidence that dying occurs as a natural, final event in the wholeness of human life is culturally, artistically, and scientifically persuasive. Very elderly patients eventually undergo a process of functional declines, progressive apathy, and loss of willingness to eat and drink that culminates in death, even in the absence of acute illness or severe chronic disease. Despite clinical resemblances to depression and dementia, aging itself and a loss of will to live are the most probable explanations for natural dying. Acceptance of the naturalness of dying, however, directly conflicts with the medicalization and legalization of death that characterizes modern society's treatment of dying elderly patients. We prefer instead to believe that dying results from disease and injury, which may yield to advances in medical technology. The progressive move of the dying out of the home and into acute and long-term care facilities suggests that medicalization may be an irreversible process. Viewing dying as an independent diagnosis in patients who are obviously undergoing terminal declines from aging and chronic diseases can facilitate communication about spiritual and palliative care needs, which tend to be neglected in the medicalized view of dying. Physicians and nurses may need to assume the role of medical stewardship to help prevent the overtreatment and overtesting of modern medicine's approach to the dying. The emotional burdens of caring for the dying elderly, however, must be addressed openly through collaborative work, institutional policies on limitation of treatment, and support building among physicians and other caregivers.

(JAMA. 1995;273:1039-1043)

REFERENCES

1 +
Nuland SB. How We Die:Reflections on Life's Last Chapter . New York, NY: Alfred A Knopf Inc; 1994;.
2 +
Callanan M, Kelley P. Final Gifts . New York, NY: Poseidon Press; 1992;.
3 +
Callahan D. Setting Limits: Medical Goals in an Aging Society . New York, NY: Simon & Schuster; 1987;.
4 +
Callahan D. The Troubled Dream of Life: Living With Mortality . New York, NY: Simon & Schuster Inc; 1993;.
5 +
Quill T. Death and Dignity . New York, NY: WW Norton & Co Inc; 1994;.
6 +
Glick HR. The Right to Die . Irvington-on-Hudson, NY: Columbia University Press; 1992;.
7 +
Macklin R. Enemies of Patients . Oxford, England: Oxford University Press; 1993;.
8 +
Tolle SW, Elliot DL, Hickam DH.  Physician attitudes and practices at the time of death. Arch Intern Med . 1984;;143:1447-1449.
9 +
Aries P. The Hour of Our Death . New York, NY: Vintage Books; 1981;.
10 +
Southwick F.  Who was caring for Mary? Ann Intern Med . 1993;;118:146-148.
11 +
Hull FM.  Death, dying and the medical student. Med Educ . 1991;;25:491-496.
12 +
Gates MF, Kaul M, Speece MW, Brent SB.  The attitudes of beginning nursing and medical students toward care of dying patients: a preliminary study. Hospice J . 1992;;8:17-32.
13 +
Kitchen AD.  Second-year medical students' experiences with death among their families and friends. Med Educ . 1986;;61:760-761.
14 +
Howells K, Gould M, Field D.  Fear of death and dying in medical students: effects of clinical experience. Med Educ . 1986;;20:502-506.
15 +
Mendez OE.  Death in America: a clinician's perspective. Crit Care Clin . 1993;;9:613-626.
16 +
Shakespeare W. As You Like It. Act II; scene 7.
17 +
Erikson EH. The Life Cycle Completed: A Review . New York, NY: WW Norton & Co Inc; 1982;: 60-61.
18 +
Aurelius M; Long G, trans. The Meditations of Marcus Aurelius Antonius. AD 160.
19 +
de Beauvoir S. The Coming of Age . New York, NY: GP Putnam; 1972;.
20 +
Miller RA.  The biology of aging and longevity.  In: Hazzard WR, Bierman EL, Blass JP, et al, eds. Principles of Geriatric Medicine and Gerontology . 3rd ed. New York, NY: McGraw-Hill International Book Co; 1994;:3-18.
21 +
White N, Cunningham WR.  Is terminal drop pervasive or specific? J Gerontol . 1988;;43:141-144.
22 +
Moehle KA, Long CJ.  Models of aging and neuropsychological test performance decline with aging. J Gerontol . 1989;;44:176-177.
23 +
Larrabee GT, Levin HS, High WM.  Senescent forgetfulness: a quantitative study. Dev Neuropsychol . 1986;;2:373-385.
24 +
Reed HBC, Reitan RM.  Changes in psychological test performances associated with the normal aging process. J Gerontol . 1963;;18:271-274.
25 +
Johansson B, Berg S.  The robustness of the terminal decline phenomenon: longitudinal data from the digit-span memory test. J Gerontol . 1989;;44: 184-186.
26 +
Jarvik LF.  Aging of the brain: how can we prevent it? Gerontologist . 1988;;28:739-737.
27 +
Bortz WM.  The trajectory of dying: functional status in the last year of life. J Am Geriatr Soc . 1990;;38:146-150.
28 +
Branch LG, Katz S, Kniepmann K, et al.  A prospective study of functional status among community elders. Am J Public Health . 1984;;74:266-268.
29 +
Botwinick J, Weston R, Storandt M.  Predicting death from behavioral test performance. J Gerontol . 1978;;33:755-752.
30 +
Mortimer JA.  Epidemiology of dementia: cross-cultural comparisons. Adv Neurol . 1990;;51:27-33.
31 +
Crum RM, Anthony JC, Bassett SS, Folstein MF.  Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA . 1993;;269:2386-2391.
32 +
Perls TT, Morris JN, Ooi WL, Lipsitz LA.  The relationship between age, gender and cognitive performance in the very old: the effect of selective survival. J Am Geriatr Soc . 1993;;41:1193-1201.
33 +
Callahan D.  On defining a natural death. Hastings Cent Rep . 1977;;7:32-37.
34 +
Monmeyer RW. Confronting Death . Bloomington: Indiana University Press; 1988;.
35 +
Bocquet H, Grosclaude P, Cayla F, et al.  Disabilities, subjective health and mortality after a 3-year follow-up of a rural aged population. Rev Epidemiol Sante Publique . 1987;;35:151-156.
36 +
Rosengren A, Orth-Gomer K, Wedel H, Wilhelmsen L.  Stressful life events, social support, and mortality in men born in 1933. BMJ . 1993;;307: 1102-1105.
37 +
Schneiderman ES.  Death: the enemy. Psychology Today . 1970;;4:67-72.
38 +
Schneiderman ES.  You and death. Psychology Today . 1970;;5:43-45.
39 +
Warren WG. Death Education and Research: Clinical Perspectives . New York, NY: Haworth Press Inc; 1989;.
40 +
Ueda K, Hasuo Y, Ohmura T, et al.  Causes of death in the elderly and their changing pattern in Hisayama, a Japanese community: results from a long-term and autopsy-based study. J Am Geriatr Soc . 1990;;38:1332-1338.
41 +
Clark LP, Dion DM, Barker WH.  Taking to bed: rapid functional decline in an independently mobile older population living in an intermediate-care facility. J Am Geriatr Soc . 1990;;38:967-972.
42 +
Blazer D.  Depression in the elderly. N Engl J Med . 1989;;320:164-166.
43 +
Murphy E.  The prognosis of depression in old age. Br J Psychiatry . 1983;;142:111-119.
44 +
Murphy E, Smith R, Lindesay J, et al.  Increased mortality rates in late-life depression. Br J Psychiatry . 1988;;152:347-353.
45 +
Koenig HG, Shelp F, Goli V, et al.  Survival and health care utilization in elderly medical inpatients with major depression. J Am Geriatr Soc . 1989;;37: 599-606.
46 +
Lee MA, Ganzini L.  Depression in the elderly: effect on patient attitudes toward life-sustaining therapy. J Am Geriatr Soc . 1992;;40:983-988.
47 +
Rovner BW, German PS, Brant LJ, Clark R, Burton L, Folstein MF.  Depression and mortality in nursing homes. JAMA . 1991;;265:993-996.
48 +
Lee MA.  Depression and refusal of life support in older people: an ethical dilemma. J Am Geriatr Soc . 1990;;38:710-714.
49 +
Friedland RP, Koss E, Haxby JV, et al.  Alzheimer disease: clinical and biologic heterogeneity. Ann Intern Med . 1988;;109:298-311.
50 +
Stern Y, Gurland B, Tatemichi TK, et al.  Influence of education and occupation on the incidence of Alzheimer's disease. JAMA . 1994;;271:1004-1010.
51 +
Goodwin JS.  Geriatric ideology: the myth of the myth of senility. J Am Geriatr Soc . 1991;;39:627-631.
52 +
Von Dras DD, Blumenthal HT.  Dementia of the aged: disease or atypical-accelerated aging? bio-pathological and psychological perspectives. J Am Geriatr Soc . 1992;;40:285-294.
53 +
Forbes WF, Hirdes JP.  The relationship between aging and disease: geriatric ideology and myths of senility. J Am Geriatr Soc . 1993;;41:1267-1271.
54 +
Koenig HC, Goli V, Shelp F, et al.  Antidepressant use in elderly medical inpatients: lessons from an attempted clinical trial. J Gen Intern Med . 1989;; 4:448-450.
55 +
Koenig HF, Meadow Cohen HJ, Blazer DG.  Depression in elderly hospitalized patients with medical illness. Arch Intern Med . 1988;;148:1929-1936.
56 +
Koenig HG.  Depressed or just sick? Arch Intern Med . 1990;;150:1349-1350.
57 +
Kaotona CLE.  Depression in old age. J Med Gerontol . 1991;;1:371-384.
58 +
Radman D, Mattson DE, Nagraj HS, et al.  Antecedents of death in the men of a Veterans Administration nursing home. J Am Geriatr Soc . 1987;; 35:496-502.
59 +
Tayback M, Kumanyika S, Chee E.  Body weight as a risk factor in the elderly. Arch Intern Med . 1990;;150:1065-1072.
60 +
Lee IM, Paffenbarger RS.  Change in body weight and longevity. JAMA . 1992;;268:2045-2049.
61 +
Klonoff-Cohen H, Barrett-Connor EL, Edelstein SL.  Albumin levels as a predictor of mortality in the healthy elderly. J Clin Epidemiol . 1992;;45: 207-212.
62 +
Launer LJ, Harris T, Rumpel C, Madans J.  Body mass index, weight change, and risk of mobility disability in middle-aged and older women. JAMA . 1994;;271:1093-1098.
63 +
Sandman P, Adolfsson R, Nygren C, et al.  Nutritional status and dietary intake in institutionalized patients with Alzheimer's disease and multi-infarct dementia. J Am Geriatr Soc . 1987;;35:31-38.
64 +
Dwyer JT, Coleman KA, Krall E, et al.  Changes in relative weight among institutionalized elderly adults. J Gerontol . 1987;;42:246-251.
65 +
Keller HH.  Malnutrition in institutionalized elderly. J Am Geriatr Soc . 1993;;41:1212-1218.
66 +
Thompson MP, Morris LK.  Unexplained weight loss in the ambulatory elderly. J Am Geriatr Soc . 1991;;39:497-500.
67 +
Phillips PA, Rolls BJ, Ledingham JGG, et al.  Reduced thirst after water deprivation in healthy elderly men. N Engl J Med . 1984;;311:753-759.
68 +
Berlinger WG, Potter JF.  Low body mass index in demented outpatients. J Am Geriatr Soc . 1991;;39:973-978.
69 +
Bernat JL, Gert B, Mogielnicki RP.  Patient refusal of hydration and nutrition: an alternative to physician-assisted suicide or voluntary active euthanasia. Arch Intern Med . 1993;;153:2723-2727.
70 +
Cook ML.  The end of life and the goals of medicine. Arch Intern Med . 1993;;153:2718-2719.
71 +
Youngner SJ, Bartlett ET.  Human death and high technology: the failure of the whole-brain formulations. Ann Intern Med . 1983;;99:252-258.
72 +
Youngner SJ, Landefeld CS, Coulton CJ, et al.  'Brain death' and organ retrieval: a cross-sectional survey of knowledge and concepts among health professionals. JAMA . 1989;;261:2205-2210.
73 +
Yarborough M.  Continued treatment of the fatally ill for the benefit of others. J Am Geriatr Soc . 1988;;36:63-67.
74 +
Smedira NG, Evans BH, Grais LS, et al.  Withholding and withdrawing life support from the critically ill. N Engl J Med . 1990;;322:309-315.
75 +
Halevy A, Brody B.  Brain death: reconciling definitions, criteria, and tests. Ann Intern Med . 1993;;119:519-525.
76 +
Phillips DP, Smith DG.  Postponement of death until symbolically meaningful occasions. JAMA . 1990;;263:1947-1951.
77 +
Burgess MM.  The medicalization of dying. J Med Philos . 1993;;18:269-279.
78 +
Wanzer SH, Federman DD, Adelstein SJ, et al.  The physician's responsibility toward hopelessly ill patients. N Engl J Med . 1989;;320:844-849.
79 +
Brurera E, de Stoutz N, Velsco-Leiva A, et al.  Effects of oxygen on dyspnoea in hypoxaemic terminal-cancer patients. Lancet . 1993;;342:13-14.
80 +
Kubler-Ross E, ed. Death: The Final Stage of Growth . New York, NY: Touchstone Books; 1975;.
81 +
Hilfiker D.  Allowing the debilitated to die: facing our ethical choices. N Engl J Med . 1983;;308: 716-719.
82 +
Lo B, Josen AR.  Clinical decisions to limit treatment. Ann Intern Med . 1980;;93:764-768.
83 +
Emanuel EJ.  Should physicians withhold life-sustaining care from patients who are not terminally ill? Lancet . 1988;;1:106-108.
84 +
Lynn J, ed. By No Extraordinary Means: The Choice to Forgo Life-Sustaining Food and Water . Bloomington: Indiana University Press; 1986;.
85 +
Callahan D.  On feeding the dying. Hastings Cent Rep . 1983;;13:22.
86 +
Gruman GJ.  Ethics of death and dying: historical perspective. Omega . 1978-1979;;9:203-237.
87 +
Dozor RB, Addison RB.  Toward a good death: an interpretive investigation of family practice residents' practices with dying patients. Fam Med . 1992;;24:538-543.
88 +
Payer L. Medicine and Culture . New York, NY: Henry Holt & Co; 1988;.
89 +
Artiss KL, Levine AS.  Doctor-patient relation in severe illness. N Engl J Med . 1974;;288:1210-1214.
90 +
McCue JD.  The effects of stress on physicians and their medical practice. N Engl J Med . 1982;; 306:458-463.
91 +
Garland J.  Adaptation skills in the elderly, their supporters and careers. Br J Psychol . 1985;;58:267-274.
92 +
Vickio CJ, Cavanaugh JC.  Relationships among death anxiety, attitudes toward aging, and experiences with death among nursing home employees. J Gerontol . 1985;;40:347-349.
93 +
Krakowski AJ.  Stress and the practice of medicine, II: stressors, stresses and strains. Psychother Psychosom . 1982;;38:11-23.
94 +
Krakowski AJ.  Stress and the practice of medicine, I: the myth and reality. Br J Psychosom Res . 1982;;26:91-98.
95 +
Martin CA, Julian RA.  Causes of stress and burnout in physicians caring for the chronically and terminally ill.  In: Paradis LA, ed. Stress and Burnout Among Providers Caring for the Terminally Ill and Their Families . New York, NY: Haworth Press Inc; 1987;:121-146.
96 +
Mount BM.  Dealing with our losses. J Clin Oncol . 1986;;4:1127-1134.
97 +
Feifel H, Branscomb A.  Who's afraid of death? J Abnorm Psychol . 1973;;49:278-286.
98 +
Seravalli EP.  The dying patient, the physician, and the fear of death. N Engl J Med . 1988;;319: 1728-1730.
99 +
Schulz R, Aderman D.  Physicians' death anxiety and patient outcomes. Omega . 1978-1979;;9:327-332.
100 +
Kane AC, Hogan JD.  Death anxiety in physicians: defensive style, medical specialty, and exposure to death. Omega . 1985-1986;;16:11-22.
101 +
Feifel H, Hanson S, Jones R, et al. Physicians consider death. In: Proceedings of the 75th Annual Convention of the American Psychological Association. 1967;2:201-202.
102 +
Tolle SW, Girard DE.  The physician's role in the events surrounding patient death. Arch Intern Med . 1983;;143:1447-1449.
103 +
Kinsella TD, Stocking CB.  Failed communication about life-support therapy: silent physicians and mute patients. Am J Med . 1989;;86:643-644.
104 +
Finucane TE, Shumway JM, Powers RL, et al.  Planning with elderly outpatients for contingencies of severe illness: a survey and clinical trial. J Gen Intern Med . 1988;;3:322-325.
105 +
Quill TE.  Recognizing and adjusting to barriers in doctor-patient communication. Ann Intern Med . 1989;;111:51-57.
106 +
Graham H, Livesley B.  Dying as a diagnosis: difficulties of communication and management in elderly patients. Lancet . 1983;;2:670-672.
107 +
Martin CA, Julian RA. Stress and Burnout Among Providers Caring for the Terminally Ill and Their Families . New York, NY: Haworth Press Inc; 1987;.
108 +
Luddington AV.  The 'death control' dilemma: who is to make end-of-life decisions: you and your patient, or 'the system'? Geriatrics . 1993;;48:72-77.
109 +
Slomaka J.  The negotiation of death: clinical decision making at the end of life. Soc Sci Med . 1992;;35:251-259.
110 +
Lasch C. The Culture of Narcissism: American Life in an Age of Diminishing Expectations . New York, NY: WW Norton & Co Inc; 1978;:207-217.
111 +
Emanuel EJ, Emanuel LL.  The economics of dying: the illusion of cost savings at the end of life. N Engl J Med . 1994;;330:540-549.
112 +
Maksoud A, Jahnigen DW, Skibinski CI.  Do not resuscitate orders and the cost of death. Arch Intern Med . 1993;;153:1249-1253.
113 +
Bayer R, Callahan D, Fletcher J, et al.  The care of the terminally ill: morality and economics. N Engl J Med . 1983;;309:1490-1494.
114 +
Chambers CV, Diamond JJ, Perkel RL, Lasch LA.  Relationship of advance directives to hospital charges in a medicare population. Arch Intern Med . 1994;;154:541-547.
115 +
Merman AC.  Spiritual aspects of death and dying. Yale J Biol Med . 1992;;65:137-142.
116 +
Palmore E, Cleveland W.  Aging, terminal decline, and terminal drop. J Gerontol . 1976;;31:76-81.
117 +
Guralnik JM, LaCroix AZ, Branch LG, et al.  Morbidity and disability in older persons in the years prior to death. Am J Public Health . 1991;; 81:443-447.
118 +
Dontas AS, Tzonou A, Kasviki-Charvati P, et al.  Survival in a residential home: an eleven-year longitudinal study. J Am Geriatr Soc . 1991;;39:641-649.
119 +
Reuben DB, Rubenstein LV, Hirsch SH, Hays RD.  Value of functional status as a predictor of mortality: results of a prospective study. Am J Med . 1992;;93:663-669.
120 +
Schmitz P, Lynn J, Cobbs E.  The care of the dying patient.  In: Hazzard WR, Bierman EL, Blass JP, et al, eds. Principles of Geriatric Medicine and Gerontology . 3rd ed. New York, NY: McGraw-Hill International Book Co; 1994;:383-390.
121 +
Jennings B, Callahan D, Caplan AL.  Ethical challenges of chronic illness. Hastings Cent Rep . 1988;;18( (suppl) ):1-16.
122 +
Tolstoy L; Solotaroff L, trans. The Death of Ivan Ilyich . New York, NY: Bantam Books; 1981;.
123 +
Uhlman RF, Clark H, Pearlman RA, et al.  Medical management decisions in nursing home patients: principles and policy recommendations. Ann Intern Med . 1987;;106:879-885.
124 +
Braithwaite S, Thomasma DC.  New guidelines on forgoing life-sustaining treatment in incompetent patients: an anti-cruelty policy. Ann Intern Med . 1986;;104:711-715.
125 +
Miles SH, Singer PA, Siegler M.  Conflicts between patients' wishes to forgo treatment and the policies of health care facilities. N Engl J Med . 1989;;321:48-50.
126 +
Sager M, Volks S, Drinka P, et al.  Do the elderly sue physicians? Arch Intern Med . 1990;;150: 1091-1093.
127 +
Perkins HS, Bauer RL, Hazuda HP, Schoolfield JD.  Impact of legal liability, family wishes, and other 'external factors' on physicians' life-support decisions. Am J Med . 1990;;89:185-194.
128 +
Solomon MZ, O'Donnell L, Jennings B, et al.  Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health . 1993;;83:14-23.
129 +
Peters AL.  Death and medicine: a personal account. Am J Med . 1990;;89:81-82.
130 +
Branch WT.  Meaningful experiences in medicine. Am J Med . 1990;;88:56-59.
131 +
Matthews DA, Suchman AL, Branch WT.  Making 'connexions': enhancing the therapeutic potential of patient-clinician relationships. Ann Intern Med . 1993;;118:973-977.
132 +
Suchman AL, Matthews DA.  What makes the patient-doctor relationship therapeutic? exploring the connexional dimension of medical care. Ann Intern Med . 1988;;108:125-130.
133 +
Durand RP, Dickinson GE, Sumner ED.  Family physicians' attitudes toward death and the terminally-ill patient. Fam Pract Res J . 1990;;9:123-129.
134 +
Quill TE, Williamson PR.  Healthy approaches to physician stress. Arch Intern Med . 1990;;105:1857-1861.
135 +
Eddy DM.  A conversation with my mother. JAMA . 1994;;272:179-182.
136 +
Jonas H.  The burden and blessing of mortality. Hastings Center Rep . 1992;;22:34-40.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Nuland SB. How We Die:Reflections on Life's Last Chapter . New York, NY: Alfred A Knopf Inc; 1994;.
2 +
Callanan M, Kelley P. Final Gifts . New York, NY: Poseidon Press; 1992;.
3 +
Callahan D. Setting Limits: Medical Goals in an Aging Society . New York, NY: Simon & Schuster; 1987;.
4 +
Callahan D. The Troubled Dream of Life: Living With Mortality . New York, NY: Simon & Schuster Inc; 1993;.
5 +
Quill T. Death and Dignity . New York, NY: WW Norton & Co Inc; 1994;.
6 +
Glick HR. The Right to Die . Irvington-on-Hudson, NY: Columbia University Press; 1992;.
7 +
Macklin R. Enemies of Patients . Oxford, England: Oxford University Press; 1993;.
8 +
Tolle SW, Elliot DL, Hickam DH.  Physician attitudes and practices at the time of death. Arch Intern Med . 1984;;143:1447-1449.
9 +
Aries P. The Hour of Our Death . New York, NY: Vintage Books; 1981;.
10 +
Southwick F.  Who was caring for Mary? Ann Intern Med . 1993;;118:146-148.
11 +
Hull FM.  Death, dying and the medical student. Med Educ . 1991;;25:491-496.
12 +
Gates MF, Kaul M, Speece MW, Brent SB.  The attitudes of beginning nursing and medical students toward care of dying patients: a preliminary study. Hospice J . 1992;;8:17-32.
13 +
Kitchen AD.  Second-year medical students' experiences with death among their families and friends. Med Educ . 1986;;61:760-761.
14 +
Howells K, Gould M, Field D.  Fear of death and dying in medical students: effects of clinical experience. Med Educ . 1986;;20:502-506.
15 +
Mendez OE.  Death in America: a clinician's perspective. Crit Care Clin . 1993;;9:613-626.
16 +
Shakespeare W. As You Like It. Act II; scene 7.
17 +
Erikson EH. The Life Cycle Completed: A Review . New York, NY: WW Norton & Co Inc; 1982;: 60-61.
18 +
Aurelius M; Long G, trans. The Meditations of Marcus Aurelius Antonius. AD 160.
19 +
de Beauvoir S. The Coming of Age . New York, NY: GP Putnam; 1972;.
20 +
Miller RA.  The biology of aging and longevity.  In: Hazzard WR, Bierman EL, Blass JP, et al, eds. Principles of Geriatric Medicine and Gerontology . 3rd ed. New York, NY: McGraw-Hill International Book Co; 1994;:3-18.
21 +
White N, Cunningham WR.  Is terminal drop pervasive or specific? J Gerontol . 1988;;43:141-144.
22 +
Moehle KA, Long CJ.  Models of aging and neuropsychological test performance decline with aging. J Gerontol . 1989;;44:176-177.
23 +
Larrabee GT, Levin HS, High WM.  Senescent forgetfulness: a quantitative study. Dev Neuropsychol . 1986;;2:373-385.
24 +
Reed HBC, Reitan RM.  Changes in psychological test performances associated with the normal aging process. J Gerontol . 1963;;18:271-274.
25 +
Johansson B, Berg S.  The robustness of the terminal decline phenomenon: longitudinal data from the digit-span memory test. J Gerontol . 1989;;44: 184-186.
26 +
Jarvik LF.  Aging of the brain: how can we prevent it? Gerontologist . 1988;;28:739-737.
27 +
Bortz WM.  The trajectory of dying: functional status in the last year of life. J Am Geriatr Soc . 1990;;38:146-150.
28 +
Branch LG, Katz S, Kniepmann K, et al.  A prospective study of functional status among community elders. Am J Public Health . 1984;;74:266-268.
29 +
Botwinick J, Weston R, Storandt M.  Predicting death from behavioral test performance. J Gerontol . 1978;;33:755-752.
30 +
Mortimer JA.  Epidemiology of dementia: cross-cultural comparisons. Adv Neurol . 1990;;51:27-33.
31 +
Crum RM, Anthony JC, Bassett SS, Folstein MF.  Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA . 1993;;269:2386-2391.
32 +
Perls TT, Morris JN, Ooi WL, Lipsitz LA.  The relationship between age, gender and cognitive performance in the very old: the effect of selective survival. J Am Geriatr Soc . 1993;;41:1193-1201.
33 +
Callahan D.  On defining a natural death. Hastings Cent Rep . 1977;;7:32-37.
34 +
Monmeyer RW. Confronting Death . Bloomington: Indiana University Press; 1988;.
35 +
Bocquet H, Grosclaude P, Cayla F, et al.  Disabilities, subjective health and mortality after a 3-year follow-up of a rural aged population. Rev Epidemiol Sante Publique . 1987;;35:151-156.
36 +
Rosengren A, Orth-Gomer K, Wedel H, Wilhelmsen L.  Stressful life events, social support, and mortality in men born in 1933. BMJ . 1993;;307: 1102-1105.
37 +
Schneiderman ES.  Death: the enemy. Psychology Today . 1970;;4:67-72.
38 +
Schneiderman ES.  You and death. Psychology Today . 1970;;5:43-45.
39 +
Warren WG. Death Education and Research: Clinical Perspectives . New York, NY: Haworth Press Inc; 1989;.
40 +
Ueda K, Hasuo Y, Ohmura T, et al.  Causes of death in the elderly and their changing pattern in Hisayama, a Japanese community: results from a long-term and autopsy-based study. J Am Geriatr Soc . 1990;;38:1332-1338.
41 +
Clark LP, Dion DM, Barker WH.  Taking to bed: rapid functional decline in an independently mobile older population living in an intermediate-care facility. J Am Geriatr Soc . 1990;;38:967-972.
42 +
Blazer D.  Depression in the elderly. N Engl J Med . 1989;;320:164-166.
43 +
Murphy E.  The prognosis of depression in old age. Br J Psychiatry . 1983;;142:111-119.
44 +
Murphy E, Smith R, Lindesay J, et al.  Increased mortality rates in late-life depression. Br J Psychiatry . 1988;;152:347-353.
45 +
Koenig HG, Shelp F, Goli V, et al.  Survival and health care utilization in elderly medical inpatients with major depression. J Am Geriatr Soc . 1989;;37: 599-606.
46 +
Lee MA, Ganzini L.  Depression in the elderly: effect on patient attitudes toward life-sustaining therapy. J Am Geriatr Soc . 1992;;40:983-988.
47 +
Rovner BW, German PS, Brant LJ, Clark R, Burton L, Folstein MF.  Depression and mortality in nursing homes. JAMA . 1991;;265:993-996.
48 +
Lee MA.  Depression and refusal of life support in older people: an ethical dilemma. J Am Geriatr Soc . 1990;;38:710-714.
49 +
Friedland RP, Koss E, Haxby JV, et al.  Alzheimer disease: clinical and biologic heterogeneity. Ann Intern Med . 1988;;109:298-311.
50 +
Stern Y, Gurland B, Tatemichi TK, et al.  Influence of education and occupation on the incidence of Alzheimer's disease. JAMA . 1994;;271:1004-1010.
51 +
Goodwin JS.  Geriatric ideology: the myth of the myth of senility. J Am Geriatr Soc . 1991;;39:627-631.
52 +
Von Dras DD, Blumenthal HT.  Dementia of the aged: disease or atypical-accelerated aging? bio-pathological and psychological perspectives. J Am Geriatr Soc . 1992;;40:285-294.
53 +
Forbes WF, Hirdes JP.  The relationship between aging and disease: geriatric ideology and myths of senility. J Am Geriatr Soc . 1993;;41:1267-1271.
54 +
Koenig HC, Goli V, Shelp F, et al.  Antidepressant use in elderly medical inpatients: lessons from an attempted clinical trial. J Gen Intern Med . 1989;; 4:448-450.
55 +
Koenig HF, Meadow Cohen HJ, Blazer DG.  Depression in elderly hospitalized patients with medical illness. Arch Intern Med . 1988;;148:1929-1936.
56 +
Koenig HG.  Depressed or just sick? Arch Intern Med . 1990;;150:1349-1350.
57 +
Kaotona CLE.  Depression in old age. J Med Gerontol . 1991;;1:371-384.
58 +
Radman D, Mattson DE, Nagraj HS, et al.  Antecedents of death in the men of a Veterans Administration nursing home. J Am Geriatr Soc . 1987;; 35:496-502.
59 +
Tayback M, Kumanyika S, Chee E.  Body weight as a risk factor in the elderly. Arch Intern Med . 1990;;150:1065-1072.
60 +
Lee IM, Paffenbarger RS.  Change in body weight and longevity. JAMA . 1992;;268:2045-2049.
61 +
Klonoff-Cohen H, Barrett-Connor EL, Edelstein SL.  Albumin levels as a predictor of mortality in the healthy elderly. J Clin Epidemiol . 1992;;45: 207-212.
62 +
Launer LJ, Harris T, Rumpel C, Madans J.  Body mass index, weight change, and risk of mobility disability in middle-aged and older women. JAMA . 1994;;271:1093-1098.
63 +
Sandman P, Adolfsson R, Nygren C, et al.  Nutritional status and dietary intake in institutionalized patients with Alzheimer's disease and multi-infarct dementia. J Am Geriatr Soc . 1987;;35:31-38.
64 +
Dwyer JT, Coleman KA, Krall E, et al.  Changes in relative weight among institutionalized elderly adults. J Gerontol . 1987;;42:246-251.
65 +
Keller HH.  Malnutrition in institutionalized elderly. J Am Geriatr Soc . 1993;;41:1212-1218.
66 +
Thompson MP, Morris LK.  Unexplained weight loss in the ambulatory elderly. J Am Geriatr Soc . 1991;;39:497-500.
67 +
Phillips PA, Rolls BJ, Ledingham JGG, et al.  Reduced thirst after water deprivation in healthy elderly men. N Engl J Med . 1984;;311:753-759.
68 +
Berlinger WG, Potter JF.  Low body mass index in demented outpatients. J Am Geriatr Soc . 1991;;39:973-978.
69 +
Bernat JL, Gert B, Mogielnicki RP.  Patient refusal of hydration and nutrition: an alternative to physician-assisted suicide or voluntary active euthanasia. Arch Intern Med . 1993;;153:2723-2727.
70 +
Cook ML.  The end of life and the goals of medicine. Arch Intern Med . 1993;;153:2718-2719.
71 +
Youngner SJ, Bartlett ET.  Human death and high technology: the failure of the whole-brain formulations. Ann Intern Med . 1983;;99:252-258.
72 +
Youngner SJ, Landefeld CS, Coulton CJ, et al.  'Brain death' and organ retrieval: a cross-sectional survey of knowledge and concepts among health professionals. JAMA . 1989;;261:2205-2210.
73 +
Yarborough M.  Continued treatment of the fatally ill for the benefit of others. J Am Geriatr Soc . 1988;;36:63-67.
74 +
Smedira NG, Evans BH, Grais LS, et al.  Withholding and withdrawing life support from the critically ill. N Engl J Med . 1990;;322:309-315.
75 +
Halevy A, Brody B.  Brain death: reconciling definitions, criteria, and tests. Ann Intern Med . 1993;;119:519-525.
76 +
Phillips DP, Smith DG.  Postponement of death until symbolically meaningful occasions. JAMA . 1990;;263:1947-1951.
77 +
Burgess MM.  The medicalization of dying. J Med Philos . 1993;;18:269-279.
78 +
Wanzer SH, Federman DD, Adelstein SJ, et al.  The physician's responsibility toward hopelessly ill patients. N Engl J Med . 1989;;320:844-849.
79 +
Brurera E, de Stoutz N, Velsco-Leiva A, et al.  Effects of oxygen on dyspnoea in hypoxaemic terminal-cancer patients. Lancet . 1993;;342:13-14.
80 +
Kubler-Ross E, ed. Death: The Final Stage of Growth . New York, NY: Touchstone Books; 1975;.
81 +
Hilfiker D.  Allowing the debilitated to die: facing our ethical choices. N Engl J Med . 1983;;308: 716-719.
82 +
Lo B, Josen AR.  Clinical decisions to limit treatment. Ann Intern Med . 1980;;93:764-768.
83 +
Emanuel EJ.  Should physicians withhold life-sustaining care from patients who are not terminally ill? Lancet . 1988;;1:106-108.
84 +
Lynn J, ed. By No Extraordinary Means: The Choice to Forgo Life-Sustaining Food and Water . Bloomington: Indiana University Press; 1986;.
85 +
Callahan D.  On feeding the dying. Hastings Cent Rep . 1983;;13:22.
86 +
Gruman GJ.  Ethics of death and dying: historical perspective. Omega . 1978-1979;;9:203-237.
87 +
Dozor RB, Addison RB.  Toward a good death: an interpretive investigation of family practice residents' practices with dying patients. Fam Med . 1992;;24:538-543.
88 +
Payer L. Medicine and Culture . New York, NY: Henry Holt & Co; 1988;.
89 +
Artiss KL, Levine AS.  Doctor-patient relation in severe illness. N Engl J Med . 1974;;288:1210-1214.
90 +
McCue JD.  The effects of stress on physicians and their medical practice. N Engl J Med . 1982;; 306:458-463.
91 +
Garland J.  Adaptation skills in the elderly, their supporters and careers. Br J Psychol . 1985;;58:267-274.
92 +
Vickio CJ, Cavanaugh JC.  Relationships among death anxiety, attitudes toward aging, and experiences with death among nursing home employees. J Gerontol . 1985;;40:347-349.
93 +
Krakowski AJ.  Stress and the practice of medicine, II: stressors, stresses and strains. Psychother Psychosom . 1982;;38:11-23.
94 +
Krakowski AJ.  Stress and the practice of medicine, I: the myth and reality. Br J Psychosom Res . 1982;;26:91-98.
95 +
Martin CA, Julian RA.  Causes of stress and burnout in physicians caring for the chronically and terminally ill.  In: Paradis LA, ed. Stress and Burnout Among Providers Caring for the Terminally Ill and Their Families . New York, NY: Haworth Press Inc; 1987;:121-146.
96 +
Mount BM.  Dealing with our losses. J Clin Oncol . 1986;;4:1127-1134.
97 +
Feifel H, Branscomb A.  Who's afraid of death? J Abnorm Psychol . 1973;;49:278-286.
98 +
Seravalli EP.  The dying patient, the physician, and the fear of death. N Engl J Med . 1988;;319: 1728-1730.
99 +
Schulz R, Aderman D.  Physicians' death anxiety and patient outcomes. Omega . 1978-1979;;9:327-332.
100 +
Kane AC, Hogan JD.  Death anxiety in physicians: defensive style, medical specialty, and exposure to death. Omega . 1985-1986;;16:11-22.
101 +
Feifel H, Hanson S, Jones R, et al. Physicians consider death. In: Proceedings of the 75th Annual Convention of the American Psychological Association. 1967;2:201-202.
102 +
Tolle SW, Girard DE.  The physician's role in the events surrounding patient death. Arch Intern Med . 1983;;143:1447-1449.
103 +
Kinsella TD, Stocking CB.  Failed communication about life-support therapy: silent physicians and mute patients. Am J Med . 1989;;86:643-644.
104 +
Finucane TE, Shumway JM, Powers RL, et al.  Planning with elderly outpatients for contingencies of severe illness: a survey and clinical trial. J Gen Intern Med . 1988;;3:322-325.
105 +
Quill TE.  Recognizing and adjusting to barriers in doctor-patient communication. Ann Intern Med . 1989;;111:51-57.
106 +
Graham H, Livesley B.  Dying as a diagnosis: difficulties of communication and management in elderly patients. Lancet . 1983;;2:670-672.
107 +
Martin CA, Julian RA. Stress and Burnout Among Providers Caring for the Terminally Ill and Their Families . New York, NY: Haworth Press Inc; 1987;.
108 +
Luddington AV.  The 'death control' dilemma: who is to make end-of-life decisions: you and your patient, or 'the system'? Geriatrics . 1993;;48:72-77.
109 +
Slomaka J.  The negotiation of death: clinical decision making at the end of life. Soc Sci Med . 1992;;35:251-259.
110 +
Lasch C. The Culture of Narcissism: American Life in an Age of Diminishing Expectations . New York, NY: WW Norton & Co Inc; 1978;:207-217.
111 +
Emanuel EJ, Emanuel LL.  The economics of dying: the illusion of cost savings at the end of life. N Engl J Med . 1994;;330:540-549.
112 +
Maksoud A, Jahnigen DW, Skibinski CI.  Do not resuscitate orders and the cost of death. Arch Intern Med . 1993;;153:1249-1253.
113 +
Bayer R, Callahan D, Fletcher J, et al.  The care of the terminally ill: morality and economics. N Engl J Med . 1983;;309:1490-1494.
114 +
Chambers CV, Diamond JJ, Perkel RL, Lasch LA.  Relationship of advance directives to hospital charges in a medicare population. Arch Intern Med . 1994;;154:541-547.
115 +
Merman AC.  Spiritual aspects of death and dying. Yale J Biol Med . 1992;;65:137-142.
116 +
Palmore E, Cleveland W.  Aging, terminal decline, and terminal drop. J Gerontol . 1976;;31:76-81.
117 +
Guralnik JM, LaCroix AZ, Branch LG, et al.  Morbidity and disability in older persons in the years prior to death. Am J Public Health . 1991;; 81:443-447.
118 +
Dontas AS, Tzonou A, Kasviki-Charvati P, et al.  Survival in a residential home: an eleven-year longitudinal study. J Am Geriatr Soc . 1991;;39:641-649.
119 +
Reuben DB, Rubenstein LV, Hirsch SH, Hays RD.  Value of functional status as a predictor of mortality: results of a prospective study. Am J Med . 1992;;93:663-669.
120 +
Schmitz P, Lynn J, Cobbs E.  The care of the dying patient.  In: Hazzard WR, Bierman EL, Blass JP, et al, eds. Principles of Geriatric Medicine and Gerontology . 3rd ed. New York, NY: McGraw-Hill International Book Co; 1994;:383-390.
121 +
Jennings B, Callahan D, Caplan AL.  Ethical challenges of chronic illness. Hastings Cent Rep . 1988;;18( (suppl) ):1-16.
122 +
Tolstoy L; Solotaroff L, trans. The Death of Ivan Ilyich . New York, NY: Bantam Books; 1981;.
123 +
Uhlman RF, Clark H, Pearlman RA, et al.  Medical management decisions in nursing home patients: principles and policy recommendations. Ann Intern Med . 1987;;106:879-885.
124 +
Braithwaite S, Thomasma DC.  New guidelines on forgoing life-sustaining treatment in incompetent patients: an anti-cruelty policy. Ann Intern Med . 1986;;104:711-715.
125 +
Miles SH, Singer PA, Siegler M.  Conflicts between patients' wishes to forgo treatment and the policies of health care facilities. N Engl J Med . 1989;;321:48-50.
126 +
Sager M, Volks S, Drinka P, et al.  Do the elderly sue physicians? Arch Intern Med . 1990;;150: 1091-1093.
127 +
Perkins HS, Bauer RL, Hazuda HP, Schoolfield JD.  Impact of legal liability, family wishes, and other 'external factors' on physicians' life-support decisions. Am J Med . 1990;;89:185-194.
128 +
Solomon MZ, O'Donnell L, Jennings B, et al.  Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health . 1993;;83:14-23.
129 +
Peters AL.  Death and medicine: a personal account. Am J Med . 1990;;89:81-82.
130 +
Branch WT.  Meaningful experiences in medicine. Am J Med . 1990;;88:56-59.
131 +
Matthews DA, Suchman AL, Branch WT.  Making 'connexions': enhancing the therapeutic potential of patient-clinician relationships. Ann Intern Med . 1993;;118:973-977.
132 +
Suchman AL, Matthews DA.  What makes the patient-doctor relationship therapeutic? exploring the connexional dimension of medical care. Ann Intern Med . 1988;;108:125-130.
133 +
Durand RP, Dickinson GE, Sumner ED.  Family physicians' attitudes toward death and the terminally-ill patient. Fam Pract Res J . 1990;;9:123-129.
134 +
Quill TE, Williamson PR.  Healthy approaches to physician stress. Arch Intern Med . 1990;;105:1857-1861.
135 +
Eddy DM.  A conversation with my mother. JAMA . 1994;;272:179-182.
136 +
Jonas H.  The burden and blessing of mortality. Hastings Center Rep . 1992;;22:34-40.

Letters

Submit a Letter
CME Course for:


You need to register in order to view this quiz.


To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
Submit a Response

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

© 2012 American Medical Association. All Rights Reserved.
Powered bySilverchair Information Systems