Initiating End-of-Life Discussions With Seriously Ill Patients

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.

He'd been on oxygen 24 hours a day. Roughly a month after he started taking antidepressant pills he started picking up . . . he was eating and seemed to have more energy. He was doing a little exercise program and was starting to look pretty good. We were somewhat encouraged that he might even be able to get to the point where we could wheel him around in a wheelchair, or do something with him, rather than having him just lay there in bed. We had been scrambling for several months trying to find another place for him because his [insurance] coverage had run out at the original nursing home. We found a place that seemed very nice. I drove him over in my car on a Monday. It was difficult to get him in the car; he was very weak but I think he was glad to be driving around. He was okay at first. But when we got there he was in very bad shape. He perked up after a couple of days. He started on a physical therapy regimen, which may have been a little premature since I think the ride over there took a certain toll on him. We explained to the new staff that he did not want to be resuscitated in case something happened. The next Thursday morning, May 8, 2000—four days after he moved into the new home—he got up to use the bathroom, with the nursing staff assisting him. He got about halfway there and then collapsed and died. They made no attempt to resuscitate him.

He had a good life. He was realistic and knew that things come to an end. I think he was happy with the way things had gone so far. He wasn't happy with his condition, of course. I think he wanted out of that situation. He didn't like living like that.

I think it is important that doctors care about the patients and exhibit some sense of caring, rather than just going through the perfunctory medical functions. There's a kind of loneliness when you're trying to deal with this situation. I'm sure that doctors can't get too emotionally involved; there has to be some detachment, but still, a friendly attitude and warmth is a good thing.

I saw Mr B at the skilled nursing facility about a month before he died, just to see how things were going. From the family it sounds like things went okay because they were prepared. They knew he was dying. It is patients like Mr B that made me want to go into geriatrics.