Edited by Margaret A. Winker, MD, and Annette Flanagin, RN, MA
Physicians who care for high-risk newborns often face decisions about
starting or continuing life-sustaining treatment when the long-term prognosis
is known to be very poor. To study the relationship between attitudes toward
limiting intensive care and actual clinical decision making, Rebagliato and
colleagues surveyed physicians regularly employed in neonatal intensive care
units in 10 European countries. Physicians with beliefs valuing quality of
life were more likely to report having set limits to intensive neonatal interventions
in cases of poor neurological prognosis than physicians with beliefs valuing
sanctity of life at any cost. Of several factors associated with physicians'
attitudes and practices, including religious background and professional experience,
country was the most important.
Emanuel and colleagues interviewed terminally ill patients and their
caregivers to determine their attitudes toward euthanasia or physician-assisted
suicide (PAS). Almost two thirds of terminally ill patients supported euthanasia
or PAS in a scenario-based hypothetical situation, but only a small proportion
of terminally ill patients seriously considered euthanasia or PAS for themselves,
and about half of those changed their preference when interviewed again 2
to 6 months later.
Little is known about the association between parental understanding
of prognosis in children with cancer and decisions about treatment goals and
palliative care. Wolfe and colleagues interviewed the parents of children
who had died of cancer and the child's primary oncologist, and reviewed the
medical records. At diagnosis, concordance between parents' and physicians'
beliefs about the likelihood of cure was fairly good, but parents' recognition
that their child had no realistic chance for cure lagged behind medical record
documentation of this prognosis by the primary oncologist by more than 3 months.
When both physician and parent recognized earlier that the child had no realistic
chance for cure, cancer therapy with the goal to lessen suffering and provide
elements of palliative care were more likely to be integrated into the child's
Understanding what patients, families, and clinicians consider important
at the end of life is necessary to improve end-of-life care. Steinhauser and
colleaguesArticle conducted a survey of seriously ill patients, recently bereaved
family members, and physicians and other care providers. Twenty-six of 44
attributes of quality at the end of life were rated as being important across
all 4 groups, but 10 items varied broadly, including decisions about life-sustaining
treatments, dying at home, and talking about the meaning of death. Among 9
major attributes, participants ranked freedom from pain as most important
and dying at home least important. In a commentary, Daaleman and VandeCreekArticle
discuss religion and spirituality in end-of-life care.
The effectiveness of legislation promoting advance directives and legalizing
physician-assisted suicide depends on patients' understanding of their legal
options about care at the end of life. In this survey of 728 adult outpatients
in Oregon, Silveira and colleagues found that a notable proportion of respondents
appeared to misunderstand what end-of-life care is legally permissible based
on their responses to a series of questions posed in a vignette about a patient
who eventually dies from cancer. Sixty-nine percent of respondents answered
correctly about refusal of treatment, 46% for withdrawal of treatment, 23%
for assisted suicide, 32% for active euthanasia, and 41% for double effect.
"Al had received the kind of care that I worked hard to deliver to my
own patients. Why then were his dying and death so horrible for Al and his
family?" From "Sometimes Dying Still Stings."
Etiology, diagnosis, and treatment of delirium at the end of life.
In the United States, local coalitions dedicated to palliative care
and the creation of programs for children with terminal illness are growing.
Addressing barriers to palliative care for patients in nursing homes
and in the African American community.
See Article and Article
A consensus panel from the American College of Physicians-American Society
of Internal Medicine discusses current myths about legal barriers to end-of-life
The first article in a new series of case-based discussions explores
initiating end-of-life discussions with seriously ill patients.
For your patients: Information about decisions about care at the end
This Week in JAMA. JAMA. 2000;284(19):2417. doi:10.1001/jama.284.19.2417