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July 11, 2011

Improving Care at the End of Life

Author Affiliations

Author Affiliations: Department of Emergency Medicine and Brookdale Department of Geriatrics and Palliative Medicine, Mt Sinai School of Medicine, New York, New York (Dr Grudzen); and Department of Medicine, University of California, San Francisco (Dr Grady).

Arch Intern Med. 2011;171(13):1202. doi:10.1001/archinternmed.2011.132

It is widely assumed that more medical care (ie, more tests and procedures) results in better outcomes and that adequately treating pain and other symptoms brings death closer, but there is mounting evidence to suggest otherwise. In addition to the risk of harm that is inherent in all tests and procedures and the discomfort associated with much end-of-life care, new evidence suggests that treating patients' pain and other symptoms is associated with improvements in physical status and may even lengthen survival.1 In fact, at Mt Sinai School of Medicine, New York, New York, an elderly man with hematemesis who was treated with “comfort measures” fared better than a woman with end-stage renal disease who was treated aggressively. Over the next 5 months, the woman was admitted twice to revise her fistula, once for urosepsis, once for hyperkalemia, and finally, for a high-grade small bowel obstruction. After resection of ischemic bowel, she developed overwhelming sepsis and multiorgan failure. One day before her death, the surgical and intensive care unit team communicated her poor prognosis to the family, and she was given a do-not-resuscitate order and weaned from the ventilator. After transfusion, the elderly man was back to baseline and was discharged the following day. He never returned to the emergency department or the hospital.

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