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November 15, 2000

Finding Our Way—Perspectives on Care at the Close of Life

Author Affiliations

Author Affiliations: University of California, San Francisco (Drs McPhee, Rabow, and Pantilat and Ms Markowitz). Dr Winker is Deputy Editor, JAMA.

JAMA. 2000;284(19):2512-2513. doi:10.1001/jama.284.19.2512

Hope does not lie in a way out, but in a way through .—Robert Frost

Dying is inevitable; there is no escape, no way out. Despite an ideal vision of the end of life in which people die peacefully and comfortably at home, surrounded by supportive family and friends, many individuals die in hospitals, and many are in pain and alone.1 Increasingly, clinicians are recognizing the difficulties that arise when caring for dying patients.2 Perceiving death as a personal defeat or professional failure despite its being a natural event,3,4 clinicians caring for patients at the close of life may feel lost in a foreign land without a map. Clinicians sometimes fear that recognizing the imminence of death may remove a patient's hope. They also may have little confidence in their ability to manage severe pain, dyspnea, and other terminal symptoms. The intense emotions that patients and their families display, and the equally strong emotions that clinicians experience, can be uncomfortable and troublesome. Too frequently, clinicians feel out of place negotiating the complexities of a family's dynamics at a time when the integrity of the family is most at stake. When spiritual questions and longings arise, clinicians may feel ill-equipped to help patients in their search for meaningful answers. Even years of experience caring for dying patients does not lessen the challenge of confronting the deaths of friends and family or, ultimately, oneself.