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Good Care of Dying Patients: The Alternative to Physician-Assisted Suicide and EuthanasiaGreg A. Sachs, MD,' Judith C. Abronbeim, MD,' Jill A. Rbymes, MD,' Ladislav Volicer, MD, PhD.' and Joanne Lynn, MD, MAA t the 1992 annual meeting of the American Geriatrics Society (AGS), an unusual gathering occurred. The AGS Ethics Cornmittee had organized an open forum to allow members to discuss physician-assisted dying (PAD), including phvsician-assisted suicide and voluntary active euthana sia, a controversial topic receiving increasing attention in both the lay and professional media. What was so striking about the open forum was not so much what was said about PAD, but rather the consensus that PAD was, in a sense, the wrong thing to be talking about. Many of the annual meeting attendees came, and most of them contended that the priority should lie with improving the palliative care of dying patients. The sense of the meeting was that the interest in ano demand for legalization of PAD would dramatically decline if not nearly disappear, if the health care community did etter job of providing attentive and compassionate care to dying patients.In response to this open forum discussion, the AGS Ethics Committee undertook two activities. One was drafting a new position paper on good care of dying patients. Thi position paper was approved by the AGS Board of Directors at the annual meeting in May 1994 and is published else where in this issue of JAGS." The other activity was organiz ing a symposium for the
November 1993 annual meeting on the same topic. The presenrations at thatsymposium form th basis of this paper.Five topics relating to the care of dying patients ar covered in this paper. Joanne Lynn discusses why geriatri cians need to take an active role in the debate over PAD supporting improved care of dying patients as the priority issue. Judith Ahronheim reviews the challenges of providing good care to dying patients in today's acute care hospitals.Jjil Rhymes describes some of the barriers to effective care of dying patients despite the advent of hospices in the Unitee States in the last several vears. Ladislay Volicer explains hov palliative care can be provided effectively for patients with severe dementia, a group not often referred to hospices Finally, Greg Sachs outlines several wavs in which those whe care for older people can contribute to the effort to improve the care of dying patients.From the "University of Chicago, Chicago, I, tMoent Sinai Medical Ceeter Niew York, NY: Veterans AEairs Medical Center (Houston) and Baylor University, Houston, TX; S EN. Rogers Memorial Veterans Hospital, Redford, MA and 1 Dartmouth Medical School, Hanover, NH.Address correspondence to Gres A, Sachs, MD. University of Chicago Medical Center, Depe, of Medicins, MC 6098, 5841 S Marland Ave, Chicago, IL60637-1470.Before discussing the care of dying patients, we offer the definitions of some important terms used in this article. When is someone "dying"? is it when an incurable disease is diagnosed, when the physician believes the patient is unlikely to live longer than 6 months, or when the patient's death is imminent as indicated by physiological markers such as blood pressure and respirations? In her section of this article loanne Lynn persuasively argues that it is a mistake to em phasize defining "the dying patient." What most people wan from their medical care is a life-enhancing "mix of curative preventive, rehabilitative, and palliative care" regardless of how close one is to death. Nonetheless, to facilitate discus sion and clarity, the authors of this paper found it useful to adopt the definitions used in the AGS position paper "The Care of Dying Patients." Thus, dving patients are those who "have a progressive illness that is expected to eventuate in death and for which there is no treatment expected to alter the course substantially" or who "have elected ro forgo available treatments that might forestall death." "Pallistive care," used interchangeably with "comfort care," refers to care directed at improving quality of life by reducing symp toms and providing support. "Hospice care" refers to the provision of palliative care within a specific organizationa structureA few final comments will help orient readers to the scope and purpose of this article. This article is not an exhaustive, scholarly review of palliative medicine, pain con trol, or organized hospice care. The authors all have consid erable experience caring for dying patients in hospice systems and more conventional settings. We aim to challenge, provoke, and motivate those who provide medical care for older patients in all settings. Even without a major federal health reform package, health care delivery in the United States is being shaped increasingly by state initiatives and market forces that emphasize cost containment and that are largely inattentive to the needs of patients near the end of life. In addition, Oregon recently became the first state to legalize physician-assisted suicide. Professionals in geriatric medicine need to become involved in these debates and to help shap how their patients will confront dying in the future.GERIATRICIANS, PUBLIC POLICY, AND PRACICESTANDARDS FOR THE CARE OF DYING PATIENTSJoanne Lynn, MD, MAProblems with the Status QuoIn public and professional media alike, an odd misstate ment of the mission of medicine in caring for dying persons
