Death and dying in America

Seeking a ‘Beautiful Death’

[...] Dr. Volandes, a staff physician at Massachusetts General Hospital in Boston, noted that “in the abstract, fighting every second of the way and pursuing aggressive life-prolonging interventions sounds admirable.” But he wants doctors, patients and families to consider the likely outcome of the fight and how much suffering it will involve.

He recognizes that “there are no right and wrong decisions about medical care at the end of life” but insists that all decisions should be fully informed. To ensure that patients and families understand the options, he has developed a video tour of what medical interventions like ventilation, CPR or placement of a feeding tube look like, which often prompts a change of heart. As one patient put it, “It looks so different on television.”

The video, produced by ACP Decisions, a nonprofit group devoted to advanced-care planning, is licensed to health care providers and insurers who can show it to patients and families to facilitate shared decision making in planning for care at the end of life.

In a randomized trial of the video’s effectiveness among 50 patients with advanced brain cancer, a quarter of patients in the control group who had only a verbal discussion about end-of-life care with their doctors chose life-prolonging care, half opted for limited medical care and only one-quarter chose comfort care. But none of those who saw the video opted for life-prolonging care, a handful chose limited medical care, and 92 percent decided on comfort care, Dr. Volandes reported. After watching the video, patients said they had a better understanding of their choices.

However, even just a discussion with their doctors about goals for end-of-life care can often make a huge difference. The one-third of patients in a 2008 national Coping With Cancer study who had such a discussion were less likely to undergo CPR, be put on a ventilator or be placed in an intensive care unit. Most enrolled in hospice, suffered less and were in better physical shape and better able to interact with others and for a longer time.

Their survivors, too, fared better; six months after the deaths, they were markedly less likely to experience major depression.

Options regarding end-of-life care should be discussed well before an emergency — or for those with dementia, during the early stages of mental decline. “The absolute worst time to contemplate decisions about medical care is when one is critically ill and in the hospital,” Dr. Volandes writes.

The kinds of questions doctors should be asking:

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They are some good questions. Read the whole thing for embedded links and more.