Laura C. Hanson, MD, MPH; Marion Danis, MD; James A. Tulsky, MD
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Hanson LC, Danis M, Tulsky JA. Care at the End of Life. Ann Intern Med. 1997;127:574-575. doi: 10.7326/0003-4819-127-7-199710010-00021
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Published: Ann Intern Med. 1997;127(7):574-575.
These letters highlight two of the most promising strategies for innovation in end-of-life care. Although mentioned in our discussion, improvements in communication skills and palliative care services deserve special emphasis.
Gertner and colleagues discuss the limitations of advance directives that focus on specific treatment decisions. They encourage physicians to share more information on diagnosis and prognosis and to search out the patient's values and goals for treatment. In this manner, the content of advance planning discussions can move away from the technical details of treatment choices and focus on designing treatment to meet a patient's true needs. We agree with this approach, with the added caution that it requires new and creative training for physicians. In addition, we wonder about the impact of such discussions in a health care system that increasingly disrupts the physician–patient relationship. In contemporary medical practice, the physician who elicits a values history from a capable, ambulatory patient is not likely to be at his or her bedside when death is imminent.
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