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On Being a Doctor |

Death Panels

Mark Vierra, MD
[+] Article and Author Information

Requests for Single Reprints: Mark Vierra, MD, Monterey County Surgical Associates, 2 Upper Ragsdale, Suite 230, Building B, Monterey, CA 93940; e-mail, mailto:mvierramd@montereysurgery.com.


From Monterey County Surgical Associates, Monterey, CA 93940.


Ann Intern Med. 2012;156(5):394-395. doi:10.7326/0003-4819-156-5-201203060-00016
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“He is 69 years old, on an experimental treatment for metastatic colon cancer, and he has free air,” explained the emergency department physician. It was a Sunday afternoon, and I was the surgeon on call.

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Death Panel, or simply "Policy in the case of terminal patients"
Posted on March 18, 2012
Daniel F, Lombard, Writer
none
Conflict of Interest: None Declared

Cannot assume that care rationing is limited to senior citizens or medicare. Private insurance, such as an HMO, will also do so, especially in a clearly terminal case, as with cancer. The real problem is when the patient is excluded from the decision making. I tell about just this case in my book Death Panel, a novel based on our family's true experience. Unfortunately, if the HMO denies a death panel, then they can only plead "guilty" to gross incompetence, neither of which is an appealing choice.

Conflict of Interest:

None declared

Helping To Let Go
Posted on March 18, 2012
Denise Baird, Schwartz, MS, RD, FADA, CNSD, Nutrition Support Coordinator
Providence Saint Joseph Medical Center, Burbank, CA
Conflict of Interest: None Declared

Thank you for your insightful article. Your 69 year old patient was fortunate to have a wife and an on call surgeon who readily recognized the scenario that this gentleman was going to encounter if "do everything" was the directive by the decision maker and endorsed or at least followed by the health care professional. Instead of going home to experience a peaceful death with loving family all around him, this individual would have been in the ICU for an extended period.

I could have been the nutrition support dietitian involved in providing nutrition therapy to prolong this process and ultimately documenting when the decision to withdraw therapies occurred due to the futility of continued medical and surgical interventions, "continue nutrition support only as anticipated to benefit overall outcome as assessed by MD in conjunction with patient/family wishes based on quality of life goals."

After nearly 40 years as a health care professional, predominately in the ICU, I want to help resolve this practice gap that we have between clinical ethics from organization and national societies' guidelines, position and practice papers to what actually happens. To help the public better understand the importance of this conversation between the individual, family and their health care providers about health care choices before the health care crisis, I wrote Breathe by Anne Bland (pen name). The royalty is donated for the Millennium Development Goal #1 to eradicate extreme poverty and hunger.

Conflict of Interest:

None declared

Parting is such sweet sorrow (Romeo and Juliet)
Posted on March 19, 2012
Hugh, Mann, Physician
Eagle Rock, Mo 65641
Conflict of Interest: None Declared

Saying goodbye is awkward. We never know how or when to say it. It's always too soon or too late. It's never the right time. What should we do? We should recognize that it's always the right time, because once we've shared a heartfelt goodbye, we're ready to embrace each other with a real hello and face a final goodbye.

Conflict of Interest:

None declared

Death Panels - or - 'When you're dying'
Posted on April 12, 2012
David V, Power, Program Director, Medical Student Education
Department of Family Medicine, University of Minnesota Medical School
Conflict of Interest: None Declared

I really appreciate Dr Vierra's well written piece (Ann Intern Med 2012:156:394-395). I would like it to be required reading for year 1 medical students taking ethics. I love the way his piece traverses clinical management, interpreting test results, human interaction and shared decision making - certainly the 'stuff' of primary care practice and, clearly, of some surgical consults.

As a non-US trained physician, I would add that proper clinical care is not just about responding to patient (or family) preferences. If this man's wife had, on the other hand, responded 'no, I want everything to be done' ('the full court press'), would that have been pursued? Maybe ..indeed in some places, probably.

Globally, other less financially endowed health systems need to go an additional step. This man is dying, his prognosis is gravely poor, aggressive interventions are essentially futile: he needs to be allowed to die in peace and comfort and, no, we are not proceeding with heroic interventions (even if you or your family want them).

I don't know all the details of Dick Cheney's recent heart transplant. But the American notion that if you pay for health insurance, you can get what you need today - needs to go away. We need to have a fair and reasonable health system where all healthy patients get good health care when they are sick - and where dying patients and their families are not even offered the option of pursuing futile and ridiculously expensive interventions. As Dr Vierra writes, 'every one of my patients [including myself] is going to die one day'.

Conflict of Interest:

None declared

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