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Engaging Public Health in End-of-Life Issues: It Is Time to Step Up to the PlateEngaging Public Health in End-of-Life Issues

Jaya K. Rao, MD, MHS, Deputy Editor
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 9 December 2014.

From the American College of Physicians, Philadelphia, Pennsylvania.

Disclaimer: Dr. Rao worked at the CDC from 2000 to 2008, and the CDC funded the work that she describes here. She is currently Deputy Editor, Annals of Internal Medicine. The opinions expressed in this article are those of the author and do not necessarily represent those of the American College of Physicians.

Acknowledgment: The author thanks Dr. Lynda Anderson from the CDC for her constructive comments on an earlier version of this commentary.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2479.

Requests for Single Reprints: Jaya K. Rao, MD, MHS, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, jrao@acponline.org.

Author Contributions:Conception and design: J.K. Rao.

Drafting of the article: J.K. Rao.

Critical revision of the article for important intellectual content: J.K. Rao.

Final approval of the article: J.K. Rao.

Ann Intern Med. 2015;162(3):230-231. doi:10.7326/M14-2479
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This commentary discusses the recent report from the Institute of Medicine Committee on Approaching Death, noting that it is the first Institute of Medicine report on the end of life to explicitly mention public health as having a role in this arena and discusses the promise of this approach.

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comment on article: Engaging the public in end-of-life issues: it's time to step up to the plate.
Posted on February 18, 2015
George Everett MD MS FACP
Program Director, Internal Medicine Residency, Florida Hospital Medical Center, Orlando, Florida
Conflict of Interest: None Declared
Dear Editor,
The quartet of articles on death and dying in America (1,2,3,4) contains useful perspectives but the article by Rao (4) seems to be closest to a practical direction. The Institute of Medicine (IOM) treatise, referred to by Rao and the other articles, is exhaustive and scholarly but misses the mark by beating around the bush.
The main problems we clinicians and our society face are not: lack of palliative care and pain management, or lack of hospice care, or a lack of knowledge of personal choices, nor health providers who encourage the use of futile, end-of-life care, although there are deficiencies in each of those components. If those problems were dominant, then the improvements in each of those components noted by Halpern (1) in paragraph 1 would have moved the needle forward. Paragraph 2 of that same article documents nearly complete failure of meaningful change in the futile aggressiveness and extraordinary cost of terminal care. The default position of nearly every US medical and societal institution is to provide heroic care until the patient or family will consent to stop or death occurs. We can’t talk our way out of these problems by engaging in philosophical discussions, one person at a time, in the clinician’s office or around the dinner table. The bush that the IOM report beats around is that it mostly focuses on enhancing individual choices and improving quality of care surrounding the dying process. We have addressed that already. The real issue is that people don’t want to die and thus are very unlikely to engage in meaningful conversations about the dying process, even when enticed by the enhanced comfort that can be offered.
What potential new direction is alluded to by Rao (4) that is underplayed in the IOM report and the other trio of articles? A public health figure such as the Surgeon General (if only we could awaken Everett Koop) coupled with courageous political and spiritual leaders might be effective. However, the focus of the public health discussion should deemphasize individual choices at the end-of-life, which will necessarily need to be resource limited in the future, and emphasize what quality-of-life looks like. Perhaps a robust discussion of what constitutes quality living can substitute for the less palatable, euphemistic hope for discussions of dying that our society abhors and avoids.
1.Halpern SD, Emanuel EJ. Can the United States buy better advance care planning? Ann Intern Med. 2015;162:224-5.
2.Ness DL, Johnson BH. Dying in America. A constructive step forward and an opportunity to deepen partnerships with patients and families. Ann Intern Med. 2015;162:226-7.
3.Pizzo PA. The doctor: for life and at the end of life. Ann Intern Med. 2015;162:228-9.
4.Rao JK. Engaging public health in end-of-life issues: it is time to step up to the plate. Ann Intern Med. 2015;162:230-1.

George Everett, MD, MS, FACP
Program Director, Internal Medicine Residency
Florida Hospital Medical Center, Orlando, Florida.
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