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w r Clinical Ethics C Reprinted from the Archives ol.lntemal Medicine August7979,.Volume 139Copynght 1979, American Medical Association. C Clinical Ethics and Clinical Medicine . Mark Siegler, MD n this issue of the ARCHIVES, a new editoriall d'epartment. I is introduced. It will appear occasionally and will present' the views of practicing physicians on a broad range of clinical problems that force themito confront directly moral and ethical questions arising in their routine practice. The articles will be written by clinicians, and will be directed toward an audience of practicing physicians. This new section will be called CLINICAL F,'exlCS, refleeting the fact that„in the practice of medicine, clinical and ethical issues are deeply interdependent. THE RISE OF BIOMEDICAL ETHICS Clinical ethics, which focuses on issues that confront the physician, in his daily int'~eractionswith patients, is to be contrasted w,i'th biomedical et'~hics(B1VZE), which is greatly concerned with public policy issues. In the past 15 years, there has been a remarkable rise of interest in, BME; it has captured the fancy of the public. The media! have focused increasedl attention on, such issues as research in human subjects, the, recombinant DNA controversy, policy issues concerning, national' health insurance, and others; the courts have become increasingly active in the medical arena. Biomedicali ethics has become an established "field" in the United States. New scholarly journals in BME appear regularly; institutes of BME have been established; there is a proliferation of books, both academic and lay, in the field. Universities have developed graduat'e: teaching, programs in bioethics, and bioethiciststestiflyregularlyfor state and federal legislative committees and the courts. Such interdisciplinary efforts are laudable, but with some reservations. The BME establishment! has been created and led to a large degree by nonphysicians, ie, theologians, philosophers, sociolbgist's, lawyers; and histo• rians. Physicians„ scientists; andl medical professionals have had only limited involvement'in its development. From the Section of General Dnternal Medicine, IDeparthnent of Internal Medicine„University of Chicago, Pritzker School of Medicine. Reprint requests to Box 72;,University of Chicago Hospitals, 950 E 59th St, Chicago;,III, 60637 (Dr Sieglnr). 914 Arch Intern Med-Vol 139, Aug 1979 CONCERN OVER BME Developments in BME are disquieting, and! are worthy of our attention. The lack ofinv.olvement by physicians is profoundly disturbing. It has been suggeste& that manybioethicists, have, a frankly antiscientific, antiimedicine bias, or at the least, that they represent interests that are quite different from~ those of the medical-scientific community."Bioethicists whoareuninvolvedlin the process of inedicallcare have produced! legislative, administrative, and legali changes that affect the practice of medicine, and! it is clear by now that medicine has merely reacted to, rather than anticipated or participated in,, most major developments in BME. Further, much of the teaching of BME to medical and other health professional students is being done by this new group of bioethicists, rather than byphysicians,Theproliferation of teaching medical ethi- cists and their virtual dominance inithe teaching of medical students is another disturbing aspect: in the growth of B141iE; It is reassuring to note that even some earlV leaders ini theBM'E establishment! have become concerned with this development, and have attempted to involve them- selves more deepl.inithe realities of clinical medieine.'Finally„BME is increasingly eoncernedwith theanalysis and formulation of large publicpolicyc options in medlcine and science; and has not directedsuffirrient attention to manM1-y of the routine ethical' questions that arise in the encountlersbet'ween patients an& phy sieians. Many of the leaders of the BME movement have actually expressed their disdain for traditional, Hippocratic, bedside medical ethics,'which, since Hippocratic times, have beenover- whelmingly physician- and patient-oriented! Biomedical ethics is an intellectual movement that concerns itself with questions affecting the daily activities of medicine, butt that has ari'sen primarily from outside the profession CLINICAL MEDICINE AND CLINICAL ETHICS It is in the context of the rapid growth of BMRan& our concerns with that development that we encourage physi- cians to consider the merits of clinical ethics. The practice ofl clinical medicine has always been a unique blend of technicall proficiency and ethical sensitivity, which togeth. er constitute the physician's art. The distinction that is too Clinical Ethics-Siegler

commonly made between clini decisions and ethicall decisions is ani invidious, but fortunately misguided, one. In a sense, the term "clinical ethics" is redundantl,' because good clinical medicine is necessarily ethical medicine: The reasonf'orselecting CLINICAL ETHics as the name of the new editorial section is that! changes in modern, medicine- particularly but not exclusively technological adrances of the last 30 years-have created an unanticipated range of ethical' dilemmas that demand creative and reflective clinical responses. We are now able to treat patients with chronic renal failure, chronic respiratory failure, and even chronic gastrointestinal failure. We have powerful antit'u- mor drugs; the techniques of cardiopulmonary resuscita- tion can be used! to prolong, for variable periods, the viabilityy of every person whose heart and lungs have stopped; advances in neonatal intensive care and neonatal surgery have assured that many congenitally abnormal infants can be treated! in ways that are certaini to extend their existence. Each of these medical capabilities gener- ates a range of clinical4ethical questions that must be taken into account in the course of formulating a clinical decision. These are examples of the kinds of clinical-ethical problems that increasingly test the mettle of conscientious, technically proficient, and morally scrupulous physicians. Clinical ethics also explores the assumption that the role of the medical professional, is unique. The physician's relationship to the patient is premised on specific technical, training and competency. This specialized! knowledge and' proficiency is used to assist patients in curing or amelio- rating their illness and disease, and to assist them in overcoming the fear, pain~ and suffering that are often associated with ill health. Once sought out byy the patient, the physiciani becomes involved in the patient's problem. He is never a mere observer. He cannot rely on the counterfeit courage of the noncombatant. The physician is personally accountable to the patient if he fails to performm his task adequately because of lack of skill'or negligence, or because, for whatever reason, he fails to act in his patient's behalf. Soren Kierkegaard perfectly captured the distinc- tion between the theoretician, and the involved participant in his response to a question that he posed: "Is knowledge changed when it is applied?"' Kierkegaard's response deserves consideration from all wholwould criticize medi- cine and! physicians from a perspective removed from the actual medical setting: Let! us imagine a pilot, and assume that he had passed every examination with distinction, but that he had not as yet been at sea. Imagine him in a storm;,he knows everything he ought to do; but he has not known before how terror grips the seafarer when the stars are lbst in the blackness of night; he has not known~the sense of' impotence that comes when the pilot sees the wheeLin his hand become a plaything,for the waves; he has not known how the blood1rushes into the head when one tries to make calculations at such a moment;,in short, he has hadi no conception of the change that takes place ini the knower when he has to apply his knowl- edge." A NEW EDITORIAL DEPARTMENT OF CLINICAL ETHICS This new editorial department will be devoted to explor- ing issues in clinical ethics: It will be addressed to those physicians who have "'. .. known how the blood rushes into the head when one tries to make calculations at such a momentl...... Our first symposium will serve as an example of the method we willl use and, it will indicate the general areas of concerni to be discussed' in this sectioni in comingg years. Each of the contributors to this discussion on the management of respiratory failure is a distinguished physician. Each of these contributions was unsolicited. The Arch Ihtern Med-Vol 139; Aug 1979 c editors did not creale a problemi or a "case"'and'itheni seek out expert commentators tlo resolve it. This symposium should' not be confused with an "ethical grand rounds." Rather, in the context of practicing clinical medicine, certain clinical quandaries appeared repeatedly. Because of the thorny nature of such problems and the lack of definitive solutions, the authors decided to struggle to articulate and defend their clinical judgment in writing. It occurred to the edit'orsof theARCH1vES-t'~hemselves practicing physicians-that the types of questions that are raised by the authors of this symposium could as easily be raised about most areas of inedicine: Future symposia on these pages will be, devoted to similar clinical-ethical problems that arise in the practice of clinical medicine, surgery, pediatrics, obstetrics, and gynecology.,, and psychiatry. Our editorial plan is as follows: We will accept unsolicited articles for refereed review and wilt also~ invite distin- guished'! clinicians to reflect on, the range of clinical-ethicall dilemmas that arise in their area of expertise. We will attempt to gather such articles together and publish them as symposia focusing on one clinical area; It is our hope t1Pat in time we will have generated a series of clinical reflections in most major areas of medical practice. These reflections will report ways in whichi physicians are dealing with these dilemmas at a time when the traditional model of the physician-patient relationship is inia state of flux, and when technological advances demand new and creative solutions. Expert clinicians will offer practical suggestions about such dilemmas from the perspective of the practicing clinician~ We are hopeful that these contributions will encourage other clinicians to offer their own observations in this area„and the editors'of the ARCHIVES OF INTERNAL MEDICINE have agreed to~publi'sh a substantiaLnumber of letters provoked by these articles„to indicate the range of clinical opinion on these complex and difficult subjects. The new editorial section of the ARCHIVES OF INTERNAL MEDICINE will differ fromi other medical journals, such as the New EnglandJoacrnalof Medicine,, Clinical'Research, and the American Journal of Medicine, all of which increasingly publish articles that relate medicine to broad social, economic, and ethical issues: This section of the ARCHIVES will serve primarilyy as a forum for clinicians: We hope it will become a resource on which nonphysician- theoreticians can base their analj ses and speculations. This new section of the ARCHIVES, CLINICAL ETHICS, is certainly not intended to be reactionary. Rather,,its inten- tion is to infuse a higher degree of contact with clinical' reality into the debate than has characterized BME in thee past. Further, it is designed to represent more forcefully theconcerns,of clinicians in the councils of bioethicists. It will never be the intention of these columns to:suggest that the judgment of medical professionals is correct merely because of theirmedical!expertise. But it will be argued with vigor and fervor that the viewpoints and reflections ofinvolved' professionals, on clinical-ethical problems, merit careful consideration in the resolution of complex issues in medical ethics. 03'75olsz References 1. Callahan D: The ethics backlash. Hastings Cent Rep 5:18, 1975. 2. Jonsen AR: Books on bioethics. Pharos 44:39-43;,1978. 3. Veatch RM, Branson~R: Ethics and'Health,Pol'ecy. Cambridge, Mass, Ballinger Publishing Co, 1976„pp xix-xx„3-16: 4: Guttentag 0: Medical humanism: A redundant phrase. Pharns32:12-I6, 1969. 5. Kierkegaard SrThoughts on orucialisit'uations in human life, in Oden TC (ed): Parab'les of Kierkegaard. Princeton, NJ, Princeton University Press, 1978, p 38: 0 Clinical Ethics-Siegler 915 16

S r Cri tical Decisions in Medic'~ne To Live and To Die Gary L. Huber, MD [There is] a, time ~to~be~born~ and a time tb~~die~ ... a~time to~kill and a~ time to heal. L' CCLBSfASTES 3:2-3 T he purpose of this contribution, and the following four related editorials,, is, to address from different view- points some of the clinical and ethical guidelines that are of concern to physicians involved with the difficult decision of what and how much to do for the patient': with chronic obst'ructive lung disease in whomisevere respiratory failure develops. These discussions, however, are also:applicablE to the management of respiratory failure associated with other forms of lung disease, and also to life-threatening problems that are unrelated to the respiratory system. Each,of these physician-commentators may be striving to follow the Hippocratlic injunction: "First, do no harm." On reading these essays, it becomes clear that the means too achieve that goalI are neither obvious nor easyy tb, find. To place matters in perspective, acute and! chrorlicc diseases of the respiratory system are now the rfiost common causes of morbidity and mortality in the United States.' Upper respiratory tract infections result inimore restricted activity andi loss of employment than any other disease. Pneumonia is the single most common cause of' hospitalization. Chronic obstructive lung disease, involving some variable combination of small airw.ayy dysfunetiorn and, emphysema withi or without bronchitis; is ani increas- ing health problem with a: steadily rising prevalence. Respiratory distress syndromes of divergent causes afflict' over 175j000 adults each year and an additionall 50,000 newborn infants, with a combined! 40% to50%o mortality. Purulent bronchitis, thromboembolism, asthma, respirato- ry decompensation secondary tocongestiiaeheart failure, and other forms of pulmonary dysfunction substantially increase the total number of individuals afflicted with respiratoryy diseases. The cause of death in ea& of these diseases (ie; the natural history of the diseases) is respiratory failure, characterized byy hypoxemia„hypercapnia, and respiratory acidosis. Respiratory failure is the "final common path- way," regardless of the specific cause of the severe respi- ratory disease. How.ever,, patient's with pulmonary diseases usually do not die untreatedl Indeed, as severali of the following editorials suggest, sometimes these patients may be "over- treated." The management of these diseases, and especial- ly our ability tbltreat respiratory failure, have undergone dramatic changes in the past decade. Our understanding of respiratory failure and our knowledge of the pathophysio- logic mechanisms of hing injury have rapidly increased. Equally important, major advances have been made in developing mechanical devices to support respiration and in discovering pharmacologic means to prolong life when respiratoryy insufficiency develops. Physiologic life now can From the Harvard Medical 5chool;,William B;,Castle Laboratory, Mount Auburn Hospital, Cambridge, Mass. Reprint! requcststb Department of; Medicine, Mount AuburnHospital;,330 Mount Auburn 5tj Cambridge, MA 02138 (Dr Huber). 916 Arch Intern Med-Vol 139„Aug 1979: be extended with respirators,, pacemakers, hemodialyzers, and extracorporeal oxygenation. It is important to not'ee that regardless of the therapeutic resources available„ when respiratory failure is severe the mortality is approx- imately- 90%, whether the patient is treated by convention- al means or with extracorporeal membrane oxygenation. The latter technique represents the most technologically advanced, intervention that is now available to reverse: acut'elife-threatening respiratoryevent's. In~less extreme, . cases, the prognosis is better, but surprisingly, not that much better. In a recent National Institutes of Health- sponsored study in several leading medical centers„ for example, 69% of all respirator patients who received an inspirectoxygen concentration of 50 % or higher for longer than 24 hours died (Lynn Blake, PhD, oral communication,, December 1978). The problem, however, is not' only one of statistics or natural history of disease. Perhaps medical technology has advanced' more rapidly than has our capacityy to employ it judiciously. Precisely the: same mechanical devices and drugs t'hat' are used to manage respiratory failure can also be employed to maintain a state of intolerable suffering from physical pain or mental anguish, beyond reasonable hope for recovery of normal human function. In other words„an indiscriminate applic.at.ioniof technical and phar- macologic means to preserve a failing organ system may lose the perspective of the quality of preservation of the patient as a whole human being. Based in part on the Sixth Commandment from the Judeo-Christian heritage of our western civilization„and in part on other reasons, we as physicians usually have been conditioned in medical school to view death as the ultimate enemy: Our profession has been taught to prolong life whenever possible. As a result, our hospitalfi and intensive care units behav.eas if death were an illegitimate occur- rence or an abomination. Dying, nevertheless, is a geneti- cally programmed natiurall event, andl may in certain circumstances be the preferable choice for some individu- als. With the teehnolbgyy that i'snowavailable, death from respiratory failure that woui&occur in the normal prog,res- sion of certain pulmonary di'seases can be deferred, andthe patient mayy be given additionali months or yearsof useful life. As physicians, we:usually feel little conflict in employ- ing this technology to manage respiratory failure: In doing so, we preserve life and fulfill'i our Hippocratic obligation to pat'ients: But physicians are asked also to relieve suffering. Unfor- tunately, there now occur instances in the treatment of many diseases when the capacity to preserve life d'elav.s,,if only temporarily, an otherwise inevitable death. Some- times this results inigreat suffering to the patient and thepat'ient's family. This is especially true for some patients ~ with~ chronic obstructihelungdisease whose oxygenation ~ must be supported by meehanicall devices. In such circum~ ~ stances; the medical care team is f'aeed' with critical ~ decisions of whether to initiate, sustain; or terminate artificialrespiratbry support, decisions that! will determine ~ whether the patient will live or die. Ideally, decisions of (r,~ this nature should be governed by scientific knowledge and Critical I Decisions-H u ber, 0

c medical ethics, ie, by the principles of science applied and practiced according to the laws and customs of our society. Again, in the ideal circumstance, suchi decisions should be "automatic," and! governed by moral-clinical rules;, which summarize covertly accepted and reinforced principles of' patient care and human values. Unfortunat'ely„ as new technologies appear, the relevant factors on which clinical ethical'decisions are based will necessarily change, and the old rules may no longer be applicable. When the rate of technological advance exceeds society's ability to under- stand and integrate these changes, a: gulf ofuncertlainty develops and there is no longer a social consensus about some medical decisions. Instead~ there is ambiguity and conflict between competing values. The resultant dilemma for the conscientious physician is addressed in the accom- panying contributions by four physicians who1ave exten- sive personal experience in patient care involving decisions of this magnitude. Not surprisingly, their perspectives differ markedly. It willl not be easy to resolve such, differ- ences; either for these physician-contributors or for the profession as a whole;,because in many areas of our society, human behavior cannot keep pace with technological growth. What of the patient who is caught up in this worl& of technology? Should decisions of this nature be made unilat- erally, as perhaps they often are„ by tlle physician alone? With the rapid, advances in technology, citizens have less and less control over all, aspects of their individual lives, includingillness. Most people with fatal illnessesdo not die with, the assurance that their death belongs to them as a meaningful'sumination of their life; rather, the responsi- bility for their dying process has been usurped by health professionals. This problem is eveni more acute for the individual who is sustained by mechanical respiratory support, who is surrounde& by a bewildering and complexx array of equipment and! tubes, and whose familyy is in the corridor and not at the bedside. Althoughithe responsibility for the dying process has been relegated to institutions, our modern medical staffs are often not trained to deal with it. Medical education focuses on biologic and physio- logic phenomena, and not always on the whole person. Yet dying is inevitable. When, if ever, is death to be preferred to a life of suffering, and how is that issue to be resolved? Two of the accompanying communications tangentially address the concept of euthanasia„ a word' of Greek origin literally meaning "the good death," but more commonly taken to~ mean "mercy killing." In one survey,,Z 80%of physicians either favored or practiced "negative euthanasia,'," ie, a decision involving a deliberate and planned omission of therapy that would have prolonged life. A lesser number advocated "positive euthanasia," ie, commission of an action that would cause death sooner than it otherwise would'occur. In the context of treating respiratoryfailure; it becomes important to know whether and'to what extent active or passive euthanasia is being practiced in respira- tory intensive care settings. What tent'atiiuesoiutions can we suggest? It would be desirable to find our answers in rules of law or religion or rules derived from tradition. But ours is a pluralistic society, and our rules and customs are in the process of changing. Perhaps one could seek guidance in some univer- sal norm of human morality that governs the practice of medicine. Such norms are not easily discovered. The follow- ing 1four contributions on the subject of' critical' care in respiratory failure are each written by a distinguished clinician. It is interesting to observe how each physician's decisiom is based on a combination of the patient's wishes, societal rules, scientific knowledge, professional experi- ence, an& a moral code that is grounded in religious- culturalltradition. Each contributor weighs.these variables differently to arriv.e at a clinical decision. The onlyy conclu- sion~ we, can ~ suggest is that to resolvebett'~er the issue in question -decision ~ making in cases of respiratory failure- widespread discussion and constant revision and evolution of our medicaU practices areneed'ed; both within ourprofessioni and in public forums. To contribute to thatt process of reflection i we present the following four commu- nications by Drs~ Skillman, Epstein, Petty, and Baum, developed in conjunction with a regional meeting of the New England Stat'eschapter of the American College of Chest Physicians. References 1. Re;spiratory Diseases: Task ForceReport, on Ptevention;, Controi, Ediecation: US Department of Health, Education, and Welfare, publication (NIH) 78=1248, 1978; 2. WilHams RH (ed): To Live and to Die: When, Why, and Hrno. New, York, Springer-Verlag, 1973. O t.~ ~ EJ1 Terminal Care in Patients With Chronic Lung Disease ~ John J. Skillman, MD ~ Lifebeings at birth and extends in~a continuum to death; seriously ill patient tlhereis a point when almost every or does it?' Is there a point when it may be said that physician and nurse of experience can say to himself or death is beginning?' Does it notl, seem that in caring for a herself (even though one may not outwardly express it), From the Department of Surgery, Harvard Medical l School, and Beth IsraellHospital, Boston. Reprint request's to Beth Israel Hospital, 330 Brookline Ave, Boston, MA 02215 (Dr Skilltnan): - that the patient is beginning to die? At times there is considerable doubt when this point has been reached, for it is clearly less precise than the moment of birth or the time of death. Those who would agree that a point of beginning death can never be defined! are likely to be the same ones Arch Intern Med-Vol 139; Aug 1979 Chronic Lung Disease-Skillman 917 X

0 f who argue most strongly against the .scontinuationiof life support systems. For themi the uncertainty is too great ever to give up seeking a cure. Their sensitivity to the time of beginning deathi is muted by an overpowering desire to continue the fight-the eyes lbok but do not see, the hands touch but do not feel, the ears hear but do not' listen. To the experienced physician and nurse, the clues are there; all that remains is to face them squarely. The seriously ill patient with chronic lung disease repre- sents an extremely difficult problem. These individuals frequently exist under severe physical limitations. It may be difficult for the patient to do the daily housework, to walk to a store for groceries, to drive to a friend's house for a visit, or to get up and walk to the bathroom. Even a prolonged converstion may be a physical effort t'~hat! is exhausting and pushes such a patient to the limits of endurance. As time goes on and the lung disease progresses, even a simple cold may add a physical burden that cannot be tolerated, and the patient's ability to ventilate himsFlf without the aid of a machine nears an end. Such individuals are often brought to the hospital by ambulance in a semicomatose state. At the hospital~ the emergency room staff rapidly evaluates the condition of the gasping patient. Theysearchi for causes of the episode of acute respiratory decompensation. Is the patient in, heart failure? Has an acute infection occurred t'hat' has further decreased'the spontaneous ventilatory efforts by increasing the dead space and metabolic rate? Both of these factors increase the minute ventilation required to maintain sufficient alveolar ventilat!ions to prevent CSF acidosis and coma, Or has the patient forgotten to take his digital:s or diuretic medication? Is there any evidence for pulmonary embolism?' Soon, we reach the first major therapeutic decision. Should we intubate the patient and' give him assistance with a ventilator? If the patient has a respiratory or cardiac arrest, the staff almost always carries out endotra- cheal intubation and' resuscitation. But before an arrest occurs, a small' dose of oxygen may forestall the need for intubation if the patient is still conscious. There may be: time to give a rapidly acting diuretic, which could relieve pulmonary edema; or an antibiotic could be employed to treat the infection;, or heparin might' be administered to treat pulmonary embolization If' a correctable condition can be diagnosed, its specific treatment may save the patient' from the need for a respirator. Frequently, the: patient is admitted directly from the emergency room~ to the intensive care unit for close observation, monitoring, and'intensive chest physical ther- apy. Gradually the patient's ventilation and oxygenation may improve and endotracheallintubation may be avoided. The intensive care unit staff carefully monitors the patient's condition and practices a form of justifiable "brinksmanship," in which the goal is to lavoid intubation and artificiall vent'ilat~ionof~ the patient if at all possible. Even when intubation seems absolutely necessary, place- ment of a Swan-Ganz catheter may frequently indicate that congestive failure has occurred, even though physical examination and the chest roent'genogram, have not! pointed' to this diagnosis as the reason for the acute respiratory decompensation. Treatment of congestive heart failure under these circumstances may obviate endo- tracheal'intubation. Although t'hesediagnost'icpossibilities and their specific therapeutic solut'ions are always sought for, in some patients no discernible reason for the episode of acute decompensationi may be found. For such patients,, the chronic lung disease has entered, a terminal' phase and the point of beginning deathi has been reached. They will 918 Arch Intern Wted-Vol'139, Aug 1979 require endotrachea ubation and artificial ventilation. ~ Efforts at weaning these patients from the assistance of the ventilator are pursued vigorously. All permutations of the weaning process are tried, ie, short periods of sponta- neous ventilation interspersed with return to the ventila- tor, intermitt'ent' mandatoryventilation„or change from a constant-volume ventilator to a patient-triggered pressure ventilator. Eventually, the caring physicians and nurses become frustrated in their attempts to~wean the patient from~t'he respirator. Anxiety and frustration, anger, and despair-these emotions are felt by the patient, hisfamily, and! the staff. Discussions, about the lack of progress are held'i with the family by the staff caring for the patient. All too often, the patient is not included in these discussions, because it is extremely difi'icult to telll a critically ill patient~ that all is not going welli I am, frequently guilty of this lack of consideration. However, the messages are giveni to the patient by nonverbal means-worried looks of staff,,or the anguish on the face of the chest therapist who gives a painful treatment to the patient. These communications, thoQgh perhaps more distressing to the patient because theyareindireet, are felt by the patient. I now believe that bot'h, the patient and his, familyshould, be kept informed about! the patient's progress or the lack of it. The second crossroa& is now reached. Even though the ventilator can be gradually removed, while keeping the patient comfortable with medication for pain and air hunger, the physician may be unable to make this decision. What should be done now? He mayy choose to continue with the ventilator. Other staff members, particularly the nurses who spend their hours caring, for the patient's needs, may wish that the ordeal, which is theirs, the family's, and the patient's, would end. In my opinion, it' is the physician's own unresolved fears and needs, and'rarely those of the family, that force him to continue therapy when alll seems lost. Certainly the patient's wishes about discontinuation of t'herapyshould'be honored, even if they are different from the wishes of the family. When such a terminall point' has been reached, when the likelihood of getting back to the previous minimal, dismal existence, without a respirator, has dfsappeared, I do not support the continuation of ventilatdoni Thedifl'icultyis in being certaimthat the point of terminal irreversible illness has been reached. II suggest that it' is not impossible to know when that point has been almost certainly reachedi The caring staff of nurses and physicians need to talkk together openly about this difficult issue, for doubts an& fears always exist. Since care should not be discontinued! without a unanimous decision from all concerned, some- times a strong difference of opinion (usually by a physician who cannot "let go") forces a confrontation that may ultimately result in the patient's transfer from the inten- sive care unit to a medical ward. There, the ventilator care is usuallycont!inued. Unfortunately, this is often regarded by a new set of house officers and nurses as "dumping" the patient'on them. In part', their feelings are justified. Anxiety and frustration, anger, and despair begin all over again because the patient's problems must be completely discussed an& faced! byy the new group, who cannot do otherwise than try to find~ some solution to the medical crisis. In rare instances, theytemporariliy succeed. The patient, meanwhile, is subjected again to more weaning t'rials, more drugs, and more painful chest' physical thera- py, until' resistant organisms finally cause an intractable infection and'the patient! dies. 03'7501s5 What is our obligation in~such cases? Ii suggest it is one of caring for the human being in the broadest sense, not in a Chronic Lung Disease-Skillman f

~ restrictedior mechanicaLway. The physician should learn to handle his guilt and frustrat~ion~ to avoid a withdrawal of emotional support and a dehumanization of the patient. I believe we need to use alliof our love and human sensitivity to d'o the best'~ that we can for these patients. Somet'~imes the very best we can do is to avoid prolonging death by continuing treatments that may lead to a cruel, slow, and painful end. Reference 1. Young EWD: Reflections on~ life and death. Stanford MD 15:20-24, 1975. 1 Responsibility of the Physician in the Preservation of Life Franklin H. Epstein, MD ~ B ecause hospital intensive care units are in some ways the epitome of mod'ernmedical technology, they are often the focus of' the questions that physicians and nurses must ask themselves from time to time about'. the very reason for their existence. Anguished! relat!ives wait in the wings, expecting and fearing that death willl come and sometimes disappoint'ed that it does not. In an attempt to relieve unbearable pressures„phy,sicians who are in charge of intensive care units are tempted to assert their sole right to determine when lifehas lost its meaning for their patients and t'o~decid'e when care cani be given over, and the plug pulled. It was easier 30 and 40 years ago in the days of therapeutic nihilism. Then, for many more patients than at present, the matter seemed to be out of our hands. There were fewer decisions to.be made, andla gentle manner and firm, wise countenance did w.onders for the physician and the family, if not! for the patient. "Pneumonia," said Dr Wilham~Osler, "is the friend of the aged." Antibiotics,were not yet available, blood transfusions were given in homeo- pathic amounts, and mechanical respiratory assistance was almost unheard of. It was easy tolet anl elderlyy patient die and' even to believe that it was God's will that he go quickly. But it is harder for us. We have become, some feel, too successful in rescuing life. For some perverse reasons God has made respirators and antibiotics available, and we don't know whether Osler (or God) woul&call them friends of the aged or not. Liberal clergymen talk easily of "the right to die" with all the fervor of a Rousseau declaiming the natural rights: of man: And, on this subject every reporter and perhaps every lawyer has recently become a philosopher. I would like to detail briefly some of the special reasons (they will be appreciated best by physicians and nurses) why myy own years in, the care of desperat'ely„ often hopelessly,, illl patients have led me to espouse this rule: When efficacious treatment is at hand4 try as hard as you can. The physician''s~ duty is to his patienti, to relieve his suffering and to preserve his life. From Harvard Medical Schoolland Beth Israel Hospital, Bostoni Reprint requests to Beth Israel Hospital, 330 Brookline Ave, Boston, MA 02215 (Dr Epstein). Arch Intern Med-Vol 139, Aug 1979 PAIN CAN BE RELIEVED With proper care and modern techniques, physical pain can be assuaged! in almost every instance. If necessary to relieve pain, a patient can~be put tosleepor made drowsy for most of the day. Excruciating pain is almost never present in dying patients, and when it is, it can be controlled. There is a clear distinction between putting a person to sleep and taking his life. DIGNITY IN DEATH Talk about a "dignified death~' usually comes from onlookers, not from the patient. Most patients want to liive: They need to have some hope of forest'alling the inevitable end, and they need tofeellthat their physician is helping to keep hope alive. Dignity lies in their fight for life an& in their struggle to maintain contact with humanity. Kind- ness, personaliattent'ion, and good nursing help to preserve a patient's dignity. Euthanasia for elderly people whose bodily functions and controll are failing primarily relieves the distress of the relatiives; not that of the patient. THE PHYSICIAN IS NOT OMNISCIENT , Physicians are fallible. Their wisdom tends to be greatly exaggerated by the popular press and, too often, by physieians themselves. Patients have an, enormous need to feel that their physicians can prognosticate with great accuracy, but the kindest, best-intentioned physician is often wrong. Moreover, a! physician's prognosis tlends to be weighted toward pessimism, becausepatient's who do badly claim most of his time and! at'tent'ion, and remain in his memory longer than those who do well. Physicians who are in charge of intensive care units have a special problem to overcome in that their training an& experience are often heavily weighted toward the care of aeut'eemergencyillness ratherthan, that'~of chronicallyilll patients. When an elderly person with chronic cardiopul- monary disease andl acute bronchitis is assisted, by a respirator, the expectations of the nurses and physicians may be attuned to the usual prompt recovery of a youngg postoperative patient with respiratory failure rather than the slow convalescence of a chronic pulmonary cripple. It is tragic to see life support withdrawn because of a mixture of impatience and' ignorance. Equally tragic is the assumption that an incurable but indolent illness is causing. 03'750166 Preservation of, Life-Epstein 919

\: s- new symptoms when in fact a coincidental curable diseasee is at fault. The best way to insure that a cure is not overlooked is to make it very hard for the physician to give up. THE PHYSICIAN IS AN INTERESTED PARTY Psychological pressures on the physician in caring for terminally ill patients conspire against his impartiality. The physician suffers wheni the patient doesn't get welll and his suffering ends when the patient. dies. It's hard! to appreciate how difficult it is to attempt to supportl a dying patient day after day with condolence and hope; how frustrating it is to contemplate monthsof decline, of weary and anxious relatives, of no treatment working. Physicians and nurses know the overwhelming sense of relief that comes when, on hurrying to the patient's room, steeling yourself to face the ordeal of a patient who is not getting, better, you learn that death has arrived, unexpectedly, an, hour earlier. The sense of relief can be so intense that it is hard to remember that the patient cannot share it. THE PHYSICIAN'S CONTRACT Our obligation t'oi assuage the pain of our patients is sometimes discussed as if it involved an equal obligation to minimize suffering of relatives, friends, and other onlook- ers. In~ fact, much of the "suffering"' of terminally ill patients from nasal oxygen tubes and intravenous drips exists only in the imagination of shocked relatives, who are sickened and frightened by unfamiliar procedures and apparatus. The physician must remember that he has only one client-the patient. He is the advocate of the patient- not the family, nor the welfare agency„ nor the kindly clergyman, squeamish at the sight'. of tracheostomy. USELESS TREATMENTS If we are indeed obligated to do everything we can to preserve our patients' lives, then we have a special and balancing obligation to evaluate our expensive methods of treatment ini impartial, prospective studies; so that resources will not be unnecessarily squanderedi It should be clear that wheni life is irretrievable, useless treatments should not be employed. But a& hoc judgments about the "quality of life"'should be discouraged as al major factor in such decisions. In the best hospitals, the principle that human life itself has dignity and worth will affect all ofe the actions in every department. To maintain that attitude is the unique responsibility of the medical profession. Ln the last analy- sis, that attitude of the professionimay be as important for societyy as any miracle t'hat'~ moderni technical medicine can perform. Death alway s comes at last, despite our best': efforts: Butl what little we can do carries a message to our patients and to the world: Human beings are important. Humanity is to be preserved! Don't Just Do Something-Stand There! Thomas L. Petty„MD The apparent transposition of the phrase that titles this article is not a mistake. It is intended to make the point that„ at times, what appears at first to be a medicall emergency is, in fact, nature's' blessing that should be allowed to remove the suffering,patient from hopeless and' intolerable agony. Certainly our skills at respiratory and' cardiac resuscitation should be deftly applied to individuals whose vital functions have suddenly failed by accident, disease, or trauma„to gain time for the resolution of acute reversible life-threatening processes affecting the circula- tory and' respiratory systems. By contrast, there are indi- viduals for whom t'hese resuscitation techniques onlyy prolong the dying, process and impose unnecessary suffer- ing before the inevitable death occurs. Faced withia patient with sudden cessationlof respirato- ry and cardiac function, how does one decide whether intubation, mechanical ventilatory support, and reestab- lishment of cardiac function with closed chest massage and/or pharmacologic agents should be instituted? The: From the Division of Pulmonary Diseases, University of Colorado Medical' Center, Denver. Reprint requests to University of Colorado Medical'Center, 4200 E Ninth Ave, Denver, CO 80262 (Dr Petty). 920 Arch Intern Med-Vol 139, Aug 1979 systematic review of four basic questions provides major assistance in this important decision. These questions aree as follows;~ (1i)Do Dknowthepatient's'underly.ingdiseaseprocess and its course and prognosis? (2) Do I know the patient's quality of life in the context of his disease process? (3) Do I have anything more to offer the patient by resuscitative efforts designed to gain more time?'(4) Do I wish to gain more time through resuscitative efforts to resolve these other questions? The physician and nurse should be able quickly to answer these questions in order to determine if the patient is best served by initiating respiratory and cardiac support. If one is unable to answer the: first two questions ini the affirma= t'ive, it i's still highly likely that support should be offered until the answers become clear. One should not fear making a mistake:in the direction of vigorous support, for certain patients will be saved to lead meaningful lives oncee again. If "yes" is the clear answer to the first twoo questions, and the thir& and fourth are clearly "no," then the physician, nurse, or allied! health worker should simplyy stand by and offer whatever comfort~, and assistance they can to the patient or the family, or both. When thee patient's life is known to be miserable at best, and when the patient has indicated no wishi to have his suffering extended by technological means-in short,, when there is 03'75016'7 Don1t Just Do Something-Petty 0

C nothing to be gained by the additional hours, days, or weeks one might achieve byy supporting respiration and' circulation-then intervention such as trachealI intubation, mechanical assistance, and! cardiopulmonary support should be set aside on behalf of the patient. Classic examples of these situations might include patients with advanced disabling emphysema with no hopes for recovery from respiratory failure or patients with uncontrolled metastatic carcinoma in whom respiratory failure devel- ops. There are many other similar clinical situations, of course. It should be clear byy now that all patients do not have to die while being assisted by ventiltttors or in intensive care units with their circulation supported artificially. After all, our job as physicians and health workers is to serve the patient, and not one or another of their failing organ systems, in a desperate attempt to extend physiologicall life. Withholding of supportive measures in certaini highly selected instances will prevent tragedies in which patients hover for extended periods between life and death, with alll of the attendant social, economic, legal, and psychological implications that such cases raise. Fortunately, the legal profession and the clergy alike realize that! the decision to support life or not requires skillful medical judgment„and ini the final analysis, should be a contract between the phy,sician, and the patient he or she serves: r