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f Clinical Ethics Reprinted from the Archives of Internal JNedicine August 1979,Volume139'Copyright 1979, American MedicaldLssociation C Clinical Ethics and Clinical Medicine V Mark Siegler, MD~ n this issue of the ARCxIVES, a new editorial, department I is introducedl It will appear occasionally and will present the views of practicing physicians on a broad range of clinicallproblems that force them to 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 CLIxICAL, ETHICS, reflecting the factt that, in the practice of medicine, clinicalland ethical issuess are deeply interdependent. THE RISE OF BIOMEDICAL ETHICS Clinicalet'~hics, which focuses on issues that conf'ront the phy sician in his dailyy interactions with patients, is to be contrasted with biomedical ethics (BME)„which is greatly concerned with public policyy 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 increased attention on such issues as research in human subjects, the recombinant DNA controversy, policy issues, concerning national health~ insurance;, and! others; the'e courts have become increasingly active in~ the medical arena. Biomedical ethics has become an established "field" in the United States. New scholarly journals in BME appear regularly; institutes of BME have been establishedl there is a proliferation of books; both academic and lay, in the field. Universities have developed- graduate teaching programs' inibioethics, andibioethieists t'~estifyregularly for statie,and'federal legislative committees and the courts, Such interdisciplinary efforts are laudable, but withi some reservat'ions. The BME establishment has beeni created and led to a large degree by nonphysicians, ie, theologians, philosophers, sociologists, lawyers, and histo- rians. Physicians, scientists, and medical professionals have ha& only liinited involvement in its development. r From the Section of General Internal Medicine, Department of! Internal Medicine„Universityof Chicago„PritakerSchool of Medicine. Reprint requests to Box 72; University of Chicago Hospitals, 950 E 59th St, Chicago;,II1 60637 (DrSieglor). 914, Arch Intern Med-Vol 139, Aug 1979 CONCERN OVER BME Developments in BME are disquieting and are worthy of our attention. The lack of involvement by physicians is profoundly disturbing. It has been suggested that many bioethicists have a frankly antiscientific, antimedicine bias, or at the least, that': they represent interests that are quite different'fromthose of the medical-scientific community.' Bioethicists who are uninvolved in the process of medical care have produced legislative„ administrative, and legal changes that affect the practice of inedicine;, and it is clear by now that medicine has merely reacted to, rather than anticipated or participate& in, most major developments in BME. Further, much of the teaching of BME t& medical and other healthi professional students is being done by this new group of bioethicists„ rather than by physicians. The proliferation of teaching medical ethi- cists and their virtual dominance in the teaching of medical students is another disturbing, aspect in the growth of BME. It is reassuring to note that even some early leaders in the BME establishment have become concerned with this development„ and' have attempted to invol've them+. selves more deeply in the realities of clinical medicine.= Finally, BME is increasingly concerned with the analysis and formulation of large public pollcy' options in medicine and science, and has not directed sufficient attention to many of the routine ethical questions that arise in the encounters between~ patients and physicians. Many of the leaders of the BME movement have actually expressed their disd'ain for traditional, Hippocratic, bedside medical ethics,' which; since Hippocratic times,, have' been over- whelmingly physician} and' patient-oriented. Biomedical ethics is an intelllectual movement that concerns itself with~ questions affecting the daily activities of medicine, but t'hat has arisen primarily from outside the profession. CLINICAL MEDICINE AND CLINICAL ETHICS It' is in the context of'the.rapid growth of BME and our concerns with that d'ev.elopment' that we encourage physi- cians to consider the merits of clinical ethics. The practiee of clinical medicine has always been a unique blend of technical proficiency and ethical sensitivity', which togeth- er constitute the phy.sician's art. The distinction that is too 03750176 Clinical Ethics-Siegl&

commonly made between clini&~ decisions and' ethicali decisions is an invidious, but fortunately misguided, one. In a sense, the term "clinicallethics"'is redundant,' because goo&clinical medicine is necessarily ethical medicine. The reason for selecting CLINICAL ETHICS as the name of the new editorial section is that changes in moderni medicine- particularly but not exclusively technological advances 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 renall failure, chronic respiratory failure, and even chronic gastrointestinal failure: We have powerful antitu mor drugs; the techniques of cardiopulmonary resuscita- tion cani be used to prolong, for variable periods, the viability of every person whose heart and hings have stopped; advances in neonatal intensive care and neonatali 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 clinical-ethical questions that must be taken into account in the course of formulating a clinical decision. Thesearsexamplesof the kinds of clinical-etihical problems that inereasingly test t.hemettle 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 t'o assist' them~ in overcoming the fear, pain, and suffering that are oftenn associat'ea with ill health. Once sought out by the patient, the physician becomes involve& in the patient's problem. He is never a mere observer. He cannot rely on the counterfeit courage of the noncombatant. The physician is personallyy accountable to the patient if he fails to perform 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 t6a question that! he posed: "Is knowledge change& when it is applied?" Kierkegaard's response deserves consideration from alll who would 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 y,et' been at sea. Imagine him in a storm; he knows everything he ought to db, but he has not known before how terror grips the seafarer when the stars are lost in the blackness of night;:he has not known the sense of impotence that comes when the pilot sees the wheeliin his hand become a plaything for the waves; he has not known how the blood rushes into t'he,head when one tries to make calculations at' such a moment; in short, he has had no conception of the change that takes place in the knower when he has,to apply his know]- edge.' A NEW EDITORIAL DEPARTMENT OF CLINICAL ETHICS This neww editorial department will be devoted to:explbr- ing issues in clinical'' ethics. It willl be addressed to those physicians who have '° . . . known how the blood rushes into the head when one tries to make calculations at such a moment. ... ." Our first symposiumwill serve as an example of the method we will use and it will indicate the general areas of concern to be discussed in this section in coming 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 editors did not cra a problem, or a"case"' and then seek out expert commentators to resolve it. This, symposium should not be confused with an "ethicall grand rounds." Rather, ini the context of practicing clinicall 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 editors of the ARCHIVES-themselves practicing physicians-that the types of questions that are raised by the authors of this symposium could as easily bee raised about most areas of medicine. 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 gy, necology, and psychiatry. Our editorial plan is as follows: We will accept unsolicite& articles for refereed review and will' also~ invite distin- guished clinicians to reflect on the range of clinical-ethical dilemmas that' arise in their area of expertise. We will attempt togat'her such articles together and! publish them as ~ymposia focusing on one clinical area. It is our hope that in time we will have generated a series of clinical reflections in most major areas of medical practice. These reflections willlreport ways in which physicians are dealing wit!h~ these dilemmas at a time when the traditional model of the physician-patient relationship is in a state off flhx; and when technolbgical 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 im this area, and the editors of the ARCHIVES'oF INTERNAL MEDICINE have agreed to publish a substantial number of letters prov oked 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 willl differ from other medical journals, such as theNew EnglaatdJoitrnal of !Vlediciize„ 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 primarily as a forum for clinicians. We hope it will become a resource on which nonphysiciam theoreticians can base their analyses and speculations: This new section of the ARCHIVES, CLINICAL ETHICS, is certainlyy 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 inAhe past. Further, it is designed! to represent more forcefully the concerns of clinicians in the councils of bioethicists, It! will never be the intention of these coltlmns t'osuggesto that the judgment of medical professionals is correct merely because of their medical expertise. But it will be argued with vigor and fervor that the viewpoints and reflections of involved professionals, on clinical-ethical problems,, merit careful consideration in the resolution of complex issues in medical ethics, Referenees 03'7501'T7 ll Callahan ID: The ethics backlash. Hastings Cent Rep 5:18, 1975. 2. Jansen AR: Bi oks on bioethics. Pharos 44:39-43, 1978. 3. Veatch RM, Branson R: Ethics and Health Poltc•y: Cambridge, Mass, Ballinger Publishing Co;,1976, pp xix-xx, 3-16. 4. Guttentag 0: Medical humanism: A redundant phrase. Pharos 32:12-15, 1969. 5. Kierkegaard S: Thoughts on crucial situations in human life, in Oden TC (ed): Parables of Kierkegaard. Princeton, NJ, Princeton University, Press, 1978, p28. 4 Arch Intern Med-Vol 139, Aug 1979 Clinical Ethics-Siegler 915

Y CAL.1cal Decisions in Medicie To Live and To Die Gary L. Huber, MD [There~is] a~t~ime to b'e~born and~a~time~~to die,.~.. aa t2me~~to k~itl~and~al tti»ze~tolheal: ECQL ES L9 S T ES '.`3.Y2-3 T he purpose of this contributions 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 obstructive lung disease in whomisevere respiratory failure develops. These discussions, however, are also applicable to the management of respiratory failure associated withh other forms of lung disease, and also to life-t'hreatening problems that are unrelated to the respiratory system. Each of these physician-commentators may be striving to follow the Hippocratic injunction: "First, do no harm." On reading these essays; it becomes clear that the means to achieve: that goal are neither obvious nor easy to find. To place matters in perspective, acute and chronic diseases of the respiratory system are now the rl"Ost common causes of morbidity and mortality in the United States.' Upper respiratory tract infections result in more restricted' activity and 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 airway dysfunction and emphysema! with or without bronchitis, is an increas- ing health problem with a steadily rising prevalbnce. Respiratory distress syndromes of divergent causes afflict over 175,000 adults each year and an additional 50;0b0~ newborn infant!s, with a combined 40% to 50"c mortality.. Purulent bronchitis, thromboembolisms asthma, respirato- ry decompensation secondary to congestive heart flailure;; and other forms of pulmonary dysfunetion substantially increase the total numberofindiividuals afflicted with respiratory diseases. The cause of death in each of these diseases (ie;, the natural history of the diseases) is respiratory failklre, characterized by hypoxemia, hypercapnia, and'respiratory acidosis. Respiratory failure is the "final common path- way," regardless of the specific cause of the severe respi- ratory disease. However, patients with pulmonary diseases' usually doo not die untreated. Indeed, as several of the following, editorials suggest, sometimes these patients may be "over- treated."'The management of these diseases, and especial- ly our ability to treat respiratory failure, have undergone dramatic changes in the past decade. Our understanding of respiratory failure and our knowledge of the pathophysio- logic mechanisms of lung injury have rapidly increased. Equally important, major advances have been made in dev.eloping mechanical devices to support respiration and in discovering pharmacologic means to prolong life when respiratory insufficiency develbps: Physiologic lifle' now- can From the HarvardlMedicallSchool, William B. Castle Laboratory, Mount Auburn Hospital, Cambridge, Mass. Reprint requests to Department of :atedibine; Mount Auburn Hospital, 330 Mount Auburn St, 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 note that regardless of the therapeutic resources available, when respiratory failure is severe the mortality is approx- imately 90%, whet'~her the patient is treated by convention- al means or with extracorporeal membrane oxygenation. The latter techniqperepresent's the most technologically advanced interventiion~ that is now available to reverse acute life-threatening respiratory events. In less extreme cases, the prognosis' is bett'er,, but surprisingly, not thatt much better. In a recent National Institutes of H'ealt'h- sponsored study in several leading medical centers, for example, 69%of all respirator patients who received an inspirryd oxygen concentration of 50% or higher for longer t'han 24's 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 capacity to employ it judiciously. Precisely the same mechanical devices and drugs that are used to manage respiratory failure can also beemployed' to maintain a state of intoler'ablesuffering from physical pain or mental anguish, beyond reasonable hope for recoveryy of normal human function. In other words, an indiscriminate application of 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 Sixt'h Commandinent from the. Judeo-Christian heritage of our western civilization, and in part on~ other reasons, we as physicians' usually have been conditionedi in medicalschooll to view death as the ult'iinateenemye Our profession has been, taught to prolong life whenever possible. As a result, our hospitalsand~ int'ensitiecare units behave as if death were an illegitimate occur- rence or an abominat~iom Dying, nevertheless, is a geneti- cally programmed natural event, and! may in certain circumstances be the preferable choice for some individu- a1s. With the technology that is now available, death from respiratoryy failure that would occur in the normal progresT sion of certaini pulmonary diseases can be deferred, and the patient! may be given additional months or years of useful life. As physicians„we usually feel little conflict in employ- ing this technology t;o manage respiratory failure. In doing so, we preserve life and fulfill our Hip~~~01~~ation to patient'~s Q $. But physicians are asked also to relieve suff'ering: Unfor- tunately, there now occur instances in the treatment of many diseaseswhen the capacity to preserve lifed'elays, if only temporarily, an otherwise inevitable death. Some- times this results in~great suffering to the patient and the patient's family. Thi'sis especially true for some patientswitih chronic obstructive lung disease whose oxygenat'ion must be supported by mechanical devices. In such circum- stances, the medical care team is faced with critical decisions of whether to initiate, sustain, or terminate artificial respiratory support, decisions that willldetermine whether the patient will live or die. Ideally, decisions of this'nature should be governed by scientific knowledge and Critical Decisions-Huber J

medical ethics, ie, by the principles of science applied and practiced according to the law.s and customs of'our society. Again, in the ideal circumstance, su& deci'sions should be "aut'omatic," and governed by moral-clinical rules, which summarize covertly accepted and! reinforced principles of patient care and human values. Unfortunately, as new technologies appear, the relevant fact'ors on which clinical ethical decisions are based will necessarily change, and the old rules may no longer be applicable. Wheni the: rate of technological advance: exceeds society's ability to under- stand and integrate these changes, a gulf of uncertainty develbps 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 who have exten- sive personal experience impatient care involving decisionss of this magnitude. Not surprisingly,, their perspectives differ markedly. It will 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 world of technology? Should decisions of this nature be made unilat- erally, as perhaps they often are, by the physician alone? With the rapid advances in technology, citizens have lesss and less control over all aspects of their individuaU lives,, including illness. Most people withi fatal illnesses do not die with the assurance that their death belongs tb them as a: meaningful summation of their life; rather, the responsi- bility for their dying process, has, been usurped by health professionals. This problem is even more acute for the individilal who is sustained by mechanical respiratory support, who is surrounded by a bewildering and complex array of equipment and tubes, and whose family is in the corridora.nd not at the bedside. Although the responsibilityy for the: dying, process has been relegated to institutions, our modern medical staffs are often not trained to deat with it. Medical education focuses on biologic and! physio- logic phenomena, and not always on the whol'e 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,2 80% of physicians either favored or practice& "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, commissiw of an action that would cause death sooner than~ it otherwise would' occur. In the context of treating respiratory failure, it becomes important to know whether and to what extent active or passive euthanasia is being practiced; in respira- tory intensive care settings. What tentatiive solutions 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 four 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 decision, is based on a combination of the patient's wishes, societal rules, scientific knowledge, professional experi- ence„ and a moral code that is grounded in religious- cultural tradition. Ench, contributor weighs these variables differently to arrive at a clinical decision. The only conclu- sion we, can suggest is that to resolve better the issue inn question-decision making in cases of respiratory failure- widespread discussion and constant revision and! evolution of our medical practices zre needed, both withim our profession and in public forums. To contribute to that process of reflection, 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! States chapter of the American College of Chest Physicians: References 1. RespiratoryDiseases: TaskF"arce Report' onFre+ention, Control, Educati:on: US Department of Hpaltlh, Ediloation, and welfare;,publication (NIH) 78'1248, 1978: 2. Williams RH (ed): To Live and'tb Die: When, Wh y„andHow. New York, Springer-Verlag, 1973, Terminal Care in Patients With Chronic Lung Disease John J. Skilltnan, MD L fe beings at birth and extends in a continuum to death4 or d'oes it? Is there a: point when it may be said that deathi is beginning?' Does it not seem that in caring for a From the Department of Surgery, Harvard Medical School, and Beth Israel Hospital, Boston, Reprint requests to Beth Ibrael Hospital, 330 Brookline Ave, Boston, MA 02215 (Dr Skillman)j Arch Interrr.Med-Vof 139; Aug 1979~ 03'7501'79 seriously ill patient there is a point when almost every physician and nurse of experience cam say to himself or herself (even~ though one may not outwardlyy express it) that the patient is beginning to dfie?' 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 Chronic Lung Disease-Skillman 917 . , '

. who argue most strongly against thQ-1continuation of life support systems. For them the uncertainty is too great ever to give up seeking a cure. Their sensitivity to the time of beginning death is muted by an overpowering desire to continue the fight~-the eyes look 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 physicall limitations. It may be difficult for the patient t'o do the daily housework, to walk to a store for groceries, to drive to a friend's house for a visit, or to getl up and' walk to the bathroom. Even a prolonged converstion may be a physical effort that is exhausting and pushes such a patient to the limits of endurance. As time goes on and the 1ung disease progresses, even a simple cold mayy add' a physical burden that cannot be tolerated, and the patient's ability to ventilate himse lf without the aid' of a machine nears an end. Su& individuals are oftembrought to the hospital by ambulance in a semicomatose state. At the hospital, the emergency room staff rapidly evaluates the condition of the gasping patient. They search for causes of the episode of acute respiratory decompensation. Is the patient in heart failure? Has an acute infection occurred that has further decreased the spontaneous ventilatory efforts by increasing the dead space and metabolic rate? Both of these factors increase the minute ventilat'iow required' to maintain sufficient alveolar ventilation, to prevent CSF acidosis and coma. Or has the patient forgotten to take his digitalis or diuretic medication? Is there any evidence for pulmonary embolism? Soon4 we reach the first major therapeutic decision. Should we intubate the patient and give him assistance with~ a vent'~ilator?Ift'he patient! has a respiratory or cardiac arrest„the staff almost always carries out endotra- cheal intubation and resuscitation. But before an arrestt 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 endotracheal intubation may be avoided. The intensive care unit staff carefully monitors the patient's condition and practices a formi of justifiable "brinksmanship," in which the goal is to avoid intubation and artificial ventilation of the patient if at all possible. Even when intubation seems absolutely necessary, place- ment of a S1van-Ganz catheter may frequently indicat'ee that congestive failure has occurred, even though physical, examination and the chest roentgenogram 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 these diagnostic possibilities and their specific therapeutic solutions are always sought for, in some patients no discernible reason for the episode of acute decompensation may be found. For such patients, the chronic lung disease has entered a terminal phase and the point of beginning death has been reached. They will 918 Arch lntern Med-Vol 139, Aug 1979 t1.~'u require endotrachea bation 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 ventilat'aon~interspersed with return to~the ventila- tor, intermittent mandatory ventilation, or change from a constantl-volume ventilator to a patient-triggered pressure ventilator. Eventually, the caring physicians and nurses become frustrated in their attempts to wean the patientt from the respirator. Anxiety an& frustration, anger, and despair-these emotions are felt by the patient, his family, and the staff. Discussions about the lack of progress are held with the familyy by the staff caring for the patient. All too often„the patient is not included in these discussions, because it is extremely difficult to tell a critically ill patient that all' is not going well. I am frequently guilty of this lack of consideration. However, the messages are given~ 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, though perhaps more distressing to the patient because the'y. are indirect, are felt by the patient. I now believe that both the patient and his family should be kept informed about the patient's progress or the lack of it. The second crossroad is now reached. Et-en 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 may choose t6eontinue with the ventilator. Other staff members, particularlyy 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 all seems lost. Certainly the patient"s wishes about discontinuation of therapy should be honored, even if they are different from the wishes of the family. When such a terminal point has been reached, when the likelihood of getting back to the previous minimal~ dismal existence, without a respirator, has disappeared, 1 do not support the continuation of ventilation. The difficulty is in being certain that the point of terminal irreversible illness has been reached. I suggest that it is not impossible to know when~ that point has beem almost certainly reached. The caring staff of nurses and physicians need to talk together openly about this difficult issue, for doubts and fears always exist. Since care should not be discontinued without a unanimous decision from all concerned, some- times a strong difference of opinioni (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 usually continued. 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. Anxietyy an6frustrat!ion, anger, and despair begin all over again because the patient's problems must be completely discussed and faced by the new group, who cannot do otherwise than try to find some solution to the medicali crisis. In rare instances, they temporarily succeed. The patient, meanwhile, is subjected again to more weaning trials, more drugs, and more painful chest physical thera- py, until resistant organisms finally cause an intract'able infection and the patient dies. (]37 j01R0 What' is our obligation in such cases? ~"suggest it is One of caring for the human being in the broadest! sense, not in a Chronic Lung Disease-Skillman

restricted or mechanicaliway. The physician should learn, to handle his guilt and frustration, to avoi& a withdrawal of emotional support and a dehumanization of the patient. I believe we need t'o use all of our love and human, sensitivity to do the best that we can for these patients. Sometimes 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: Roflections on life and death. Sianford' MD 15:2(>-24,, 1975. Responsibility of the Physician in the Preservation of Life Franklin H. Epsteip, MD B ecause hospital intensive care, units are in some ways the epitome of modern medicall technology, theyy aree oftenAhe focus of the questions that physicians and nurses must ask themselves from time t'o: time about the very reason for their existence. Anguished relatives wait in the wings„ expecting and fearing that death will come and sometimes disappointed that it does not. In an attempt to relieve unbearable pressures, physicians who are in charge of intensive care units are tempted to assert their sole right to determine when life has lost its meaning for their patients and to decide when care can be given over, and thee 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„an&a gentle manner and firm, wise countenance did wonders for the physician and the family, if not for the patient. "Pneumonia," said Dr William Oslbr, "is the friend of the aged." Antibiotics were not! yet available, blood transfusions were given in~homeo- pat'hic amounts, and mechanical respiratory assistance was almost unheard of. It was easy to let an elderly 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 reason, God has made respirators and antibiotics available, and! we d'on't know whether Osler (or God) would 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 everyy lawyer has recently become a philbsopher. I would liketoAetail briefly some,of the special reasons (they willi be appreciated best by phy.sicians and nurses) why my own years in the care of desperately, often hopelessly, ill patientshav.e led me to espouse this rule: When: efficacious treatment is at hand, try as hard as you can. The physician's dut'~yis tlo, his, patient, to relieve his, suffering and to preserve his life. From Harvard Medical School and Beth Israel Hospital, Boston. Reprint requests to Beth Israel HospitalJ,330 Brookline Ave; Boston, MA 02215 (Dr Epstein). PAIN CAN BE RELIEVED With proper care and modern techniques; phy.sical pain can, be assuaged in almost every instance. If necessary to relieve pain, a: patient can be put to sleep or 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 live. They need to have some hope of forestalling the inevifableend, and t'heyneed tia;feel that their physician is helpingt'okeep hope alive. Dignity lies in their fight for life and in their struggle to maintain contact with humanity. Kind- ness, personal attention, and good narsing help to preserve a patient's dignity. Euthanasia for elderly people whose bodily functions andl control are failing primarily relieves the distress of the relatives, not that of the patient. THE PHYSICIAN IS NOT OMNISCIENT - Physiciansare fallible. Their wisdom tends to be greatly exaggerated by the popular press and, too~ often, by physicians,themseh•es. Patients have amenormous 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 tends to be weighted toward pessimism, because patients who &badly claim most of his time and attention and remain in his memory longer than those who do welll n 7~ ~ n, p1 Physicianswho are in charge of inb'ensi~~'~"~t4' dil`t's?lsati`d`i a special problem to overcome in that their training and experience are often heavily weighted toward the care of acute emergency illness rather than that of chronically ill patients. Whem an elderly person with, chronic cardiopul- monary disease and acut'e bronchitis is assisted by a respirator, the expectations of the, nurses and physicians may be attuned to the usual prompt reco}, ery of a young 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 an& ignorance. Equally tragic isthe assumption thatt an incurable but indolent illness is,eausing Preseraation of Life-Epstein 919 Archilntern Med-Vol1139, Aug 1979 e :

Ct new symptoms when in fact a coincidental curable disease is at fault. The best way to insure that a cure is nott 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 when t'he patient doesn't get well and his suffering ends when the patient dies: It's hard to appreciate how difficult itis to attemptto support a dyingpat'ient day after day with condolence and hope; how frustrating it is to contemplat'e months of decline, of weary and anxious relatives, of no treatment working. Physicians and nurses know the overwhelming sense of relief that comes when4 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 to 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 an& 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, rior 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 met'hods of treatment in impartial, prospective studies, so that resources will not be unnecessarily squandered. It should be clear that when life is irretrievable„useless treatments should not be employed. But ad hoe judgments about the "quality of life"'should be discouraged as a major factor in such decisions. In the best hospitals, the principie that human,life itself has dignirt,y, and worth will affect alllof the actions in every department. To maintain that attitude is the unique responsibility of the medical profession. In the last analy- sis, that attitude of the profession may be as important for society as any miracle that modern technical medicine can perform. Death always comes at last, despite our best't efforts: But 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 T he 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 these resuscitation techniques only prolong the dying process and impose unnecessary suffer- ing, before the inevitable death occurs. Faced with a patient with sudden cessation of respirato- ry and cardiac function, how does one decide whether int'ubation, 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 Pultnonary Diseases, University of Colorado Medicall Center, Denver. Reprint requests to University of Colorado Medical Center, 4200 E E Ninth Ave; Denver, CO 80262 (Dr Petty). systematic review of four basic questions provides major assistance in this important decision. These questions aree as follow.s: (1) Do II know the patient's underlying disease process 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 gaini more time? (4) Do I wish to~gain~ more time through resuscitat'ive, efforts to resolve these other questions? n3~,~jP'~82 The physician and nurse should be a~le quiek yTo answer these questions in order t'odetermineif the patient is best served byy initiating respiratory and cardiac support. If one is unable to answer the first two questions in the affirma- tive, it is still highly likely that support should be offered until the answers become clear. One shoul& not fear making a mistake in the direction of vigorous support, for certain, patients will be saved to lea&meaningfullives,once agaim If "yes" is the clear answer to the first two questions, an& the third and fourth are clearly "no," then the physieian„nurse, or allied health worker should simply stand by and offer whatever comfort andli assistance they can to the patient or the family, or both. When the patient's life is known to be miserable at best, and when, the patient has indicated no wish to have his suffering extended by technological means-in short, when there is 920 Archilntern Med-Voll1'39, Aug 1979 Don't Just Do Something-Petty

nothing to be gained by the additional hours; days, or weeks one might achieve by supporting respiration and circulation -then intervention such as tracheal intubation, mechanical assistance, and cardiopulmonary support't should be set aside on behalf of the patient. Classic examples of these situations might include patients with advanced! disabling emphysemawith no hopes for recovery from respiratory failure or patients wit'~huncont'~rolled metastatic carcinoma in whom respiratory failure devel- ops. There are many other similar clinical situations, of course. It should be clear by now that all patients do not have to die while being assisted by ventilators or in intensive care units with their cireulation 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 attemptl to extend physiological life. Withholding of supportive measures in certain highly selected instances wilt prevent tragedies in which patients hover for extend'ed~ periods between lifieand death; with~all of the attendant social, economic, legal, and psychological implications that such cases raise. Fortunately, the legal professioni and the clergy alike realize that the decision to support life or not requires skillfullmedical judgment, and in the final analysis, should be a contract' between the physician and the patient he or she serves. s