Dying and Decision Making
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Quill (May 13 issue)1 advocates a "seamless transition into hospice programs if and when palliation becomes the primary objective," but does not acknowledge a major obstacle to determining that palliation has actually become the primary objective. Many patients perceive an inequality in access to optimal treatments among different races and social classes, as well as a financial pressure to conserve resources through the withdrawal of life support or referral for hospice care. Thus, they mistrust the motives of those making the recommendation.2 This is a legitimate concern that must be addressed.3,4 In the legal arena, even one life shortened because of an unfairly applied death penalty is a tragedy and a reason to reexamine the system. So should it be for lives shortened because of potentially biased decision making about the provision or withdrawal of medical care.
Marietta Angelotti, M.D.
University of Florida
Gainesville, FL 32601
angelott@ufl.edu
Lynne Rigney Barolet, Ph.D.
Gainesville Family Institute
Gainesville, FL 32601
References
Quill TE. Dying and decision making -- evolution of end-of-life options. N Engl J Med 2004;350:2029-2032.
Luce JM. Making decisions about the forgoing of life-sustaining therapy. Am J Respir Crit Care Med 1997;156:1715-1718.
Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med 1999;340:618-626.
Bloche MG. Health care disparities -- science, politics, and race. N Engl J Med 2004;350:1568-1570.
Dr. Quill replies: Angelotti and Barolet rightly direct our attention to the potential barriers to adequate health care and end-of-life care posed by race, social class, or socioeconomic status.1 In trying to understand the relative underuse of hospice programs as well as the reluctance to forgo or withdraw life-sustaining therapy among socially disadvantaged groups,2 one must consider the degree of trust required to make such decisions in the context of past experience in the health care system.3 Yet the tragedy of having had potentially effective treatment arbitrarily withheld is only compounded if patients subsequently suffer unnecessarily by being denied access to our country's premier end-of-life programs. Equal access to meaningful, effective end-of-life medical options will require better discussions with patients and families about what medicine can and cannot do4 as well as universally accessible health care delivery systems that allow the continuation of active, disease-driven treatment with concomitant provision of state-of-the-art palliative care.5 When arbitrarily forced to choose between active treatment and adequate palliation, many who have historically been denied access will choose to receive active, disease-directed treatment until the bitter end.
Timothy E. Quill, M.D.
University of Rochester School of Medicine
Rochester, NY 14642
References
Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA 2000;283:2579-2584.
Blackhall LJ, Frank G, Murphy ST, Michel V, Palmer JM, Azen SP. Ethnicity and attitudes towards life sustaining technology. Soc Sci Med 1999;48:1779-1789.
Crawley L, Payne R, Bolden J, Payne T, Washington P, Williams S. Palliative and end-of-life care in the African American community. JAMA 2000;284:2518-2521.
Quill TE. Initiating end-of-life discussions with seriously ill patients: addressing the "elephant in the room." JAMA 2000;284:2502-2507.
Morrison RS, Meier DE. Palliative care. N Engl J Med 2004;350:2582-2590.
Marietta Angelotti, M.D.
University of Florida
Gainesville, FL 32601
angelott@ufl.edu
Lynne Rigney Barolet, Ph.D.
Gainesville Family Institute
Gainesville, FL 32601
References
Quill TE. Dying and decision making -- evolution of end-of-life options. N Engl J Med 2004;350:2029-2032.
Luce JM. Making decisions about the forgoing of life-sustaining therapy. Am J Respir Crit Care Med 1997;156:1715-1718.
Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med 1999;340:618-626.
Bloche MG. Health care disparities -- science, politics, and race. N Engl J Med 2004;350:1568-1570.
Dr. Quill replies: Angelotti and Barolet rightly direct our attention to the potential barriers to adequate health care and end-of-life care posed by race, social class, or socioeconomic status.1 In trying to understand the relative underuse of hospice programs as well as the reluctance to forgo or withdraw life-sustaining therapy among socially disadvantaged groups,2 one must consider the degree of trust required to make such decisions in the context of past experience in the health care system.3 Yet the tragedy of having had potentially effective treatment arbitrarily withheld is only compounded if patients subsequently suffer unnecessarily by being denied access to our country's premier end-of-life programs. Equal access to meaningful, effective end-of-life medical options will require better discussions with patients and families about what medicine can and cannot do4 as well as universally accessible health care delivery systems that allow the continuation of active, disease-driven treatment with concomitant provision of state-of-the-art palliative care.5 When arbitrarily forced to choose between active treatment and adequate palliation, many who have historically been denied access will choose to receive active, disease-directed treatment until the bitter end.
Timothy E. Quill, M.D.
University of Rochester School of Medicine
Rochester, NY 14642
References
Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA 2000;283:2579-2584.
Blackhall LJ, Frank G, Murphy ST, Michel V, Palmer JM, Azen SP. Ethnicity and attitudes towards life sustaining technology. Soc Sci Med 1999;48:1779-1789.
Crawley L, Payne R, Bolden J, Payne T, Washington P, Williams S. Palliative and end-of-life care in the African American community. JAMA 2000;284:2518-2521.
Quill TE. Initiating end-of-life discussions with seriously ill patients: addressing the "elephant in the room." JAMA 2000;284:2502-2507.
Morrison RS, Meier DE. Palliative care. N Engl J Med 2004;350:2582-2590.