Sherwin Nuland wrote a beautiful book about How We Die. Similar to other physicians, Nuland got to observe a multitude of deaths. So he knows intuitively as well as scientifically about the dying process. From this vantage point, physicians have a unique perspective about their own morbidity and ultimate mortality which the rest of us non-clinical lay persons do not have.

Ken Murray, a retired family medicine physician and Clinical Assistant Professor at the University of Southern California, has written extensively on this and one of the conclusions that he makes is that physicians would want better quality of their remaining life rather than quantity.

Such assertions have been supported by convincing anecdotal evidence, but only recently did we obtain some proof to substantiate this.

In 2008, Marsha Wittink from the University of Rochester Medical Center, with her colleagues published a study that reported that physicians who initially wanted the most aggressive treatment for their disease, changed their mind three years later. However, although some changed their mind, there were some (41%) who still wanted the most aggressive treatment. It is therefore not clear-cut.

For some people, including physicians, they change their mind when they are dying. Some want a hasty natural ending, others hold on to life at all costs. How true is this if you know you are dying anyway?

The answer came in a study published in 2011 by Hans-Peter Brunner-La Rocca, and his colleagues from the University Hospital Basel in Switzerland. These Swiss researchers talked to 555 heart failure elderly patients about their end-of-life preferences. They repeated the interview again in twelve months and then again in another six months. What they found is that seven out of ten patients initially said they would rather live two years in their current state then live only one year in excellent health. After a year elapsed, this proportion grew to eight in ten and remained the same after eighteen months.

Some people have interpreted this finding as indicating that most people want to live at all costs which becomes more acute the closer you are to death. However, surprisingly, when the researchers asked patients whether they wanted CPR in a crisis, about a third said no. While another third said they did want CPR—even among patients with "do not resuscitate" orders in their medical files.

In all this uncertainty, the correct interpretation is that most people opt to live despite the physical discomfort. But when the time comes, a third of patients want the natural process to take its course. What this tells us is that we are dealing with a lot of variables and that one policy does not fit all.

Statistics from the Oregon Death With Dignity Act (DWDA) informs us that for the 70 or so patients who go through with DWDA a year, are exclusively White, are more likely to be better educated (four out of ten have a degree), tend to have cancer (eight out of ten) and have informed their family about their wishes. This is a very privileged and small minority, but an important one.

The lesson to take home is that each case is unique and there can be no one policy for everyone.We should respect all individual options when it comes to death and that all options need to be made available.

© USA Copyrighted 2013 Mario D. Garrett

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