A debate over end-of-life care

Brittany Maynard and the Death With Dignity movement have received significant attention this fall, but one stalwart in end-of-life care says the push for physician-assisted suicide is premature, and distracts from a much more important issue.

Joanne Lynn, a geriatrician, hospice physician, former Medicare medical director, and author, has spent her career fighting to improve care of the dying. She says laws such as Oregon's - allowing terminally ill, mentally competent people such as Maynard, with six months or less to live, to end their lives - would not be applicable to most Americans.

Maynard, the new icon for the Death With Dignity movement, moved from California to Oregon - one of five states where doctors may prescribe a lethal dose of medicine - so she could control the time, place, and manner of her death. Suffering from brain cancer, Maynard, 29, ended her life Nov. 1.

A Harris Poll released Friday found that 72 percent of Americans support physician-assisted suicide.

The fact is, Lynn said, the vast number of declining and dying Americans "won't be able to time their death to within a year or even three" to take advantage of an Oregon-like law. "Most at the end of their lives will be poor and frail, and the time of their death very uncertain."

Lynn also said the nation needs to figure out how to provide frail older people with warm, safe lodging, good medical care, and comfort at the end of life - before making it easier for them to die.

"The numbers are going to be in very old, very poor people who are going to ask to be dead rather than live a life of raw poverty," said Lynn, who leads the Altarum Institute Center on Elder Care and Advanced Illness in Washington.

"We talk as if everyone is going to be under 75 with homes and money. That's just not the case. Most frail elderly are facing Medicaid nursing homes with something close to abandonment."

The Annals of Internal Medicine, a journal, published four commentaries Monday on improving end-of-life care. They were reactions to a report last summer by the Institute of Medicine, "Dying in America," about the many Americans who still die in pain, their wishes unmet, at great expense.

In the first commentary, Scott D. Halpern and Ezekiel J. Emanuel, physicians at the University of Pennsylvania School of Medicine, argue against the movement to reimburse physicians for having conversations with patients about end-of-life wishes.

Even though the Institute of Medicine report recommends such conversations, and Medicare might begin paying for them, the doctors say there is no evidence those discussions would be of any benefit.

"Without first determining what specific elements of conversations and written directives best promote the interests of patients and their family members," they write, "there is little reason to expect that nonspecific incentives to 'have a discussion' or 'complete a form' will do much good."

Emanuel and Halpern also contend that doctors struggle with end-of-life conversations, and suggest that they must first be trained.

Finally, the pair ask, what's the point of making wishes known if they won't be followed and patients end up in a hospital anyway? They call for "changes to the overall clinical infrastructure."

Jaya K. Rao, the journal's deputy editor, suggests public health officials "could disseminate culturally appropriate materials about advance-care planning to the public, thus reaching persons before they were faced with making end-of-life decisions."

In a third essay, Debra L. Ness, of the National Partnership for Women and Families, and Beverley H. Johnson, of the Institute for Patient- and Family-Centered Care, urge that end-of-life care be considered a partnership among patient, family, and medical team, a collaboration, more responsive as needs change.

Insurers "must reimburse for social support as well as clinical care and must be flexible enough to evolve as care plans change," they write.

Philip Pizzo, a physician at Stanford University School of Medicine and co-chair of the report, advocates that oncologists present palliative care as an option early in treatment and work harder to ensure that patients clearly understand their prognosis and the benefits and burdens of treatments. He also urges oncologists not to hand patients off to hospice or palliative-care teams at the end.

"As a pediatric oncologist," he writes, "I have viewed my role as staying with patients and their families throughout the illness and potentially through death."

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@MichaelVitez