BMJ  2003;327:E255 (22 November), doi:10.1136/bmj.327.7425.E255

BMJ USA: Editor's choice

Dead issue

This month we feature material from the July 26 BMJ theme issue, "What is a Good Death?"—a topic of immediate interest to primary care doctors. Most of us can easily remember examples of patient deaths that were awful and those that we felt were dignified and even inspiring. Especially in America, where we pride ourselves on having a technological solution to almost everything, we often do not succeed in orchestrating our patients' final days satisfactorily.

The orchestra is an apt metaphor for the multi-person effort that surrounds most deaths. Family members, doctors, and hospital/hospice staffs all try to work together to do the bidding of the composer. Increasingly, the composer's role is played by the patient, who either before or at the time of death has made his or her wishes clear about how things should proceed. As physicians, we have the responsibility of turning these wishes into reality. We use our knowledge and experience to conduct the tempo, cue the appropriate resources, and bring it all to a satisfying conclusion.

Everything doesn't always go as planned, as Saunders and colleagues illustrate in their Education and Debate article (p 563). What to do when a terminally ill patient develops an acute, remediable illness poses challenges to the medical staff and the family. How aggressive should treatment be for someone who is dying? Sometimes even terminally ill patients aren't ready to die. Lynn Boland, the mother of one such patient, provides a touching coda in this case (p 566), confirming the appropriateness of staff decisions that might be viewed as overtreatment.

Glare and colleagues point out (p 550) that we physicians aren't very good at predicting how long terminally ill patients will survive. Their analysis of eight different studies finds that doctors consistently overestimate patient survival. It may be useful for us to appreciate this.

Increasingly, euthanasia and physician-assisted suicide are in the news. Are these occurring more frequently or just receiving more newsprint? Marquet and others (p 543) report Dutch trends indicating that requests to general practitioners for these services have leveled off after an initial increase. Walsh and Hendrickson (p 544) provide a US perspective from Oregon data.

The doctor's role in death and dying does not end with the patient's death. Hawton and Simkin (p 532) review the needs of a special group, those who are bereaved by suicide. BMJ USA associate editor Joanne Roberts, a hospice medical director, has put together a list of US suicide resources to accompany this editorial.

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