Defining limits in care of terminally ill patients

BMJ 2007; 334 doi: (Published 01 February 2007) Cite this as: BMJ 2007;334:239
  1. Ursula K Braun, assistant professor of medicine1,
  2. Rebecca J Beyth, associate professor of medicine2,
  3. Marvella E Ford, associate professor and associate director of health disparities research programme3,
  4. Laurence B McCullough, professor of medicine and medical ethics4
  1. 1Houston Center for Quality of Care and Utilization Studies, Sections of Geriatrics and Health Services Research, Michael E DeBakey VA Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA
  2. 2North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA
  3. 3Medical University of South Carolina, Department of Biostatistics, Bioinformatics, and Epidemiology, Charleston, SC 29425, USA
  4. 4Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA
  1. Correspondence to: U Braun ubraun{at}
  • Accepted 15 November 2006

Despite what they might say, people at the end of life rarely want everything or nothing. Ursula Braun and colleagues explain how to understand and meet their needs

Invasive procedures in terminally ill patients often fail to change the course of disease.1 2 Interventions can become inappropriate overtreatment if they result only in disease related and iatrogenic harm to the patient. Untimely referral to a hospice, poor technical performance, overuse of interventions inconsistent with preferences and prognosis, and poor communication,3 increase the likelihood of inappropriate clinical intervention.

To facilitate appropriate care and avoid inappropriate interventions doctors need to anticipate discordance between their views and those of patients or surrogates, using the informed consent process to prevent potential discordance from becoming actual discordance and responding quickly when conflicts do occur.4 5 6 It is imperative for good end of life decision making to identify, explain, and negotiate consensus therapeutic goals to ensure that appropriate treatment occurs. This process requires effective communication skills and cultural sensitivity. The clinical scenario below (which is fictitious but based on experience) illustrates the need for a proactive approach.

Clinical scenario

A 78 year old recently widowed man with non-small cell lung cancer and chronic obstructive pulmonary disease is admitted with pneumonia and impending respiratory failure for the third time within 10 months. His medical history includes congestive heart failure with an ejection fraction of 20%, a cerebrovascular infarct with mild cognitive impairment, and coronary artery disease. He has previously been difficult to wean from the ventilator and required a tracheostomy. During his last admission, he was finally weaned after 8 weeks. Afterwards, the patient told his wife and the team several times he never wanted to be on a ventilator again, but he did not complete an advance directive.

The doctor starts bilevel positive airway …

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