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To care properly for patients near the end of life, the physician must understand that palliative care entails addressing physical, psychosocial, and spiritual needs and that patients may at times require treatment in an acute care context. To provide palliative care, the physician must be up–to–date on the proper use of opioids and the legality and propriety of using high doses of opioids as necessary, to relieve suffering. The physician should know how to refer patients to appropriate palliative care, know how to use home–based and institution–based hospice care and be aware of the palliative care abilities of the nursing homes to which patients are referred.

Making Decisions Near the End of Life
Informed adults with decision–making capacity almost always have the legal and ethical right to refuse any recommended life–sustaining medical treatment. The patient has this right regardless of whether he or she is terminally or irreversibly ill, has dependents or is pregnant. Many patients, particularly those with terminal or irreversible illness, elect to forgo certain treatments or pursue treatments that their physicians may consider unwise. These situations demand empathy, thoughtful exploration of all possibilities, negotiation or compromise and may require time–limited trials and additional consultations. In the unusual circumstance that no evidence shows that a specific treatment desired by the patient will provide any benefit from any perspective, the physician need not provide such treatment. If the physician and patient cannot agree on how to proceed, there is no easy, automatic solution. Timely transfer of care to another care provider who is willing to pursue the patient’s preference may resolve the problem. Consultation with an ethics committee may be helpful.

Care of Patients Near the End of Life
End–of–life care is an important aspect of medical practice. Individual physicians and the medical community must be committed to the compassionate and competent provision of care to dying patients and their families. Patients rightfully expect their physicians to care for them and provide them medical assistance as they are dying. Good symptom control, ongoing involvement with the patient, physical, psychological and spiritual support are the hallmarks of quality end–of–life care. Care of patients near the end of life, however, has a moral, psychological and interpersonal intensity that distinguishes it from most other clinical encounters.