It was with some hesitancy and concern that I have posted the article by Pizzo and Walker shown below.  The reason for my hesitancy and my concern is that the overall purpose of the article seems to be to support that form of palliative care that the promoters of the Third Path favor that leads to passive euthanasia.  What prompts me to post the article however is the statement by the authors that there is a disconnect between what some doctors would wish for themselves at the end of their life and what those same doctors impose on their patients.  What is at issue here is more than the classical distinction between ordinary and extraordinary means of preserving life, it is rather an issue of hard to identify and classify motivation that prompts medical professionals to push either of the two immoral courses of medical treatment:  prolonging the life of a dying patient by means of expensive, invasive and painful extraordinary treatment, or cutting short the life of a dying patient by withholding ordinary treatment including even nutrition and hydration artificially supplied.  Prior to the extraordinary growth of the human organ transplantation industry, the motivation of medical professionals to adopt the latter course of action could be attributed to a philosophical belief in the value of ending the life of a seriously ill patient.  However, since the appearance of the Mega-business of human organ transplantation there is now the added reason to suspect greed as well as or in place of philosophical conviction as the motivation for imposing death on the patient.  I urge the reader to keep in mind that the ultimate goal being advanced by the authors of the article seems to be to promote palliative care, care that lends itself so easily to passive euthanasia
– Abyssum

Should We Practice What We Profess? Care near the End of Life

Philip A. Pizzo, M.D., and David M. Walker, B.S.


12 February 15

Physicians should be in a better position than people without medical training to judge the likely value of health care services available near the end of life. Yet several studies have revealed a disconnect between the way physicians themselves wish to die and the way the patients they care for do in fact die [emphasis by Abyssum].

A 1998 survey of participants in the Precursors Study, which en- rolled 999 physicians who graduated from Johns Hopkins School of Medicine between 1948 and 1964, revealed that 70% had not had a conversation with their own personal physician about end-of- life care. But 64% had an advance directive that they’d discussed with their spouse or family, and more than 80% indicated that they would choose to receive pain medication but would refuse life- sustaining medical treatments at the end of life.1 Similar preferences were expressed in a 2013 survey of 1147 younger academic physicians (a group that was more diverse and included more women): 88.3% indicated that they would forgo high-intensity end-of-life treatment.2

Although physicians ought not assume that their views about dying should apply to others, public surveys and research studies have shown that 80% of Americans, like the large majority of surveyed physicians, say they’d like to die at home and avoid high- intensity care and hospitalization. Yet their wishes are too frequently overridden by the physicians car- ing for them, who undertake more medical interventions than patients desire [emphasis by Abyssum].  

Physicians also sometimes find themselves responding to the wishes and demands of patients’ families who want more medical therapy than medical providers believe is indicated or beneficial. In a study examining the care of more than 848,000 people who had died in 2000, 2005, or 2009 while covered by fee-for-service Medicare, Teno et al. noted that the rate of acute care hospitalization decreased from 32.6% in 2000 to 24.6% in 2009 but that use of intensive care in the last month of life increased from 24.3% to 29.2%.3 Although hospice use increased during this period, 28.4% of the decedents studied had used hospice for 3 days or less in 2009.

Complex social, cultural, economic, geographic, and health system factors and impediments contribute to this discordance between how doctors treat their patients and how they themselves (and the majority of surveyed Americans) wish to be cared for at the end of life. We are experiencing the greatest demographic shift in U.S. history. According to current projections, by 2030, 20% of Americans will be more than 65 years old. Cultural diversity is also increasing, as is the percentage of people with one or more chronic illnesses. It is therefore imperative that the medical community listen to patients and recognize that their end-of-life preferences may change over time, especially as longevity increases. The goal should be to help people receive care in keeping with their personal preferences as they near the end of life.

In Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life, an Institute of Medicine (IOM) committee (which we co-chaired) concluded that the U.S. health care system is poorly designed to meet the needs of patients and their families at the end of life and that major changes are needed. We need to begin by foster- ing patients’ ability to take control of their quality of life throughout their life and to choose the care they desire near the end of life.4 The committee recognized that these goals could be achieved only by making major changes to the education, training, and practice of health care professionals, as well as changes in health care policy and payment systems, Simultaneously, individual and public education would have to be radically reformed to reshape expectations and allow patients and clinicians to have meaningful discussions about end-of-life planning.

The IOM committee concluded that “federal, state, and private insurance and health care delivery programs should integrate the financing of medical and social services to support the provision of quality care consistent with the values, goals, and informed preferences of people with advanced serious illness nearing the end of life.” More specifically, the committee recommended that insofar as additional legislation is required to allow for such financing, relevant laws should be enacted (e.g., authorization of payments for ser- vices delivered in ambulatory or home settings rather than only in inpatient settings) and that the federal government should “re- quire public reporting on quality measures, outcomes, and costs regarding care near the end of life . . . for programs it funds or administers (e.g., Medicare, Medicaid, the Department of Veterans Affairs)” and encourage other U.S. payment and delivery systems to follow suit. We believe that physicians can and should work with their professional organizations to advocate for these changes — but rather than waiting for new legislation, they can take action now, in part by setting aside time to encourage patients to express their preferences regarding end-of-life care.

Physician practices can also organize their clinical services so as to provide seamless, high- quality, patient- and family centric care that is consistently available to their patients, especially those who have advanced serious illness or are nearing the end of life. Even by simply providing patients with a consistent and accessible place to call when they need help, physicians can avert unnecessary trips to the emergency department or another acute care setting where patients’ individual preferences may not be known or honored. Becoming more accessible in this way improves the quality of care and should reduce unnecessary utilization of expensive medical treatments.

Physicians can also work to ensure that their patients have access — in all care settings — to skilled palliative care or, when appropriate, hospice care. We believe that basic palliative care skills should be part of the knowledge base of all physicians caring for people with advanced serious illness or near the end of life. Physicians can also seek out collaboration, whenever possible, with skilled palliative care specialists, whether doctors, nurses, social workers, or clergy persons, to ensure the best possible care of their patients. It has been demonstrated that when palliative care is combined with active treatment for patients with advanced cancer, the quality and duration of life are enhanced.5 All this care should be coordinated, and handoffs should be avoided at critical junctures for patients, such as when they first encounter a chronic illness or a life-threatening disease.

Ideally, physicians would initiate discussions about advance directives with their patients at key milestones throughout their lives — perhaps when they get a driver’s license, get married, begin a new job, relocate, or become eligible for Medicare — not just when advanced illness or death is imminent. Many physicians need to learn how to conduct these conversations respectfully and successfully. Physicians can then make their patients’ preferences known to all members of the health care team. Physicians should be compensated for the time required to have these discussions — a change they can prod the government and other payers to make.

Changing the culture in these ways will require intervention at all stages of physicians’ education. Physician educators can develop new models of teaching (including the use of simulation) for students, residents, and fellows. But physicians can also learn and teach about compassionate patient care in their practice settings and communities. They can then contribute to public dialogues about end-of-life issues in their communities and religious groups — working especially to help to dispel misinformation.

Physicians’ experiences with medical care and dying patients have helped crystallize their desires for their own end-of-life experiences. As Dying in America makes clear, physicians should now practice what they profess, to ensure that their patients have the same options that they them- selves, and a majority of Americans, would choose and that they honor patients’ preferences at the end of life.


Dr. Pizzo is a professor of pediatrics and of microbiology and immunology and former dean at Stanford University School of Medicine, Stanford, CA; and Mr. Walker is a for- mer comptroller general of the United States.

1. Gallo JJ, Straton JB, Klag MJ, et al. Life- sustaining treatments: what do physicians want and do they express their wishes to others? J Am Geriatr Soc 2003;51:961-9.
2. Periyakoil VS, Neri E, Fong A, Kraemer H. Do unto others: doctors’ personal end-of-life resuscitation preferences and their attitudes toward advance directives. PLoS One 2014; 9(5):e98246.
3. Teno JM, Gozalo PL, Bynum JPW, et al. Change in end-of-life care for Medicare ben- eficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA 2013;309:470-7.
4. Institute of Medicine. Dying in America: improving quality and honoring individual preferences near the end of life. Washington, DC: National Academies Press, 2014.
5. Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology pro- visional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol 2012;30:880-7.


About abyssum

I am a retired Roman Catholic Bishop, Bishop Emeritus of Corpus Christi, Texas
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