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Key points * In Britain and America there appears to have been a general shift from truth withholding to truth disclosing. However the practices of healthcare professionals did not always [...]

A brother and sister clash over their mother's final wish. Our panel of physicians and ethicists parses the conflict. The case: Among internist Philip Weber's nursing home patients is 87-year-old [...]

A number of sources are available to clinicians to help them communicate a life threatening diagnosis to patients. However many of the guidelines are written from the perspective of the expert or physicians and the receivers' perspective has been less documented. There are also substantial variations in recommendations. Database reference material from 1994-1997 is reviewed., Literature related to breaking bad news to medical patients was reviewed. An analysis of citations appearing between 1994 and August 1997 updated earlier work and indicated that a minority (24%) [...]

Clinicians are encouraged to adopt the best practices for conveying bad news to medical patients. It is difficult to alter clinical behavior of medical personnel, however it is found that clinicians are under-informed in this area. Clinicians should be provided with feedback on their performance and training guidelines should be disseminated., Steps to encourage clinicians to adopt the best practices for communicating bad news to patients are outlined. First, official, credible guidelines endorsed by key organizations or professional bodies, giving a [...]

In this article, I write about dialogue on ethical issues in the field of death and dying. I leave it to others to address the specific ethical issues. My focus is applied ethics in general and especially our manners of speaking about ethical issues. I first consider an appropriate approach to applied ethics that places great emphasis on narrative and dialogue. I then treat the theme of dialogue itself. The title 'Can We Talk?' defines the shape of my treatment of that theme. As talk, dialogue has distinctive contour and value. To engage in dialogue, persons must conceive of themselves and behave as a distinctive type of we, and through dialogue they aim to define the kind of we they wish to be. Persons can engage in dialogue only if they avoid personal and social factors that tend to inhibit or undermine it. The near unavoidability of these inhibitors makes necessary dialogue about ethical issues elusive.

Terminal patients give their free consent to participate in clinical trials because they believe the experiments will cure their diseases. Their beliefs persist even if they are told by medical researchers that the trials are meant to help others and are not primarily aimed as a treatment process. Ethicist George Annas believes that terminal patients should be told that the experiments will not help them. Fellow ethicist Ruth Macklin thinks that the placebo effect may play a great part in this situations. She suggests that more prudence should be taken in telling patients that they will not be cured.

Decisions concerning how, when and where patients should die have traditionally been the exclusive domain of health care professionals. More recently, patients and their families are demanding increasing control over these decisions. This paper reports on the responses of 20 physicians and 20 nurses in a major teaching hospital regarding the desire of patients to exert more control over the circumstances of their dying. The findings, based on in-depth, semi-structured interviews, suggest that while health care professionals are generally in favour of the principle of patient control over dying, they have reservations about accommodating patients' wishes in actual clinical situations. Key factors that underly their ambivalence on this point are: (1) specific patient circumstances, such as age, severity of illness and mental competence; (2) moral and legal concerns; and (3) the type of intervention requested by patient. The results indicate that patient control over dying represents a challenge to the clinical judgement of health care professionals; that it runs counter to their perception of their role as healers and supporters; that it raises crucial concerns about their personal ethics and legal liability and that it poses a challenge to their professional autonomy and power. It is likely that health care practitioners will increasingly be pressured to concede their autonomy and enter into a partnership with patients in the decision-making process.

This paper examines the conundrum facing an individual with a terminal disease who wishes to end his or her life in a manner that maintains a minimum of dignity. The State's interest versus the individual's right to live or die is examined in its various aspects. The interference by the State supplanting the Church as the authority that interprets the boundaries between life and death, with the individual losing his voice as well as his body to the impersonality of maintaining a life not worth living, is studied, as well as the implicit dangers when the freedom to decide when and who should die is measured against the present international economic situation. The need to listen to the language of the dying as well as to their need for a |closure' is approached with a view to future study.

Since the 1970s, the general consensus has been that decisions regarding life-sustaining treatment should be based on the values and wishes of the patient. Research studies suggest that these decisions are more often based on the values of the physician. Physicians may not know a patient's wishes, they may feel uncomfortable asking about them, or feel that they are not important. Patients' wishes may be influenced by the opinions of their physician, and many patients defer treatment decisions to their physician. The concept of patient participation in treatment decisions is relatively new, and it may take more time for this concept to be practiced. Under the informed consent law, physicians must obtain consent from their patients before treatment. But when this law is violated, the burden of proof is put upon the patient rather than the physician. Physicians should not impose their values on their patients, and more courses on medical ethics should be provided in medical schools. Laws that protect patients' rights should be strengthened, and patients should learn their doctor's views on end-of-life decisions.

ABSTRACT: Decisions to limit care for terminally ill patients present a number of ethical and legal issues. For the past 13 years, the Optimum Care Committee (OCC) of the Massachusetts General Hospital, Boston, has provided advice for physicians faced with such issues. I have reviewed the experience of the committee with the 73 cases on which it provided consultation from 1974 through 1986. In addition, I have compared these cases with those of all 113 patients at the Massachusetts General Hospital who were accorded do-not-resuscitate status without OCC input during a three-month period and found that the two groups differed significantly on a number of clinical variables. I have also found that the OCC cases fall into six categories, each of which presents different ethical and legal issues. In addition, the use of the OCC within the hospital is increasing especially with regard to certain categories of cases. The committee has dealt with controversial issues in a consistent and ethically forthright manner, but legal and moral questions remain. More discussion of the role of ethics committees in withdrawal-of-care cases is needed.

The concept of futility involves the inevitable death in spite of desperate measures to prevent it. This includes substitutes for patient insisting on the need for continued care of a dying patient when the physicians are convinced otherwise. Also, the use of CPR when there is no chance for recovery. Futility simply masks the ethical question of when physicians should cease administering life support system to dying patients. It is difficult to discern when a case is futile. Better communication with patients and ethical experties were recommended.

Donating Your Health Care Benefits We have devised a health care system that effectively discourages sharing of medical resources. In concentrating on responding to the needs of self-regarding health care [...]