PREFACE

I’ve watched many families struggle with end of life. In this book I describe from my practice what has worked and not worked in the treatment of the dying patient, and I give the reader my observations as to what can ensure, as nearly as possible, a peaceful dying process.

Based on experiences from my practice and interactions with my colleagues, I address the turning points near the end of life when it is time to redefine the purposes of medical treatment. Is the goal to restore health, or is it time to change gears and instead concentrate on shepherding the patient as comfortably as possible through the dying process? Has life become so intolerable that dying is preferable to continued living? These are questions that need to be asked in a formal way with purposeful reasoning whenever a person is approaching the end of life. We shall see that a proper definition of the goals of treatment is critical to a peaceful dying.

This book also explores the ways in which patients and families can work with physicians to maintain control over the manner of dying. There are important questions to ask of physicians, appropriate in a time when the former paternalistic approach by doctors is being replaced with shared decision-making in which patients’ and families’ wishes are paramount.

I’ve been able to write this book because of my own experience in the practice of medicine, in addition to work with organizations that promote the rights of the dying patient. I’ve written on end-of life-issues, and in the 1980s was the lead author of two articles, five years apart, in the New England Journal of Medicine on “The Physician’s Responsibility Toward the Hopelessly Ill.” Co-authored with medical colleagues from around the country, one of these articles stated for the first time in a major medical publication that under certain circumstances it could be ethical to assist in the suicide of a dying patient who was suffering intolerably.¹ This belief, addressed in the chapters on hastened death, I still hold firmly.

The hastening of death in a terminal situation is different from what we usually consider as suicide. Most of the time, we think of suicide as an inappropriate ending of life in a person who is psychiatrically depressed, whereas at the end of life the hastening of death in a situation of intolerable suffering should be regarded more appropriately as part of the whole spectrum of treatment. All of these actions are examined in detail in the chapters on hastened dying.

Many patients or families have graciously allowed me to include their stories in the book in the hope that their experiences might help others. All stories actually happened. Except for members of my own family, I have changed names and places and changed the story in minor ways to protect confidentiality.

Joseph Glenmullen, MD, helped me in the writing of this book through his discussions with me as to what should be in the book, his continuing critiques and suggestions during its writing, and his friendship.

Sidney H. Wanzer, MD
January 2007