meditation

Dealing with the end of life and the decisions that accompany it bring critical challenges for everyone involved-patients
families
friends and physicians. In fact
managing
the progression toward death
particularly when a dire diagnosis has been made
can be a highly complex process. Each person involved is often challenged in a different way.

Communication is the first objective
and it should start with the physicians. In their role
physicians are often tasked to bridge the chasm between lifesaving and life-enhancing care; thus
they often struggle to balance hopefulness with truthfulness. Determining "how much information

within what space of time" and "with what degree of directness for this particular patient" requires a skillful commitment that matures with age and experience.

A physician's guidance must be highly personalized and must consider prognosis
the risks and benefits of various interventions
the patient's symptom burden
the timeline ahead
the age and stage of life of the patient
and the quality of the patient's support system.

At the same time
it's common for the patient and his or her loved ones to narrowly focus on life preservation
especially when a diagnosis is first made. They must also deal with shock
which can give way to a complex analysis that often intersects with guilt
regret and anger. Fear must be managed and channeled. This stage of confusion can last some time
but a sharp decline
results of diagnostic studies
or an internal awareness usually signals a transition and leads patients and loved ones to finally recognize and understand that death is approaching.

Once acceptance arrives
end-of-life decision-making naturally follows. Ongoing denial that death is approaching only compresses the timeline for these decisions
adds anxiety
and undermines the sense of control over one's own destiny.

With acceptance
the ultimate objectives become quality of life and comfort for the remainder of days
weeks or months. Physicians
hospice
family and other caregivers can focus on assessing the patient's physical symptoms
psychological and spiritual needs
and defining end-of-life goals. How important might it be for a patient to attend a granddaughter's wedding or see one last Christmas
and are these realistic goals to pursue?

In order to plan a death with dignity
we need to acknowledge death as a part of life-an experience to be embraced rather than ignored when the time comes. Will you be ready?

Mike Magee
M.D.
is a Senior Fellow in the Humanities to the World Medical Association
director of the Pfizer Medical Humanities Initiative
and host of the weekly Web cast "Health Politics with Dr. Mike Magee."