Introduction

Summary

Dying patients confront complex and unique challenges that threaten their physical, psychosocial, and spiritual integrity. Many patients die prolonged and painful deaths, receiving unwanted, expensive, and invasive care. Patients' suffering at the end of life can be profound, yet healthcare providers are too frequently ill-equipped to respond to this suffering. Excellent palliative care demands careful attention to diagnostic, prognostic, and therapeutic challenges. The clinician must demonstrate sensitivity to psychosocial and spiritual concerns and provide thoughtful, empathic communication with patients and families. Yet, even when these are done with superb skill, patients and providers will still find that the experience of living with life-limiting illness presents ethical dilemmas. Some are subtle and, perhaps, not recognized. Other dilemmas are easily apparent. This section outlines the key ethical challenges in caring for patients at the end of life.

Chapter 8 is on quality end of life care and presents a conceptual framework with three main elements: (i) control of pain and other symptoms, (ii) decisions on the use of life-sustaining treatments, and (iii) support of dying patients and their families. These elements are key to delivering quality care. They are also the nexus upon which ethical conflicts arise. For example, control of pain, in its extreme, may hasten death. Decisions on the use of life-sustaining treatments depend upon advance care planning and, in its absence, substitute decision making. And support of dying patients and their families recognizes the important role for healthcare providers even when conflicts arise.