Urologists, fortunately do not often have to deal with end of life decisions. Most diseases that we deal with are either curable, or treatable and patients often succumb to other causes of death. Even when patients are diagnosed with severely advanced malignancy, many of the treatments that we now offer can cure disease. Lance Armstrong’s well publicized testicular malignancy is an excellent example of this.
Certain disease states that we do care for require discussions with patients regarding end of life or terminal care issues. Speaking to a patient or their family at the end of life is not the time to address issues regarding a patient’s preferences with regard to the management of their health, or the prolongation of life. The concept of a health care proxy and a living will helps to effectively deal with this. When speaking with patients who are critically ill, it is difficult to approach this topic. Mental status changes clearly may interfere with their decision making process. Familial conflicts also limit effective decision making. Knowing a patient’s intents which were expressed while they were still healthy simplifies this process.
Families want to hold on to their loved ones as long as possible however with terminal disease states, the utilization of hospice care becomes very important. Many times a hospice is able to provide care that a family would otherwise find difficult to do. Many communities provide both home hospice and facility based hospice care.
Pain management is another crucial part of managing the end of life. Many terminal diseases result in a severely debilitated patient. Metastatic disease to bone in advanced cases of prostate cancer can result in severe pain. Nobody wants to see a family member suffer. Making sure that the patient is comfortable is very important. Numerous drugs are available for both short-term and long-term pain management. Specialists in pain management (usually anesthesiologists) have a wide array of minimally invasive techniques including local injection therapy, regional blocks, or possible an implantable pain pump that can provide significant relief.
The nutritional state of the patient becomes extremely important. Patients who are terminally ill often may not eat, nor may it be possible for them to do so. The need for a feeding tube (PEG) may be raised. The question of prolonging life with the use of tube feedings needs to be considered. This will often be addressed in a living will and knowing the patient’s intents prior to the development of the disease is extremely important.
Some patients who have renal failure may not be candidates for renal transplantation. Patients with terminal disease states may not be willing to continue with a lifetime of dialysis, and the limitations that it poses. The decision to not proceed with dialysis will result in a rapid, relative painless death. This is certainly a difficult decision for a patient and family to reach.
With the impending changes in health care, we as a nation have to decide how much we spend on various aspects of healthcare. The discussion over spending massive quantities of healthcare money during the end of life has been debated extensively by bioethicists, and will be a topic of future concern.
Published On: March 25, 2010