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The Dying Experience

TO THE EDITOR: Dr. Lynn and colleagues [1] present, but do not discuss in depth, a paradox that I believe partially explains the failure of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) [2]. Most patients in this study stated that they preferred comfort care, but 56% of patients received aggressive life-prolonging care in the last few days of life. nevertheless, in only 10% of cases did surrogates report that care was at odds with patient preference. The other 90% of patients wanted the care they received. This discrepancy suggests that in principle, people want a peaceful, dignified, comfortable death but that in reality, they do not want it quite yet. They prefer life-prolonging care in the hope that their peaceful, dignified, comfortable death can occur later. As shown by the 53% of study patients who survived for 6 months [2], that hope is often justified. Furthermore, despite ever more sophisticated and accurate prognostic tools [3], we cannot answer the patient's and our most pressing question: When exactly will I die? How can I recommend palliative care to a patient whose chance of surviving 6 months is as low as 20%? I would not accept treatment abatement myself in that situation; I would try to be in the lucky 20%. Like all species, humans have a biological urge to live. Our extraordinary technology and our culture both reflect and reinforce that urge. I do not believe that we will achieve more comfortable or peaceful deaths by trying to persuade our patients that comfort care is their best option when they still have what many perceive as reasonable odds for longer survival. We will have an impact only when we assiduously treat the uncomfortable symptoms of all seriously ill patients, whether they are receiving life-prolonging care with its treatment-induced discomforts or only palliative care.