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ON THE DO NOT RESUSCITATE POUCY HYMAN MUSUN* and STANLEY SCHADEt It appears to us that a questionable orientation has entered into physician -patient relationships involving the terminally ill. This orientation emphasizes the legal and ethical aspects of our encounters with our patients and does not recognize what is to us the central concern of the physician—the actual experience of the terminally ill patient and the empathie observations required to see the world from the side ofthe patient . There is now much literature that has addressed the major social, legislative, and ethical issues regarding the terminally ill [1—8]. We wish to enter this ongoing debate with the conviction that the physician determine his posture with the terminally ill patient on the basis of the physician 's empathie observations, a point of view that we feel has not been adequately voiced. In the literature on medical practice in general and on the physicianpatient relationship in particular, it is customary to speak of the patient's right to make decisions about any aspect of his or her medical care. Although there has been a debate on this issue—physicians in advocacy ofa paternalistic position versus physicians, ethicists, and others in advocacy of a rights-of-patient doctrine—we feel that neither side has concerned itself sufficiently with what the patient needs: a uniquely tailored relationship to maintain his psychological equilibrium. The emphasis on the patient's right to make decisions about his treatment and on his right to accept or refuse life-prolonging treatment has developed over the past 25 years, influenced by the doctrine ofinformed consent and the disclosures on human experimentation [8]. Overall, a trend has evolved to alter and limit the power ofthe medical practitioner over the lives of his patients. Item.—In some 15 states, legislatures have given guarantees to the public in the form of "natural death" laws protecting the right to forgo resuscitation at the time of terminal respiratory collapse [3]. Departments of Psychiatry^ and Medicine,t University of Illinois at Chicago, 912 South Wood Street, Chicago, Illinois 60612.© 1988 by The University of Chicago. AU rights reserved. 0031-5982/88/3102-0574$01.00 Perspectives in Biology and Medicine, 31, 2 ¦ Winter 1988 | 285 Item.—A presidential commission was recently constituted to study the decision to reject life-sustaining treatments. The commission did not offer a guidebook of morally correct choices for physicians but underlined the rights of the competent patient to reject life-sustaining treatment [7]. Item.—There is now a valid apprehension on the part of physicians treating terminally ill patients that there may be negligence suits as a result of the actions of the physicians at the time of the death. These apprehensions about civil liability were recently expanded to the threat of criminal liability when two California physicians faced murder charges after they withdrew life support from a comatose patient. The charges were dismissed, but at the level of the court of appeals [3]. It seems fair to assert that major alterations in the physician-patient relationship are taking place at an alarming rate. From the side of the physician, we see encroachments into the ability to freely advise and choose plans for the diagnosis, treatment, and disposition of patients during all stages of illness. These encroachments come from social, economic , legislative, and litigious sectors of our society. From the side of the patient, we see an altered form of medical care in which a physician is no longer experienced as the primary caretaker over one's psychological and physiological distresses. The price for the new egalitarianism is the loss of the medical caretaker as one's personal guide and deliverer from pain or distress. With regard to the Do Not Resuscitate (DNR) codes and the physician affected by them, it is our thesis that the physician's role should continue to be that of the leader of the medical team who responds to the needs of the patient for succor during times of physiological and psychological disease. This is certainly the case in those situations in which the physician must present the patient or the family with the grave news that the patient's illness is beyond cure...


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