With the changes in health care today, end of life decisions are increasingly more difficult for patients, families, and physicians. Physicians must balance patient wishes with realistic expectations. They also have to take into consideration a patients beliefs. This can all be accomplished best if the patient and physician have a long term relationship. It is imperative for physicians making end of life decisions for patients with acute life threatening conditions, to be aware of the patient's quality of life and level of performance prior to being stricken. Unfortunately, as a nursing student I have observed elderly in-firmed patients being presented to the emergency room where a physician or hospitalist, without prior knowledge of the patient, has to make a decision regarding end of life care or "Do not Resuscitate" (DNR) status.
In years past, patients were more likely to have a long term relationship with their physician and a one on one relationship. The physician would admit and follow the patient in the hospital and was in the best position to make end of life decisions.
Today patients seem more likely to be treated by a revolving door of physicians and physician extenders. The special bond between the physician and patient unfortunately is often lost. When admitted to a hospital with an acute life threatening illness, patients are assigned a hospitalist du jour who very often has to make end of life (DNR) decisions knowing little about the patient. Was he/she playing golf three days earlier? Was he/she singing in the choir? Was he/she looking forward a granddaughters wedding? Or was the patient living a lonely solitary existence with little happiness and little to look forward to, welcoming end of life?
Sadly, with the de-personalization of healthcare, lack of traditional family physicians, and the use of hospitalists, end of life decisions are not necessarily being made by those best in a position to do so. Therefore, I feel it is important for the elderly to have continuity of care as an outpatient and for this continuity to continue as an inpatient, allowing a physician, familiar with the patient to have an important role in end of life decisions. Further, it is incumbent that elderly patients make clear and concise end of life directives when healthy and this must be encouraged by all health care providers.
