Hastings Cent Rep. 2017 Jan;47(1):28-29. doi: 10.1002/hast.669.
A good death is hard to find. Family members tell us that loved ones die in the wrong place-the hospital-and do not receive high-quality care at the end of life. This issue of the Hastings Center Report offers two articles from authors who strive to provide good end-of-life care and to prevent needless suffering. We agree with their goals, but we have substantial reservations about the approaches they recommend. Respect for the decisions of patients and their surrogates is a relatively new and still vulnerable aspect of medical care. For thousands of years, patients and surrogates had no say in medical decision-making. Today, standards support shared decision-making, but these articles both carve out exceptions to those standards, limiting the rights of patients and families in decisions about specific end-of-life treatments. As bioethics consultants in an acute care setting, we frequently confront conflicts similar to those described by Jeffrey Berger and by Ellen Robinson and colleagues. In such cases, our service emphasizes redoubled efforts at communication and mediation. Focusing on goals and values, rather than interventions, produces the best possible collaboration in health care decision-making. Cases in which we would overturn a surrogate's recommendations regarding palliative sedation or do-not-resuscitate orders are rare and require careful processes and clear evidence that the surrogate's choice is contrary to patient values.
善终难寻。家属告诉我们，临终时亲人在错误的地方——医院去世，并未得到高质量的关怀。本期《 Hastings 中心报告》收录了两位作者的文章，他们努力提供善终关怀，避免不必要的痛苦。我们认同他们的目标，但对他们所推荐的方法存在重大保留意见。尊重患者及其代理人的决定是医疗保健中一个相对较新且仍很脆弱的方面。几千年来，患者及其代理人在医疗决策中没有发言权。如今，标准支持共同决策，但这两篇文章都对这些标准进行了例外处理，限制了患者和家属在特定临终治疗决策中的权利。作为急症护理环境中的生物伦理顾问，我们经常面临与杰弗里·伯格和艾伦·罗宾逊及同事所描述类似的冲突。在这种情况下，我们的服务强调加倍努力进行沟通和调解。关注目标和价值观，而不是干预措施，可在医疗保健决策中实现最佳的合作。推翻代理人关于缓和性镇静或不复苏医嘱的建议的情况很少见，需要经过仔细的程序和明确的证据表明，代理人的选择违背了患者的价值观。
