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Published in CenterView on April 09, 2012

End-of-life talks a reality for UMMC physicians, chaplains

By Patrice Guilfoyle

Sometimes the discussion comes easily. The physician sits down with the patient and tells him that despite best efforts to treat his disease, the diagnosis is terminal. The conversation shifts to the patient's wishes for care until his death.

At other times, the members of the family have to make the end-of-life decision when a loved one is unable to do so, and they know the patient would not want any extraordinary life-saving measures.

Then there are the difficult cases, the ones in which the patient hasn't expressed his wishes. That's when the health-care providers and families wade into the murky waters of faith, medicine and death.

Physicians and chaplains at the University of Mississippi Medical Center are working together to determine how to best help the patients, families, and caregivers reach a decision that focuses on the quality of life rather than the quantity. The faith-based initiative is a new effort to take advantage of the expertise within UMMC to bring closure to all involved.

"Faith plays a great deal into end-of-life decision making," said Dr. Michael Baumann, professor of pulmonary and critical care medicine. "Some families say, ‘We're praying for a miracle,' or ‘God's going to heal them.' You don't want to take away their faith but you want to imbue them with information on the medical end of things."

In the absence of an advanced directive, the conversation about end-of-life decisions can be hard for both the caregiver and the families. Dr. Demondes Haynes, assistant professor of pulmonary and critical care medicine, said that health-care providers struggle with the issue as well. They have their own sets of prejudices, beliefs and ideas, and they may not have been taught how to deal with conflict that surrounds some end-of-life cases.

"You're taught as a physician to do something, but sometimes the best thing to do is nothing," Haynes said.

This crossroads of faith and medicine is particularly common in the Southeast, Baumann said, and the range of beliefs varies based on cultural factors. Every family and medical situation is different and often the solution has to be created through several conversations. The earlier the discussion can begin, the better, especially before the disease progresses to a critical stage.

"We as health-care providers don't use these lines of thought as much as we need to. We should be talking about this before the patient is even this sick," Baumann said.

Dr. Ruth Black, director of pastoral services, said when she and her staff are called for patients who have been given a poor prognosis, or are facing end-of-life issues, they are in a position to support the patient's faith.  If patients have questions about their own faith, chaplains are able to facilitate theological and devotional discussions focused on the patient's spiritual crisis. At times, they encounter patients who have no formal belief system at all, and the chaplains are able to enter into a dialogue with them.

Like Baumann, Black said she is respectful of patients and families who have their faith set on a miracle. 

"We also believe in miracles," Black said. "We want to uphold them in their faith, but we also want to help them integrate the medical implications of the situation," she said.

UMMC Chaplain Doris Whitaker said she can tell when the family is ready to enter end-of-life discussions, and when they are not. She said her purpose is to hear them and to validate their faith, as well as to help them understand that healing may look different from what they envisioned. 

"I want to plant a seed that may lead to a broader understanding of end-of-life issues and discussions," she said.

Haynes said that it's innate for people to want their loved ones around as long as possible, and many families don't have the medical background to understand that medicine and hospitals can't cure everyone.

Unrealistic expectations about life and death may be the cause for some of the conflict. Television programs portray a patient coding and the medical professional bringing them back and the patient eventually leaving the hospital. That rarely happens in real life.

Additionally, mechanical ventilation was originally meant to be a bridge to get patients to better health, Haynes said. Now, long-term ventilation is available as treatment for a chronic illness.

Dr. William Cleland, chief medical officer, said the medical center often has patients whose families don't want to see their loved ones die so they are kept alive through ventilators and medication. These patients require specialized care, but no family members want to take care of them nor do they want the patient in a nursing home.

"Our mission is to be an acute care hospital. We cannot have it become a nursing home. These cases have been particularly difficult," he said. 

Costs of prolonging a patient's life must be considered as well, from ventilator care to bone marrow transplants.

Baumann said some physicians talk to families by opening with the question of what do they want to get out of the medical care of their loved one. That may be enough to get them thinking about the reality of the disease and its effects.

Black said fear or uncertainty may be at the root of some of the conflicts. "Sometimes people are more fearful of the process of dying than the event of death. That's when an advanced directive is so important because there may be days when they can't make the decision. Coming to that place of peace is infinitely easier for families who have discussed end-of-life issues," she said.

Black said the process of letting go of a loved one should be reverenced. She said a chaplain's role at the end of life is like that of a midwife in the other end of life.  In the beginning of life, the midwife facilitates the birth of persons into this life. At the end of this life, chaplains assist their birth into the larger life.  

"We help them transition, no matter their beliefs," she said.