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The researchers found that in areas where end-of-life care costs were normally high, having an advance directive significantly lowered the cost of care. On average, end-of-life care spending was $5,585 less per person in the high-spending regions when someone had an advance directive. > Having an advance directive didn't necessarily limit the initiation of aggressive treatments, but seemed to lead to their earlier withdrawal. Author said this finding was particularly important because some people make the argument that having an advance directive might limit all of the care you receive at the end of your life. But, this finding shows that while treatments are often started, for "patients with an advance directive, there's an earlier recognition of when treatments aren't working and when it's time to go to hospice."

'If you met me, you'd never know I was mentally ill. In fact, I've gone through most of my adult life without anyone ever knowing - except when I've had to reveal it to a doctor. And that revelation changes everything. It wipes clean the rest of my résumé, my education, my accomplishments, reduces me to a diagnosis. I was surprised when, after one of these run-ins, my psychopharmacologist said this sort of behavior was all too common. At least 14 studies have shown that patients with a serious mental illness receive worse medical care than "normal" people. Last year the World Health Organization called the stigma and discrimination endured by people with mental health conditions "a hidden human rights emergency." If you met me, you'd never know I was mentally ill. In fact, I've gone through most of my adult life without anyone ever knowing - except when I've had to reveal it to a doctor. And that revelation changes everything. It wipes clean the rest of my résumé, my education, my accomplishments, reduces me to a diagnosis. I was surprised when, after one of these run-ins, my psychopharmacologist said this sort of behavior was all too common. At least 14 studies have shown that patients with a serious mental illness receive worse medical care than "normal" people. Last year the World Health Organization called the stigma and discrimination endured by people with mental health conditions "a hidden human rights emergency." I never knew it until I started poking around, but this particular kind of discriminatory doctoring has a name. It's called "diagnostic overshadowing." According to a review of studies done by the Institute of Psychiatry at King's College, London, it happens a lot. As a result, people with a serious mental illness - including bipolar disorder, major depression, schizophrenia and schizoaffective disorder - end up with wrong diagnoses and are under-treated. That is a problem, because if yo

"...beyond the medical advances, Dr. DeBakey's story is emblematic of the difficulties that often accompany care at the end of life. It is a story of debates over how far to go in treating someone so old, ... and risky decisions that, while still being argued over, clearly saved Dr. DeBakey's life. It is also a story of Dr. DeBakey himself, a strong-willed pioneer who at one point was willing to die, concedes he was at times in denial about how sick he was and is now plowing into life with as much zest and verve as ever. But Dr. DeBakey's rescue almost never happened. He refused to be admitted to a hospital until late January. As his health deteriorated and he became unresponsive in the hospital in early February, his surgical partner of 40 years, Dr. George P. Noon, decided an operation was the only way to save his life. But the hospital's anesthesiologists refused to put Dr. DeBakey to sleep because such an operation had never been performed on someone his age and in his condition. Also, they said Dr. DeBakey had signed a directive that forbade surgery. As the hospital's ethics committee debated in a late-night emergency meeting on the 12th floor of Methodist Hospital, Dr. DeBakey's wife, Katrin, barged in to demand that the operation begin immediately.

From: Keating N, et al "Physician factors associated with discussions about end-of-life care" Cancer 2010; DOI: 10.1002/cncr.24761.

Discussion of palliative sedation at end of life (Franklin Hospital Hospice Unit, NSLIJHealth System & Hospice Care Network of L.I.)

Readers largely support measures to allow death in dignified environment with palliative approach, as opposed to repeated aggressive interventions that are rarely successful when the prognosis is poor.

>'With unrealistic expectations of our ability to prolong life, with death as an unfamiliar and unnatural event, and without a realistic, tactile sense of how much a worn-out elderly patient is suffering, it's easy for patients and families to keep insisting on more tests, more medications, more procedures. >Doing something often feels better than doing nothing. Inaction feeds the sense of guilt-ridden ineptness family members already feel as they ask themselves, "Why can't I do more for this person I love so much?" >...At a certain stage of life, aggressive medical treatment can become sanctioned torture. When a case such as this comes along, nurses, physicians and therapists sometimes feel conflicted and immoral. We've committed ourselves to relieving suffering, not causing it. A retired nurse once wrote to me: "I am so glad I don't have to hurt old people any more." '

Pro's & con's on assisted suicide, & adequate support for patients & caregivers at end-of-life - initiated by letter by Janice Lynch Schuster, at Ctr for Elder Care & Advanced Illness, Altarum Institute

NYH palliativist fights for her own life to the end

Ben Rich - from law to health law & bioethics. See also: Rich BA. Prognosis terminal: truth-telling in the context of end-of-life care. Camb Q Healthc Ethics 2014;23:209-19.

Palliative care program at Montefiore Hospital

Most readers favor palliative sedation if its primary intent is to allay intolerable suffering even if it may accelerate dying - as opposed to allowing the suffering because its treatment may lead to an earlier death.

letters re Montefiore palliative program description in NYTimes