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Clinicians need to ask themselves how they want to be treated if they become seriously ill and are potentially dying. Answering this question helps them discover and clarify their own beliefs and values concerning the care of their very ill patients. The goals of medical practice based exclusively on cure and restoration of function are frequently called into question when patients are irreversibly ill and potentially dying. Goals of pain and symptom management, enhancing quality of life, and finding meaning in the face of death may take precedence, or at least be an important part of the treatment plan. Is death something to be fought at all costs, or is relieving suffering a central part of our responsibility as clinicians? Enhancing quality of life for those afflicted with serious chronic illness is the cornerstone of the rapidly developing specialty of palliative care. As illustrated in Figure 37-1 below, palliative care can be provided alongside aggressive treatment of a patient's underlying disease, but as the patient becomes sicker and closer to death, palliation often becomes the primary objective.

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Figure 37-1.
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The place of palliative care in the course of illness. (Adapted from Clinical Practice Guidelines for Quality Palliative Care. Available at: www.nationalconsensusproject.org.)

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Case Illustration 1

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Ella, a 71-year-old woman, develops pains in her lower chest for a month before visiting her personal physician. When a chest film shows several nodular masses suggestive of widespread lung cancer, the physician phones Ella and tells her there is a problem, making an office appointment for the next day. At this visit, the doctor discusses the results of the chest film with the patient and her son. Ella, having long suspected she might get lung cancer from smoking heavily, weeps openly upon hearing the results. Bronchoscopy is recommended, and she is referred to a pulmonologist. Bronchoscopic biopsies show a small-cell lung cancer. The pulmonologist refers Ella to an oncologist who recommends chemotherapy.

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The patient and her son return to her primary care doctor to discuss her options. Ella says she would like to proceed with chemotherapy but wants to stop it if she becomes too ill from the treatments. A Roman Catholic, she has discussed with her priest the morality of refusing extraordinary care, including feeding tubes, if she were to have a terminal condition. She has appointed her son as her health care proxy, and discusses her desire not to undergo cardiopulmonary resuscitation (CPR). The physician gives Ella a living will and a do-not-resuscitate (DNR) document; she and her son complete them together. She wants to try all other potentially effective disease-directed treatments, and she also agrees to have her pain and shortness of breath treated aggressively as well. She also knows that cure is very unlikely with this treatment, so she begins to work with a financial planner to get her affairs in order....

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