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The American Battle Monuments Commission (AMBC) is a small independent agency of the Executive Branch of the federal government which is responsible for commemorating the services of the American Armed Forces by establishing suitable memorial shrines and overseeing the design, operation, and maintenance of American military burial grounds in foreign countries. The ABMC Web site provides online forms to order photographs of the headstone or marker of any individual buried or memorialized at World War I and II overseas cemeteries. They also provide forms which allow family members to arrange for the placement of floral decorations at overseas veteran's graves or memorialization sites.

Doctors are strongly encouraged to initiate discussions about end-of-life directives with their older patients, according to a study in the January issue of the Journal of General Internal Medicine. The study was led by William M. Tierney of Indiana University School of Medicine in Indianapolis.

Researchers found that doctors think patients should initiate such a conversation and patients think the doctor should bring it up, so no one is doing it. In additions, they found that some doctors thought their patients won't like such conversations, and that they might worry patients needlessly, especially older patients. However, the study reports that elderly or chronically ill patients who had such conversations with their primary care physician were happy they did.

They surveyed 686 patients who were at least 75 years old or at least 50 years old with serious underlying diseases, along with their 87 primary care physicians, and found that 98% of the participants had never spoken with their primary care physician about end of life details. 51% of the patients who discussed end-of-life directives evaluated their later office visits as excellent, but only 34% of those who did not have such discussions rated later visits as well.

In a special article, done for the Mayo Clinic Cancer Center Quality of Life Working Group and published in the Mayo Clinic Proceedings, authors note that physicians as a group may prolong the end-of-life suffering with aggressive approaches to "cure" the patients? underlying disease rather than acknowledging that the time has come to provide the patient with palliative care services. But the physician can help alleviate the suffering of a patient by orchestrating a multidimensional approach to helping ensure the quality of life at the end.

The authors point out that the death process has changed over the years. Before the 1900s, most Americans died at home surrounded by their loved ones. Now, as many as 60% will die in hospitals, and about 25% will die in healthcare-related facilities such as nursing homes. The role of the physician has had an ever-expanding role in the manner which people die with so many Americans dying in hospitals and other health care facilities.

"With modern medicine emphasizing genetic manipulations, high technology, and cure at all costs, we often neglect what was once the most sacred aspect of being a physician: alleviating suffering," the authors write. "Therefore, we contend that the approach to a person dying in the hospital must change from simply postponing death to focusing medical interventions on maintaining quality of life to the end."

The Mayo Clinic authors conclude their article: "We believe that the principles that have been so successful in improving the quality of life for hospice patients must be adopted in hospitals and related facilities such as nursing homes so that suffering can be relieved where the vast majority of Americans continue to die."

Kokua Mau is a partnership of individuals and organizations working with the general public and with the leaders of healthcare and government to improve the way that people in Hawaii are cared for at the end of their lives. They have created a web site designed for and dedicated to Hawaii's ohana. The links on the site will take users to various pages that can better prepare Hawaii families to begin difficult, but necessary conversations about end of life issues with their loved ones. The program is a joint effort of the Executive Office on Aging, St. Francis Healthcare System of Hawaii, the Hawaiian Islands Hospice Organization, and the University of Hawaii Center on Aging.

Bill Moyers will host a unique PBS television series "On Our Own Terms: Moyers on Dying", a public education event dealing with end of life decisions and issues which will be aired from September 10-13. It is anticipated that this program series will stimulate public demand for information about end of life care in the United States and in parts of Canada which are within range of PBS stations. "With Eyes Open" is a companion series which consists of four half-hour programs that will follow the Moyers programs in over 150 cities in the United States. "With Eyes Open" is designed to deal with the emotional fallout which the Moyers programs are expected to produce, with each half-hour followup covering a theme which was raised by the preceeding Moyers program, encouraging families to start asking questions and make decisions about end of life issues.

Two extensive web sites have been developed which include additional information to supplement the TV programming. "On Our Own Terms," the main PBS web site for the series, includes audio and video clips, resource guides, and downloadable discussion guides to support public education events local communities. The "With Eyes Open" companion web site has complementary content, including discussion guides for viewers, teachers, and parents, and places where viewers can submit questions to experts or join online discussion groups. ElderWeb is proud to be on a short list of recommended resources on the "With Eyes Open" site.

On September 10, 2000, a four-part PBS series from a team of award-winning journalists led by Bill and Judith Davidson Moyers will report on the end-of-life issues facing Americans. Based on two years of research, ON OUR OWN TERMS: MOYERS ON DYING will reveal the stories of the dying, their families, and their care givers, and illustrate the growing struggle to balance medical intervention with comfort and humanity. will explore America's search for new ways of thinking about death. It will focus on people -- patients and caregivers -- who are finding ways to overcome the fear and denial that dominate mainstream American culture and open conversations that help us live with dying. They will be launching a companion web site on August 28.

The Senate Special Committee on Aging held testimony on "The End of Life: Improving Care, Easing Pain and Helping Families." Committee chairman, Senator Grassley, said, "Studies show that the general public lacks the knowledge to be good consumers in this area. Most of us know little about the availability of good care for the dying, including elements such as hospice and pain care. In addition, health care providers are uncomfortable talking to patients and their loved ones about dying. They also tend to be uninformed about what constitutes appropriate pain relief."

Witnesses presented examples of both satisfying and frustrating experiences in dealing with end-of-life care forfamily members. Many concluded that end-of-life care education for both the public and professional health care providers is the best tool for bringing about a transformation in the quality of this experience.

End of Life Care Checklist for Seniors
From Senator John Breaux

Before visiting your doctor, think about any questions or concerns you have and want to discuss with your health care provider.

When visiting your doctor, bring a list of all medications you are taking.

Ask your doctor about hospice services in your area.

Let your doctor know if you don't understand an explanation regarding your diagnosis, likely symptoms or side effects of medications.

If you are in physical pain be sure to tell your doctor, who will likely ask how intense it is on a scale from one to 10.

When visiting your doctor, consider bringing a family member or friend.

Talk to your family and loved ones about your treatment preferences, and consider documenting your wishes in a living will.

Consider appointing someone you trust to make your health care decision, in case you can no longer make decisions for yourself.

If you are feeling overwhelmed or sad, consider talking to a pastor, chaplain, rabbi or other trusted person in your faith community.

Keep open lines of communication with family, friends and your health care providers. The more you tell them the more likely you will get the care you need!

The Journal of the American Medical Association has issued a call for papers on End of Life Care for inclusion in a special November issue on this subject. Papers are due by March 30, 2000.