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Am Fam Physician. 1998;58(6):1305-1306

to the editor: I laud the editorial by Dr. Whitten that proposes “Ten Commandments for the Care of Terminally Ill Patients.”1 Addressing the emotional climate that surrounds terminal illness is an appropriate exercise in primary medical care. However, I would like to suggest a preamble to his commandments—an early hospital referral. Hospice care is provided through a team approach. It includes the skills of nurse aids, social workers, chaplains, nurses and physicians. Each program has a hospice physician on hand for consultation, but the physician who refers the patient usually remains the primary physician and is an integral part of the team. The remainder of Dr. Whitten's commandments can be more easily carried out through this team concept.

For diagnosis or acute treatment, the commandment to “ask about consultations” should not be followed unless its purpose is to aid in the management of the patient's symptoms in a palliative manner. Good communication often starts with finding out what the patient, the family or both desire or expect of the physician. Such knowledge will greatly aid the consultative process. Consulted physicians, who are usually acute care specialists, may confuse the patient and family by making recommendations that are not consistent with the concept of palliative symptom management. The primary physician should remain in charge of the patient's overall care regardless of the process of consultation.

Finally, I would like to suggest that physicians give their dying patients the hope that they will be free of symptoms at the time of death. It is the most powerful and kindest service we can provide.

in reply: Reading the letter from Dr. Wright made me aware that we both are concerned with the care of the dying patient and that many ways are available to provide excellent care. A team approach, as he recommends, is most appropriate and was suggested in Commandments III and IV described in my editorial. However, many patients either do not want a hospice or find a hospice to be impractical because of distance or availability. Cost is another factor. I am sure that in some large cities, the availability of hospices is good. However, in the West and Southwest, areas with which I am most familiar, hospices are not always available and many patients prefer to “be at home when their time comes.” Dr. Wright implies that the terminally ill patient should be in the hospice of a hospital or other hospice. This may be seen as distancing the traditional physician from the patient and family.

With regard to his point about consultations, I feel I made it clear that all that can be done should be done for the patient and that what I suggest is that the patient's family be offered additional consultations in the management and care of a terminally ill family member. Death is a family affair and this suggestion is more often for the benefit of the family members and not directly for the patient.

Finally, I appeal to the family physician to use the most powerful of all medicines—a human relationship in which there is trust, empathy, understanding and the willingness to see the dying patient through not only the good times but also the final time.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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