Heyland and colleagues be worthy of congratulations for their study.

Heyland and colleagues be worthy of congratulations for their study, "Dying in the Intensive Care Unit: Perspectives of Family Members" in this issue of CHEST (see page 392) In this multicenter cogitation conducted at tertiary care center the authors documented the fact that 83% of family members were satisfied with the care that their lov undivideds received. The authors credit the advantageous communications, decision making, respect, and compassion shown in the care of patients and their families for these be deriveds The experience of the American investigators has been abundant less satisfactory than their Canadian counterparts. Lynn and colleagues (1) reported in 1997 in succession the larger Study To Understand Prognosis and choices for Outcomes and Risks of Treatment (SUPPORT) and the Hospitalized somewhat old Longitudinal Project. They were les sanguine about their findings. forward interviewing surrogates of the somewhat advanced in life or seriously ill patients who had died within a year of the hospitalization, they construct that almost 60% of patients would have preferr comfort care. They also discovered that in 10% of the cases, care was contrary to the preferr approach. The 11% rate of attempted resuscitation was almost four times higher than the 3% rate in the meditation by Heyland et al. The SUPPORT studious mood revealed that one third of the patients were in unexpect pain at the time of death v worthy pain management found in 90% of Canadian patients.

Lynn et al referr to the solely substantial study published by legendary William Osier in 1908 Reporting upon 486 deaths at Johns Hopkins, he was convinced that and nothing else 90 patients felt pain at the time of death. Unfortunately, Osler's admit end was not that unrestrained of pain! Nuland, (2) between the sides of Osler's own words, provides a poignant description of the 6 weeks of his enduring sharp pleuritic pain and trials of coughing. In those primitive days, he had undergone sum of two units operations to drain empyema subject to general anesthesia. Two weeks later when he died, pneumonia had not been the "friend of the aged." Nuland observ "By and large dying is a messy business."

The stark contrast between the findings of the studious mood by Heyland et al and the SUPPORT studies is painful Is that difference due to cultural, attitudinal, and organizational differences for the delivery of critical care in Canada and America? The easy explanation that American patients want more treatment on the same level at the risk of discomfort may or may not be genuine After years of public and frequently acrimonious debate, a la Quinlan and Cruzan, physicians may be impressed unsettled with the following question. Are our medical practices regarding the dying more humane than they were 30 or 40 years ago?

Legally and ethically, a destiny of ground has been overlayed The death-with-dignity movement, living wills, durable power of attorney, and equal assisted suicide (in Oregon) are society's attempts to deal with difficult bioethical issues. nevertheless why do most family members have feeling betrayed and burdened when their nearest of kin die in the ICU? The vigorous ethical debates do nothing for the anguish of surrogates caught in the maze of "full code" and "DNR" designations in the hospital. Practically, who decides the question of whether to institute mechanical ventilation or artificial feeding becomes more important than the essential goodnes of the decisions.

Although the common study did not report too many out-of-control treatments, many families are fearful. Callahan (3) has referr to the illusion that we could master our medical choices: "Yet there is hardly below the surface, a remarkable and rising anxiety about dying--not necessarily death as like but the combination of an reach outed critical illness gradually transformed into an widened dying." His personal considerations border forward accepting decline and death in an almost fatalistic manner, which is unusual in Western thought

In an ever-shrinking world, we should not underestimate the efficiency of life-support technology and medical know-how in societies in which ethical and legal constraints are weak or nonexistent. the same often hears of the "illegality" of discontinuing mechanical ventilation in dying patients! to this time with few support systems, these interventions may be stopped abruptly after the financial ruin of the families. Unfortunately, the immorality of of that kind practices is rarely questioned. Decision making in these highly paternalistic medical bodys requires some scrutiny. I be warmed that we have an obligation to our colleagues in les affluent societies. A universal ethical collection of laws for the use of life-support technology in this young hundred is a laudable goal.

Vinod K Puri, MD FCCP

Southfield, MI

REFERENCES

(1) Lynn J Teno JM Phillips R et al. Perspectives by dint of family members of the dying experience of older and seriously ill patients. Ann Intern M 1997; 126:97-106

(2) Nuland SB by what means we die: reflections on life's final chapter. recent York, NY: Vintage Books, 1993; 141-142

(3) Callahan D The troubl dream of life: living with mortality. of recent origin York, NY: Simon & Schuster, 1993; 23

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