Life-sustaining treatments: what doctors do, what theywant for themselves and what elderly persons want
Sara Carmel*
Department of Sociology of Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva,
84105, Israel
Abstract
In view of the current social dilemmas regarding the use of life-sustaining treatments (LST) at the end of life, thepurpose of the study was to reveal sources of interpersonal and intrapersonal con¯ict among the most involvedparties, in a society where open doctor±patient communication about end-of-life treatment is rare. Two comparative
analyses were conducted: (a) between physicians' practice and elderly persons' preferences regarding the use ofdi�erent life-sustaining treatments in di�erent illness conditions, and (b) between physicians' hypothetical practicefor an elderly person in a metastatic cancer condition, elderly persons' preferences and physicians' preferences for
themselves, should they be in the same illness condition.Data were collected in Israel from 339 physicians working in two medical centers, and from a random sample of
987 elderly persons. Attitudes and practice regarding arti®cial tube feeding, mechanical ventilation and
cardiopulmonary resuscitation (CPR) in three di�erent illness conditions were evaluated by close-ended questions.The ®ndings indicate disagreements between the elderly and the physicians on a number of issues: in general,physicians report that they would use more LST than what the elderly report that they would want. Physiciansdi�erentiate among di�erent illness conditions and di�erent LST more than elderly persons do. Physicians are more
likely to use arti®cial feeding than CPR, while elderly persons prefer the use of CPR more than arti®cial feeding.The comparison of physicians' hypothetical practice, the wishes of the elderly, and physicians' wishes for themselvesregarding the use of LST in a metastatic cancer condition, shows that physicians would use LST di�erently from
what the elderly want, and that they want less LST for themselves than they would order for elderly patients.The discrepancies found between the physicians' practice and the elderly persons preferences re¯ect di�erences in
perceptions of arti®cial feeding and a lack of public knowledge regarding the e�ectiveness of CPR. They also re¯ect
di�erences in attitudes regarding the prolongation of life in various illness conditions. The discrepancy betweenphysicians' practice and their preferences for themselves underscores the personal and professional dilemmas relatedto these issues, which are faced daily by many physicians, and impede their compassionate behavior towardpatients. Increasing the awareness of physicians of such discrepancies, and providing them with appropriate
behavioral tools, including communication skills, is a timely need which should be addressed by the medicalprofession, medical services and medical schools. # 1999 Elsevier Science Ltd. All rights reserved.
Keywords: Life-sustaining treatments; Cancer; Israel; Physicians; Elderly persons
Social Science & Medicine 49 (1999) 1401±1408
0277-9536/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.
PII: S0277-9536(99 )00221-X
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* Tel.: +972-76477428; fax: +972-76477635.
E-mail address: [email protected] (S. Carmel)
Introduction
At the end of the second millennium advances inmedical technology have become a two-edged sword:
they enable physicians to be more potent then ever in®ghting disease, improving the quality of life, andprolonging life; but when they are used on terminally
ill or dying people, they often prolong su�ering andmisery, and do not enhance quality of life.
This problematic social situation is an outcome of acultural lag caused by rapid developments in the mate-rialistic±technological component of culture, and the
lack in concomitant adjustments in the other culturalcomponents, the value system and the normative sys-
tem (Ogburn, 1957). In the past, the medical profes-sion's basic principles were congruent with society'sdominant system of values. The sanctity of life was the
highest on the ladder of social values, and physicians'major mission was to cure disease and save life, or inother words, to do all they can in order to preserve life
(Parsons, 1964). This situation has become problematicsince compliance to these professional principles has
started to result in temporary prolongation of lives ofvery low quality.Furthermore, this approach, which has led phys-
icians to perceive themselves as the guardians of life,has neglected issues related to the physicians' role in
dealing with death and treating the dying. Due topopulation aging, and the use of advanced medicaltechnology, physicians, more than ever, have to care
for dying patients and face the ethical and socialdilemmas related to the arti®cial prolongation or cessa-tion of life. In spite of these signi®cant changes, phys-
icians' training has not changed signi®cantly toprovide them with the needed interpersonal skills
(Durand et al., 1990; Quill, 1991; Fallow®eld, 1993;Campbell, 1994). As regard to treating the dying,doctors usually have training in the pharmacology of
symptom control, but rarely in how to communicatewith critically ill and dying patients (Bulkin andLukashok, 1991). The lack of knowledge and training
in this area results in detachment and lack of compas-sionate care for the patients who need it most (Bedell
and Delbanco, 1984; Cartwrite, 1991). It is also amajor contributing factor to physicians' stress, job sat-isfaction, and burnout (Firth-Cozens, 1987; Ramirez et
al., 1995, 1996; Carmel, 1996).Furthermore, complying with the basic principles of
medical treatment has become problematic. TheHippocratic oath directs physicians to both prolongthe lives of patients and minimize their su�ering.
Physicians are expected to apply these two simple andappealing principles on the basis of their medicalknowledge, and according to what they believe is best
for the patient (Parsons, 1964). In this respect, causingsu�ering when the outcome has the potential of
prolonging a life of higher quality, such as an oper-
ation, is acceptable. However, when the interventionprolongs life of low quality for a short period, causingsu�ering is di�cult to accept (Quill, 1993).
Considering such medical and ethical dilemmas,what are the criteria that can help physicians make de-
cisions regarding end-of-life treatment? One mightassume that in order to comply with the principle ofserving the patient's best interest, they will rely on
what they believe they would want for themselves.However, in relation to treating terminally ill patients,physicians often experience intrapersonal con¯icts
between their professional values and personal prefer-ences.
Although patients and physicians in the developednations face such dilemmas, and all societies try tointroduce changes in the treatment of the critically ill,
signi®cant di�erence are found among them. In somesocieties, as in the USA, passive euthanasia, the with-holding of medical treatment from terminally ill
patients, is openly practiced, following discussions withpatients and/or their families. Do-not-resuscitate
orders are signed by patients in many hospitals. Inother countries, this practice is often conducted with-out involving the patient or the family (Carmel, 1996;
Mello and Jenkinson, 1998).One of the major conditions for implementing such
regulations which rest on the value of personal auton-omy, is open doctor±patient/family discussions aboutdecisions regarding the withholding or withdrawal of
LST. However, openness in doctor±patient relationsregarding diagnosis and treatment is a problematicissue in most countries. It derives partly from the
medical profession's traditional paternalistic approachto doctor±patient relationship (Szasz and Hollender,
1956; Emanuel and Emanuel, 1992), and partly fromthe lack of physician's training in communicationskills. The lack of openness in doctor±patient com-
munication is even more problematic when physicianstreat patients with life-threatening diseases, but variessigni®cantly even among neighboring countries
(Pellegrino, 1992). In northern European countries, forexample, physicians tend to inform patients about
terminal conditions, while in southern and easternEuropean countries physicians usually conceal such adiagnosis from the patient and more often inform the
patient's spouse (Thomsen et al., 1993).Even in western countries where open communi-
cation is expected, signi®cant di�culties are reported.
For example, in a study of experienced oncologists inthe United Kingdom, the researchers presented signi®-
cant di�culties with communication issues such asdelivering bad news to patients. This study also reportsthat a short intervention in training in speci®c com-
munication skills can signi®cantly reduce such di�cul-ties (Fallow®eld et al., 1998).
S. Carmel / Social Science & Medicine 49 (1999) 1401±14081402
It is even more di�cult for physicians to initiateopen discussions with patients about the possibility of
withholding treatment at the end-of-life. It is, there-fore, a problematic issue even in countries where theuse of advance directives is quite common, such as the
USA (Connors et al., 1995). Lack of doctor±patientdiscussions on these issues is especially problematic inview of the results reported in some studies, which
show that physicians' or family members' evaluationsof patients' preferences are signi®cantly di�erent frompatients' preference (Danis et al., 1988; Uhlmann et
al., 1988; Ebell et al., 1991; Druley et al., 1993;Sonnenblick et al., 1993; Teno et al., 1995).In Israel, physicians tend to withhold and withdraw
LST in treating terminally ill patients. The modal
behavior of the involved parties, however, is character-ized by a `conspiracy of silence'. Physicians do not dis-cuss death and the possibility of withholding medical
treatment at the end of life with their patients. Patientsdo not discuss it with either their physicians or theirfamily, and physicians often do not discuss it even
among themselves (Carmel, 1996). However, similar toreports from western countries (Steinbrook et al.,1986; Lo et al., 1986; Shmerling et al., 1988;
Henderson, 1990; Kelner, 1995), a study of a randomsample of Israeli elderly showed that most of themwant to be informed about a life-threatening diseaseand to be involved in treatment decisions at the end of
their lives (Carmel and Lazar, 1997).In view of the current lack of doctor±patient com-
munication about end-of-life treatment in Israel, it is
important to investigate the degree of agreementbetween physicians and patients regarding this issue.The purpose of this study is twofold: (a) to evaluate
physicians' hypothetical practice and elderly persons'expressed preferences regarding the use of di�erentLST in di�erent illness conditions, and (b) to comparephysicians' hypothetical practice for elderly persons in
a metastatic cancer condition with their preferences forthemselves, should they be in the same illness con-dition.
Methods
Samples
The analyses were undertaken on data from asample of physicians, and a random sample of elderlypersons aged 70+ in Israel.
Data from physicians were collected in two medicalcenters in Israel: one in a large hospital in the southernregion (1100 beds), and the second in a small center in
the northern region (480 beds). Specialists and resi-dents in the medical, surgical, geriatric, oncology,intensive care, and family medicine wards were asked
to ®ll out an anonymous pre-tested structured ques-tionnaire, and encouraged to add their comments.
Data collection lasted from June to November 1997.In the large center 309 questionnaires were handedout, and 252 were returned (81.5% response rate). In
the small center, 124 physicians received questionnairesand 87 returned them (70% response rate). The datafrom the two samples were combined because no stat-
istically signi®cant di�erences were found between thesamples on socio-demographic variables or on the sub-stantive variables of the study such as attitudes and
practice regarding the prolongation of life. The onlysigni®cant di�erence found was in regard to academicrank. In the southern hospital more physicians hadacademic ranks since it is an academic medical center.
The average age of the physicians was 40.3 (S.D.=8.4)with a range from 25 to 65; 70.5% were males; 86.3%were married; 39% were born in Israel, 58% in
European or American countries, and 3% in Asian orAfrican countries; 52% were specialists, 41% residentsand 6% general practitioners; 32% were surgeons,
49% were in general internal medicine, and 19% infamily medicine; the average years of practice was 14.5(S.D.=8.5), with a range from 1 to 42 years.
The elderly sample was of Israeli Jews aged 70 andolder, drawn from the records of the Israeli Instituteof National Insurance (NI), which include all Israeliswho receive a monthly social security payment from
the Institute. All elderly citizens are eligible for thispayment except for a very small and insigni®cant per-centage of elderly who receive payments from other
countries. Personal interviews at the interviewees'homes were conducted with 987 persons betweenMarch and October 1994 by trained interviewers
(further details about this sample can be found in thestudy of Carmel and Mutran, 1997). A comparisonbetween the sample and the population of elderly per-sons aged 70+ based on the Statistical Abstracts of
Israel (1994) showed that the sample represents thetotal population of elderly persons with regard to ageand ethnic origin. However, women comprise 56.4%
of the population, whereas they are only 47.4% of thesample (w 2=41.99, p < 0.01). The average age of theelderly in the sample was 77.5 (S.D.=5.4), with a
range from 70 to 101; 56% were married or lived witha partner; 22% had 13 or more years of formal edu-cation; 78.2% were born in Europe or America, 18.6%
were born in Asia or North Africa, and 3.2% wereborn in Israel.
The questionnaire
Similar questions regarding the use of LST were
included in the questionnaires of both studies.Preferences for LST were measured by asking
respondents about their attitudes toward three types of
S. Carmel / Social Science & Medicine 49 (1999) 1401±1408 1403
LST (arti®cial tube feeding, mechanical ventilation,and cardiopulmonary resuscitation (CPR)) in three
medical conditions.In the elderly's questionnaire the three medical con-
ditions were formulated as follows:
Condition A: if you had cancer and knew and feltthat the disease is spreading and your condition isdeteriorating (metastatic cancer), but that there is
still a chance for temporary improvements.Condition B: if you were in an irreversible con-dition of severe mental impairment (such as having
Alzheimer disease).Condition C: if you were in a physically irreversiblecondition, being bedridden and incontinent.
The three LST were described and it was noted thatall three interventions, which are used in order to keepthe person alive, can cause much inconvenience and
sometimes su�ering, and that it is hard to predict howwell a person will do after them.Regarding each of the three medical conditions, the
respondent was asked:
1. If you were unable to swallow, would you be willingto be fed by arti®cial means?
2. If you were unable to breath on your own, would
you be willing to go on a breathing machine?3. If your heart stopped beating, would you be willing
to have a cardiopulmonary resuscitation?
A 5-point scale followed each question ranging from1 Ð `de®nitely no' to 5 Ð `de®nitely yes', so that thehigher the score, the more positive the respondent is
about receiving the treatment.In the physicians' questionnaire the same medical
conditions for an 80 years old person were presented.
The medical conditions were followed by questionsabout their hypothetical practice regarding the use ofthe same three types of LST, with the same responsescales. They were also asked the same questions about
their wishes for the three LST for themselves, shouldthey be in the metastatic cancer condition (conditionA).
Results
The ®ndings of the analyses regarding wishes for the
use of LST in three illness conditions are presented inTable 1. The comparisons regarding wishes for thedi�erent LST among the elderly (based on the average
scores) indicate that they have a stronger preferencefor the use of CPR than for arti®cial feeding in allthree illness conditions. In percentages: in the con-
dition of metastatic cancer, 32% of the elderly wouldwant CPR and 28% would want tube feeding (have ascore of 4 or 5 on a 5-point scale); in the condition of
an irreversible mental illness, 25% versus 22%, and inthe condition of an irreversible severe physical con-dition, 25% versus 23%. Although these di�erences (in
the average scores and percentages) are relativelysmall, they are statistically signi®cant. These distinc-
tions among di�erent LST are similar when separateanalyses are conducted on men and women, although
women have lower scores than men.The physicians distinguish among the three LST
more clearly, but report the opposite: they wouldorder signi®cantly less CPR than arti®cial feeding or
mechanical ventilation for an elderly person in all thethree illness conditions. In the metastatic cancer con-
dition, 54% would provide tube feeding but only13.1% would provide CPR; in the mental condition,
74.6% would provide tube feeding and 33.7% CPR; inthe irreversible physical condition, 89% would provide
feeding, and 51% CPR. All the results remained stat-istically signi®cant also after conducting the
Bonferonni correction for multiple comparisons.In regard to the illness conditions, the results in
Table 1 indicate that the elderly are more likely towant the use of all the three LST in the condition of
cancer than in the other two illness conditions ofphysical and mental impairment. The physicians, how-
Table 1
Physicians' practice and elderly patients perferences regarding
the use of di�erent life-sustaining treatments in three illness
conditions
Arti®cial tube
feeding
Mechanical
ventilation
CPR
elderly physicians elderly physicians elderly physicians
Metastatic cancer
mean 2.34 3.40a 2.36 2.31d 2.47b,c 1.75a,b,c
S.D. 1.64 1.56 1.65 1.49 1.70 1.29
Mental-irreversible
mean 2.11 4.15a 2.17 3.13a,d 2.19b 2.72a,b,c
S.D. 1.56 1.19 1.60 1.55 1.60 1.58
Physical-irreversible
mean 2.17 4.52a 2.18 3.73a,d 2.23b 3.34 a,b,c
S.D. 1.56 0.90 1.60 1.41 1.62 1.59
a A statistically signi®cant di�erence (group t-test,
p < 0.001) between the two samples regarding the same treat-
ment and the same illness condition.b A statistically signi®cant di�erence (paired t-test,
p < 0.001) between the scores on arti®cial feeding and CPR
in the same sample and illness condition.c A statistically signi®cant di�erence (paired t-test,
p < 0.001) between the scores on mechanical ventilation and
CPR in the same sample and illness condition.d A statistically signi®cant di�erence (paired t-test,
p < 0.001) between the scores on arti®cial feeding and mech-
anical ventilation in the same sample and illness condition.
S. Carmel / Social Science & Medicine 49 (1999) 1401±14081404
ever, report that they would order less LST to patients
in the cancer condition than in the two other con-ditions. Furthermore, a factor analysis procedure con-
ducted on the responses to the nine items (three LSTfor each of the three conditions) in each of the twosamples revealed interesting di�erences between the
samples in the degree of di�erentiation among thethree treatments and the three illness conditions. While
it revealed one factor (dimension) in the elderly'ssample (eigenvalue=7.17, Cronbach's a=0.97), threefactors were detected in the physicians' sample (eigen-
value=4.56, 1.35, 1.03). In one factor only the itemsof arti®cial feeding (in the three illness conditions)
were included. The items of arti®cial ventilation andCPR in the two conditions of mental and physical
impairment were included in another factor, and thesetwo items in the cancer condition were included in thethird factor. These ®ndings indicate that physicians
di�erentiate more than the elderly among the di�erentLST and the di�erent illness conditions.
The comparison of the average scores of the twosamples for the same treatment and the same illness
condition (Table 1) shows that in general, physicianswould order LST more than what the elderly say theywould want. This ®nding is obvious with regard to
arti®cial feeding in all the three illness conditions, andwith regard to mechanical ventilation and CPR in the
two conditions of mental and physical impairment. Inthe cancer condition, no signi®cant di�erence isdetected between the physicians and the elderly regard-
ing mechanical ventilation, while a signi®cant di�er-ence in the opposite direction is found with regard to
the use of CPR, indicating that in a severe metastaticcancer condition physicians would order less CPR
than what the elderly would want. The most noticeabledi�erences are found with regard to tube feeding in allthree illness conditions. While the elderly's average
scores for tube feeding are quite low and similar to thescores on the other LST (between 2 and 2.3 on a 5-
point scale), these scores are signi®cantly higheramong the physicians (between 3.4 and 4.5).
The comparison of physicians' hypothetical practicefor an elderly person in a metastatic cancer conditionand their wishes for themselves, should they be in the
same condition, is presented in Table 2. The results in-dicate that physicians want signi®cantly less the use ofall three treatments for themselves than they would
order for elderly patients.A similar trend of preferences for the use of the
three di�erent LST can be detected in physicians' re-
sponses to the questions about their hypothetical prac-tice, and their wishes for themselves: the highest scoresare given to arti®cial feeding, the intermediate tomechanical ventilation, and the lowest to CPR, while
the order of the preferences for the three types of LST,in the sample of the elderly (Table 1), moves in theopposite direction.
Discussion
The comparison between physicians' hypotheticalbehavior and elderly persons' preferences for di�erent
LST in three di�erent illness conditions reveals signi®-cant di�erences on three dimensions: ®rst, physiciansreport that they would order signi®cantly more LST
than what the elderly report that they would want.This disagreement re¯ects the current social restrictionsregarding withholding medical treatment at the end of
life. Physicians behave according to these social norms,while the public seems to express di�erent needs.Di�erences between physicians and elderly persons
also exist with regard to the use of the di�erent typesof LST. While physicians would rarely prevent arti®-cial feeding from patients, but would use CPR signi®-cantly less, frequently the elderly persons report
wanting the opposite. The di�erences suggest thatphysicians and elderly persons have di�erent percep-tions of the e�ectiveness and appropriateness of di�er-
ent LST. A tendency of physicians to provide for basicphysiological needs, such as hydration and nutrition,even to patients for whom it is contraindicated has
been reported (Micetich et al., 1986). This behavior isexplained by the symbolic and emotional signi®canceof giving food and drink, the essence of care and com-passion (Lynn and Childress, 1986). It is, therefore,
interesting to ®nd that this behavior is often not inaccord with the elderly persons' expressed preferences.It seems that elderly persons perceive tube feeding as
an arti®cial medical invasive procedure similar to arti®-cial ventilation, and are less in¯uenced by its symbolicmeaning than the physicians. This also indicates that
elderly persons are less in¯uenced by social values inthis regard, while the tendency of physicians to addressthe basic physiological needs of patients, such as hy-
Table 2
The use of LST in a metastatic cancer condition: a compari-
son of physicians' practice and their wishes for themselves
Arti®cial
tube
feeding
Mechani-
cal
ventila-
tion
CPR
mean S.D. mean S.D. mean S.D.
Physicians' practice
for an old person
3.40 1.56 2.31 1.49 1.75 1.29
Physicians' wishes
for themselves
2.52� 1.57 1.66� 1.78 1.40� 1.00
� p< 0.001.
S. Carmel / Social Science & Medicine 49 (1999) 1401±1408 1405
dration and nutrition, and to use heroic interventions,
such as CPR, less often is in accordance with basicsocial values, and with the position of leading Jewishreligious authorities (Steinberg, 1994). This ®nding
supports the conclusion that physicians actually actaccording to society's dominant values while theelderly persons' expressed preferences suggest the need
for change in physicians' behavior. In addition, it issuggested that elderly persons' preferences for the use
of CPR, which are even more conspicuous in lesssevere illness conditions (Carmel and Mutran, 1997),and their disagreement with physicians about it, derive
from their perception of CPR as a noninvasive inter-vention that either succeeds or fails, a perception
based on information derived from TV movies(Murphy et al., 1994; Mead and Turnbull, 1995;Carmel and Mutran, 1997).
The third di�erence between the physicians and theelderly persons regards their perceptions of di�erent ill-ness conditions. The results show that although the
elderly persons di�erentiate less than the physiciansamong the three illness conditions, they report that
they would want LST less for the physical and mentalimpairment conditions than for the metastatic cancercondition. Physicians, on the other hand, report that
they would use signi®cantly less LST in the cancer con-dition than in the other two illness conditions. This in-
dicates that the elderly persons seem to view physicaland mental impairment as more threatening thanmetastatic cancer, while physicians apparently perceive
cancer as a more terminal condition than the othertwo. These di�erences re¯ect a more profound di�er-ence in points of view of patients and physicians with
respect to the prolongation of life. While patients areconcerned more about the quality of life, physicians
are more likely to be in¯uenced by the prognosis forthe length of life. This behavior re¯ects the traditionalorientation of the medical profession, which sees the
physician as the guardian of life. It may also be thatwith regard to quality of life, physicians relate moresigni®cance to physical pain, which is associated with
cancer, rather than to other aspects of quality of lifesuch as physical and mental dysfunction. Such func-
tional limitations, on the other hand, seem to frightenelderly persons even more than cancer with its threa-tening stereotype.
The study also reveals the dilemma faced by phys-icians in their daily practice. Physicians report wanting
less use of LST for themselves, should they be in thecancer condition, than they would order for theirelderly patients in the same condition. A similar ®nd-
ing is reported in a study of a sample of Japanesephysicians (Asai et al., 1995), indicating a cross-cul-tural phenomenon. This dilemma derives from the cur-
rent social situation in many societies which forcesphysicians to distinguish between what they believe is
best for themselves and what is professionally the right
thing to do for a patient. In addition to the emotionalburden for physicians that such a psychological pro-cess causes, it is suggested that it also undermines the
basis for compassionate behavior, because physicianslearn to avoid the question ``what is best for thepatient'' in terms of ``what would be best for me.'' A
coping strategy that directs them to become moredetached than concerned, thus disrupting the delicate
balance of detached concern. Considering the organiz-ational barriers to physicians' compassionate behavior(Carmel and Glick, 1996), such intrapersonal dilemmas
carry the potential for intensifying their detachmentand alienation from dying patients.
In conclusion, this paper presents two kinds of dis-crepancies. The ®rst is the gap between physicians'practice and patients' preferences regarding the use of
LST at the end of life. This disagreement is profoundsince it encompasses three di�erent dimensions: theextent of medical intervention for prolonging life, the
di�erential use of speci®c types of treatments, and thedegree of treatment in di�erent illness conditions. The
second is the discrepancy between the treatment thatphysicians would want for themselves versus what theywould do for their patients. The medical profession
acts according to society's dominant cultural, religiousand social beliefs and attitudes. The elderly, however,as well as the physicians themselves, when assessing
their own preferences, prefer di�erent medical treat-ment than the normative one, thus expressing their
need for change.Both kinds of discrepancies are found in a society
where in general a diagnosis of a life-threatening dis-
ease is reported to patients, but the use of LST at theend of life is rarely discussed. Both derive from therapid technological developments and the lag in social
adjustment, and express the social confusion caused bylack in social consensus and regulation regarding end-
of-life care, and a lack in an appropriate exchange ofinformation on the public level and on the doctor±patient/family level. Both discrepancies are sources of
misunderstanding and con¯ict on a daily basis amongphysicians and between them and their patients.
The process of closing the current cultural gap islong because it involves con¯ict between such basicsocial values as the sanctity of life and self-determi-
nation. It is suggested that the only way to deal withsuch social discrepancies, prevent con¯icts and acceler-ate the social adjustment process is through open com-
munication. Openness is needed on the public level,among physicians, between them and their patients,
and between family members and patients. Open com-munication and provision of information, as forexample about the e�ectiveness and possible danger of
the di�erent LST, might reduce some of the misunder-standings, and reveal others. Open discussions between
S. Carmel / Social Science & Medicine 49 (1999) 1401±14081406
the medical team and the patient or the family aboutthe things that worry them regarding the speci®c illness
condition and the speci®c LST can promote under-standing and overcome the negative e�ects of di�er-ences in perceptions. Discussions in the ward about
medical decisions regarding dying patients can helpphysicians, especially young physicians who more thanothers feel the need for guidance (Carmel, 1996).
In view of the reported discrepancies between phys-icians' practice and potential patients' preferences, andphysicians' own preferences for end-of-life treatment, it
is suggested that the medical profession which has theleading role in this area, should become the agent ofsocial change by encouraging open communicationwith patients. In order to achieve this, the medical pro-
fession has to address medical treatment at the end oflife by developing courses in medical schools and incontinuing medical education, directed to raise aware-
ness of the ethical, practical, and emotional dilemmasthat physicians face regarding these issues. Suchcourses should focus on developing the appropriate
medical and interpersonal communication skills fortreating terminally ill and dying patients.
Acknowledgements
The studies were supported by a grant from theU.S.±Israel Binational Science Foundation (BSF No.92-00114), and a grant from the Israeli Ministry ofHealth (No. 3628). The author gratefully acknowledges
this support.
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