Let the conversation begin: End-of-life discussions are important, say doctors


As a medical student and later a physician, Donald Ritt was surrounded by a culture that prides itself on prolonging the lives of its patients.

“All I learned along the way was to cure and save lives, and ‘Nobody dies on my shift,’” said Ritt, who practiced as a gastroenterologist for 45 years, including a stint as chief of staff at Scripps Memorial Hospital in La Jolla.

That changed for Ritt five years ago when, at age 75, he launched a palliative care program at Scripps, which worked with some 2,000 patients in its first three years.

Palliative care, according to Ritt and his colleague, Karl Steinberg, a geriatrician who cares for patients in nursing homes, is a medical sub-specialty focused on reducing suffering and improving quality of life, rather than curative treatment.

“As a society, we have a great deal of difficulty approaching death,” said Ritt, who is now retired and speaks on end-of-life issues to homeowner associations in North County. “We’ve learned that some of the life-sustaining systems are really not addressing quality (of life). End of life needs to be quality of life as well.”

“It’s a matter of education and conversation. People have to let their loved ones know what they want and what they don’t want, so they’re not stuck on a ventilator for months on end, wishing they could die but not being able to articulate that to anybody,” said Steinberg, who along with his medical practice is president of the board of the Coalition for Compassionate Care of California.

The two physicians recently met with a reporter in their quest to educate the public on end-of-life issues, and about ways for people to make sure their desires regarding end-of-life care are known by their families and doctors.

One important document, they said, is called the “Physician Orders for Life-Sustaining Treatment,” or POLST. The document is signed by the patient and his or her doctor. It spells out what treatment is desired if the patient stops breathing and has no pulse.

The POLST form can be downloaded from the CCCC website (coalitionccc.org), and may also be available at doctor’s offices. It is especially important for those nearing the end of their lives, said Ritt and Steinberg, and should be posted in a prominent place in the home, such as on the refrigerator, and also given to the person’s doctor and family members.

Another document that works in conjunction with the POLST, they said, is the advance directive, which designates who patients want to make medical decisions if they are incapacitated.

Palliative care is separate from — but related to — hospice care, said Ritt and Steinberg. In order to be eligible for hospice care, they said, patients must have a prognosis of six months or less to live, and decide to forgo further life-prolonging or curative treatment.

Palliative care, on the other hand, is designed to relieve suffering and improve quality of life, and can be an adjunct to curative treatment, they said.

Observation of palliative care programs, said Ritt, has shown that patients with life-threatening illnesses such as cancer actually live longer when their suffering is relieved.

“The whole approach of palliative care is to relieve suffering, and in that capacity, patients do better,” Ritt said.

Palliative care is a team-based approach, said Steinberg, and includes medication for pain, nausea, anxiety and other symptoms, as well as counseling and spiritual support for those who want it.

“It’s really about what’s important to that person, what makes their life meaningful,” said Steinberg. “For a lot of people, that can have religious or spiritual overtones.”

Resources include the San Diego County Coalition for Improving End-of-Life Care, and TheConversationProject.org.

In North County, the Seaside Center for Spiritual Living in Encinitas is sponsoring a “Death Café” from 10:30 a.m. to 12:30 p.m. March 21, when attendees are invited to “have tea and cake and a rich conversation.” The Seaside Center for Spiritual Living is at 1613 Lake Drive in Encinitas.

Death is a taboo subject in our culture, said the two physicians, but it really shouldn’t be.

“It’s like hitting the finish line. We’re all on that bullet train,” said Steinberg. “We don’t have to think about it constantly, but it’s always a part of all of our lives.”