Excellence in caring for a person
at the end of life requires that the clinician understand 4 critical elements:
Understand the patient’s story, including the role of the family and ways that the
patient and family make sense of life and its vicissitudes. The clinician then can assume
a helpful and fitting role within that story.
Understand the body, and the limits and possibilities determined by its ailments over
time.
Understand the care system and what can be done routinely and in exceptional situations.
The clinician must understand regional health care resources and relevant law and ethics.
Understand oneself.
Only then can the practitioner be an effective instrument of healing in the context of
fatal illness. All of these are difficult . The last is a lifelong quest.
The most important guidepost to good care at the end of life is for the professional to
listen and come to understand the patient and family.
JAMA May 28, 1997; 277: 1633-40 "Clinical Crossroads" from George Washington
Univ. Medical Center, Washington, DC
Comment: One impediment might be a lack of time to understand the patient’s
story. I believe important conversations and understanding can take place in a short time.
RTJ
Reference Article 5-23 AORTIC DISSECTION
This review concerns pathogenesis and predisposing factors, classification, clinical
presentation and diagnosis, treatment, and long term management.
Aortic dissection is classified simply into: 1) type A—all dissections involving the
ascending aorta (regardless of the entry site location), and 2) type B—those distal
to the left subclavian artery (sparing the ascending aorta).
In type A dissection the risk of fatal rupture of the ascending aorta is extremely high
(around 90%), and requires immediate replacement of the aorta. The risk is lower in type B
dissection, unless a periaortic or left pleural hematoma is present, and can be controlled
by reducing aortic stress medically. Aortic stress is reduced by lowering blood pressure,
and by reducing the pulse upstroke and heart rate. Beta-adrenergic blockers are especially
suitable for this purpose.
Although the benefit of surgery is undisputed for essentially all cases of type A
dissections, it is less well established for type B dissections where rupture of the aorta
is less likely and 70% of cases progress to a chronic form with medical treatment.
Resection of the descending aorta carries a significant mortality and morbidity.
Lancet May 17, 1997; 349: 1461-64 Seminar from Geneva Univ. Hospital, Switzerland
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