Choosing End-of-Life Care: Exploring Options Beyond Hospitals

As our bodies age and mortality looms nearer, many Americans find themselves traveling to the nearest hospital for care. From the 20th century to the 21st century, hospital deaths surged dramatically [1]. However, for the first time in over a century, that trend has reversed. The number of individuals dying in hospitals has decreased, indicating a growing preference for dying at home or in alternative facilities [1].

Why would people opt to die in hospitals to begin with? To be away from their friends, family, and loved ones in their final moments? Perhaps it’s the promise of a cure. The promise of a prolonged life, of more time to do the things that are important, the feeling of not having lived the “best” life possible yet. Perhaps it’s the worry of loved ones having to see them frail and weak, having to burden them as your breath slows and  tears form. Perhaps it’s simply the most convenient place. Or perhaps patients simply don’t know that there is another alternative.After all, how many of us think about where we’ll die, or where we want to die if we have a choice? 

Beyond hospitals, individuals have a range of choices for end-of-life care, including nursing homes, hospice, and palliative care centers, as well as their own homes. While hospital care may offer more treatment options, non-hospital settings provide comfort, safety, and often more accessible supportive and palliative care. Increasingly, heightened awareness of decision-making in end-of-life care and the rising costs of hospital facilities contribute to this shift towards non-hospital deaths.

Ultimately, the decision between hospital and non-hospital deaths rests with  individuals and their loved ones. While not everyone can dictate how they die, for those who can, the choice hinges on what matters most to them during this critical time. Therefore, it's imperative to educate ourselves and our loved ones about end-of-life care options to make informed decisions aligned with our values and preferences. At the end of the day, there is no right or wrong choice, and people must have the resources necessary to choose what is best for them.

Edited By: Radhika Subramani

Designed By: Ariha Mehta

Works Cited

[1] Wachterman MW, Luth EA, Semco RS, Weissman JS. Where Americans Die - Is There Really "No Place Like Home"? N Engl J Med. 2022 Mar 17;386(11):1008-1010.

Can (and Should) We Reverse Aging?

Aging has been a topic of both scientific and philosophical debate throughout history. In her book “Coming of Age”, the existentialist philosopher Simone de Beauvoir writes, “I am incapable of conceiving infinity, and yet I do not accept finity. I want this adventure that is the context of my life to go on without end.”[1] The tension between the finite nature of the human lifespan and the search for eternality is similarly reflected in aging research developments and the search for mechanisms of “reverse aging”.

Part of what makes aging fascinating is our lack of understanding of its causes. It is a universal, intrinsic process, yet is also forcibly influenced by exogenous conditions [2].  It is often associated with the passage of time, yet there is a difference between chronological age– how long a person has existed– and apparent biological age– how old a person’s cells actually appear to be [3]. This discrepancy has driven research into the biological mechanisms behind gaps in these two measures of age. Most of the many theories of aging that have emerged fall into two categories: program and damage theories [4]. Program theories are driven by natural selection, suggesting that a limited lifespan is deliberately programmed because of the evolutionary benefits that a shorter lifespan brings [4]. Damage theories emphasize the absence of natural selection acting post-reproduction, instead emphasizing the role of accumulated damage on a biochemical level [4]. While there is growing evidence for various versions of program and damage theory, the exact contributions of these different factors remain unknown.

As we increase our understanding of the drivers of biological aging, interest has developed in going a step further to reverse the aging process. While efforts to slow the aging process have been in progress for some time, recent groundbreaking studies have suggested the possibility of running aging in reverse. Two of the most promising age-reversal studies to date have taken different approaches, one aiming to chemically reprogram aged cells and the other focusing on eliminating them altogether. The former, published in 2023 by Yang et al., demonstrated that several chemical mixtures were able to restore epigenetic marks characteristic of youthful cells in a timeframe of less than a week [5]. In contrast, the latter, published earlier this year by Amor et al., demonstrated the ability of CAR T cells to target and destroy uPAR-positive senescent cells, a subset of cells that accumulates with age in humans [6]. While these recent scientific breakthroughs point to the possibility of targeting and reversing the mechanisms of aging in the lab, this work is still at an early stage and has not been received without criticism. In addition to a host of ethical considerations, there are also doubts about the ability to translate this research from the context of cells to humans. Jesse Kurland, an aging researcher at the University of Colorado Boulder, points to the complications associated with such research, stating that he finds it “hard to imagine how a process that disrupts our tissues universally in such complex ways, and in fundamental cellular processes like transcription (the process in which information in a strand of DNA is copied into a new molecule of messenger RNA), could be fixed by altering one, or even handfuls, of genes” [7]. 

While our ability to reverse aging outside of the laboratory is not yet a reality, the scientific foundations have been laid, meaning that we are now able to envision the “imperceptible infinity” presented by de Beauvoir like never before. But as progress is made on scientific questions around aging, ethical questions arise around the implementation of reverse aging therapies. A series of logistical questions arise, such as the prospect of exacerbating the existing problem of overpopulation, as well as concerns around access across various income and country lines [8]. There is also a series of larger moral and philosophical questions around extending lifespan, such as the theory that the existence of a finite end provides meaning and motivation, and that changing our relationship to death could fundamentally alter the human experience. While the possibility of reversing aging is exciting and commands attention from a scientific perspective, an equally rigorous consideration must be given regarding the ethics of translating these breakthroughs into the clinic.

Designed By: Makayla Gorski

Edited By: Angie Huang

References

[1] De Beauvoir, Simone. The Coming of Age. New York, Putnam, 1972.

[2] Borrás C (2021) The Challenge of Unlocking the Biological Secrets of Aging. Front. Aging 2:676573. doi: 10.3389/fragi.2021.676573. 

[3] “What Is Your Actual Age?” Northwestern Medicine, www.nm.org/healthbeat/medical-advances/science-and-research/What-is-Your-Actual-Age.

[4] Da Costa, João Pinto et al. “A synopsis on aging-Theories, mechanisms and future prospects.” Aging research reviews vol. 29 (2016): 90-112. doi:10.1016/j.arr.2016.06.005. 

[5] Yang J, Petty CA, Dixon-McDougall T, Lopez MV, Tyshkovskiy A, Maybury-Lewis S, Tian X, Ibrahim N, Chen Z, Griffin PT, Arnold M, Li J, Martinez OA, et al. Chemically induced reprogramming to reverse cellular aging. Aging (Albany NY). 2023 Jul 12; 15:5966-5989 . https://doi.org/10.18632/aging.204896.

[6] Amor, C., Fernández-Maestre, I., Chowdhury, S. et al. Prophylactic and long-lasting efficacy of senolytic CAR T cells against age-related metabolic dysfunction. Nature Aging (2024). https://doi.org/10.1038/s43587-023-00560-5. 

[7] Sauer, Rachel. “Bad News for Boomers: There’s No Magic Cure for Aging.” Colorado Arts and Sciences Magazine, University of Colorado Boulder, 27 July 2023, www.colorado.edu/asmagazine/2023/07/27/bad-news-boomers-theres-no-magic-cure-aging.

[8] Steele, Andew. “Science Says We Could ‘Cure’ Ageing. but Should We?” Polytechnique Insights, Institut Polytechnique de Paris, 20 Sept. 2022, www.polytechnique-insights.com/en/columns/health-and-biotech/science-says-we-could-cure-ageing-but-should-we/.

“To Let Go or To Hold On?” Navigating the ethics of DNRs

In 2018, Andy Jurtschenko received a standard procedure: a heart transplant (1). But after 24 hours, Jurtschenko hadn’t woken up. After investigation by a neurologist, Andy was found to have suffered immense brain damage and would likely remain in a vegetative state for the rest of his life. Faced with a difficult decision, Andy’s children requested a do-not-resuscitate order (DNR), which mandates physicians must not administer emergency care if one’s heart stops beating or breathing ceases (2). Yet, the primary physicians declined their request only eventually relenting after immense pushback. Later, Andy recovered consciousness – but in limited form. Andy’s story is one of many that reveals the ethical dilemmas of DNRs. 

DNRs do not allow for resuscitative treatment, such as CPRs, defibrillators, and the delivery of certain drugs in the event of cardiac or respiratory arrest (3). While in-hospital DNRs affect the decisions of physicians, out-of-hospital DNRs apply to EMTs. Though different from physician-assisted euthanasia, where physicians actively induce death, like euthanasias, DNRs have significant ethical and legal complications.

Legally, DNRs lack legislation and policies regarding administration and decision-making. Within the U.S., DNRs require the explicit signature of a physician in order to be issued. Typically, those with terminal illnesses request DNRs, although fully healthy individuals can also do so. Ethically, DNRs pose a challenging question to healthcare providers, physicians, and patients. The American Medical Association ambiguously states that patients have the right to reject care, while doctors can also reject certain needs on a reasonable basis (4). But this oxymoronic statement leads to great debate in the medical community about whether DNRs are examples of withdrawing or withholding care. These debates lead to the pivotal questions: Are DNRs a form of passive euthanasia? Subsequently, with euthanasia being entirely outlawed in the U.S., should DNRs be illegal as well? Importantly, how do you consider patient autonomy? As seen in the story of Andy, if a patient is not mentally capable of making a decision, who makes the decision for them? With no clear guidelines for decision-making in DNRs, if a patient is incapable, conflict between the wishes of family members and friends can certainly occur, as it did with Terri Schiavio’s case in 2005 (5).

Lastly, there are also significant moral complications with doctors taking advantage of DNR orders. Investigations have found that during the height of the covid-19 pandemic, many doctors sought to impose illegal DNR orders on those with learning disabilities – also known as a blanket DNR that targets a certain group of people (6). Samuel R. Bagenstos, a law professor at Michigan Law School, best stated the implications of such actions as “caus[ing people with disabilities] to experience less full lives” (7).

Ultimately, as emergency and medical care continue to improve, the complexities behind DNRs will only become more dynamic. Thus, medical professionals and ethicists must continue to thoroughly evaluate this dilemma.

Reviewed by Bowen Kim

Design by Ting Ting Li

Citations

1. Chen, C. (2019, December 31). The family wanted a do not resuscitate order. the doctors didn’t. ProPublica. https://www.propublica.org/article/the-family-wanted-a-do-not-resuscitate-order-the-doctors-didnt 

2. U.S. National Library of Medicine. (n.d.). Do-not-resuscitate order: Medlineplus medical encyclopedia. MedlinePlus. https://medlineplus.gov/ency/patientinstructions/000473.htm 

3. Miceli, M. (2016). Bioethics in practice: Unilateral do-not-resuscitate orders. U.S. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896650/#:~:text=The%20answer%20is%2C%20generally%2C%20no,of%20cardiac%20or%20respiratory%20arrest. 

4. 31, J., & Jr., J. R. (2023, January 31). Physicians, not judges, should direct patient care. American Medical Association. https://www.ama-assn.org/about/leadership/physicians-not-judges-should-direct-patient-care#:~:text=Physicians%20are%20expected%20to%20provide,of%20medical%20treatment%20or%20intervention. 

5. Weijer, C. (2005). A death in the family: Reflections on the terri schiavo case. Canadian Medical Association Journal, 172(9), 1197–1198. https://doi.org/10.1503/cmaj.050348 

6. Alexiou, G. (2023, September 12). Doctors issuing unlawful “do not resuscitate” orders for disabled Covid patients “outrageous.” Forbes. https://www.forbes.com/sites/gusalexiou/2020/06/23/unlawful-do-not-resuscitate-orders-for-disabled-covid-patients-outrageous/?sh=3079ecdc6cf1 

7. Ibid.