The limitations of protocols for end-of-life care

The basic goal of practice protocols for end-of-life care is to guide clinicians toward individualized care of dying patients. The contemporary impetus for such protocols arises from the well-documented past clinical practices of direct infliction of harm on dying patients, typically through pointless pursuit of aggressive curative therapies, or abandonment of patients, typically through inattention to physical and psychological suffering. Remedial efforts protocols cannot be effective, however, unless powerful irrational impulses that accompany imminent death are acknowledged and addressed. These impulses cloud rational judgment, inspire a sense of "wrongfulness" and "wrongdoing" about death and can readily lead clinicians to new, though disguised, versions of past harmful inflictions on patients. Typical practice protocols enunciate rationally-based directives for patient care; but insofar as these protocols restrict their attention to rational considerations, they will miss (and contribute to the perpetuation) of the irrational impulses that have obstructed prior professional efforts to serve patients' welfare.