Life has been described as being.

Life has been described as being, in many ways, a river: "God makes the rivers to come They tire not, nor do they cease from flowing. May the river of my life result into the sea of like that is the Lord." (1) Or as being a journey: "Life is a journey from the cradle to the grave and beyond, and back to the cradle and in succession from life to life." (2) We do our best to help our patients choke the obstacles during this journey that are pos by means of various illnesses and accidents. We make them better, and forward they go with their travels. still as the patient nears the expiration of this journey, our focus changes. The intent at that time is not to restoration but to palliate; not to be a absolute academician, but to be a sensitive and compassionate physician who look up tos the dignity of the patient and family, and their fight to refuse treatment. (3) It has been said that "a religious physician knows the difference between postponing death and prolonging the act of dying." A physician who has understood and assimilated this advice will be able to provide eminent care to his patients as they approach the completion of life. Dr. Roger Bone who has written poignantly about his concede experience with the process of dying, in his guide entitled Reflections (4) has said: "Dying can be a peaceful fact or a great agony when it is inappropriately sustained according to life support."

When the patient reaches the completion of his journey, and life as we know degenerations out of the body, we are faced with different emblems of puzzling questions and painful decisions. Should you or should you not revive this patient? Who makes that decision: the patient, the family, or the physician? Besides the patient, who besides has the moral and legal fight to make this sensitive and irrevocable decision? Should this decision take into consideration the patient's age and the token of underlying disease? Should sumptuousness ever be one of the considerations? What should a physician do, if, in his long head it would be futile to resuscitate the patient, unless a do-not-resuscitate (DNR) directive was in no degree signed or is not available in an pinch or if the family wants "everything to be done"?

In this issue of CHEST, Kelly and colleagues (see page 957) have sought to answer individual of these questions. In a questionnaire, they neared 20 clinical vignettes based onward their actual cases and asked the physicians to quantify the hardness of their opinions on discussing and recommending DNR orders. They fix that pulmonary/critical-care medicine physicians were significantly likely to make acceptable DNR orders more strongly than were cardiologists, house staff, and general internists. Among the house staff, the likelihood of recommending a DNR order correlated significantly with increasing years of experience. Thus, it appears that the solidity of DNR order recommendations vary with the specialty training and the experience of the physicians. Mebane and colleagues, (5) in a mailed scrutinize of 280 white and 157 black physicians, establish that with regard to physicians' choices for future treatment for themselves, for a persistent-vegetative-state scenario black physicians were more than six times more likely than white physicians to entreaty aggressive treatments (ie, cardiopulmonary resuscitation [CPR] mechanical ventilation, or artificial feeding for themselves [154% v 25% respectively; p < 0001]) In a overlook of Japanese physicians in Japan and of Japanese-American physicians in the United States, Asai and colleagues (6) establish that Japanese-American physicians were les likely to approve CPR for their patients or for themselves compared to the Japanese physicians. Another factor that be seens to affect end-of-life decisions is the status of the attending physician. Kollef (7) build that patients who were cared for at a university-based ICU attending physician, compared with patients who had a private attending physician (either community-based or university-based), were more likely to meet with the active withdrawal of life-sustaining treatment.

The decisions pertaining to end-of-life care obviously would be made by means of the physician in consultation with the patient and the family. The physician, however, needinesss to remember that there are numerous factors that influence the patient and families' attitudes and decisions in this regard. an of the strongest factors look to be the underlying disease and its prognosis, and race or ethnicity. Frankl and colleagues, (8) in a overlook of 200 medical inpatients, raise that life support was desired in 90% of the patients if their health could be restored to its usual horizontal in 30% if they would be unable to care for themselves after hospital discharge, in 16% if their chance for recruiting was hopeless, and in barely 6% if they would remain in a vegetative state. Caralis et al, (9) in a inspect of 139 respondents, found that more African-Americans (37%) and Hispanics (42%) compared to non-Hispanic whites (14%) wanted their doctors to hold fast them alive regardless of for what reason ill they were. Shepardson and colleagues, (10) in their sample of 90821 consecutive admissions to 30 hospitals, also plant that the rate of DNR orders was lower in African Americans than in whites (9% v 18% respectively; p < 0001) Wenger and colleagues,n in an observational cogitation of 14,008 hospitalized Medicare patients, place that DNR orders were assigned to 116% After adjustment for patient and hospital characteristics, DNR orders were assigned more oftentimes to women and patients with dementia or incontinence and were assigned les oftentimes to black patients, patients with Medicare insurance, and patients in rural hospitals. Vaughn and colleagues (12) also rest that race plays a part in these choices. Japanese residents of an Asian nursing abode were more likely to be "no code" (ie, CPR would not be initiated upon cardiac arrest), while controlling for age, comorbidity, form relative to sex and religion, whereas Chinese residents were more likely to be "full code" (ie, CPR would be initiated upon cardiac arrest). Authors attributed this difference to social values and cultural differences. Tulsky et al, (13) forward the other hand, found no relationship between ethnicity and the demeanor of a DNR order, on a level after adjustment for covariates and separate analyses for patients who died in the hospital v those who were discharged from the hospital alive. Hopp and Duffy (14) in their examine of 454 whites and 86 blacks raise that whites were significantly more likely than blacks to discuss treatment predilections before death, to complete a living will, and to designate a durable power of attorney for health care. The treatment decisions for whites were more likely to involve withholding or limiting treatment, whereas for blacks the treatment decisions were more likely to be based forward the desire to provide all care possible in order to continue lengthen in time life.

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