Tennessee End of Life Report

The Tennessee End of Life Report is produced by students and a faculty member at Sewanee: the University of the South in order to understand and evaluate the process Tennesseeans go through while dying. The inspiration of the report is the Last Acts report "Means to a Better End," which ranks Tennessee from average to poor in every aspect of end of life care assessed. In this report, we seek to update and analyze the Tennessee data used in Last Acts and draw appropriate conclusions about how well Tennesseeans fare at the end of their lives.

The last Acts investigators are fully aware of the problems in some of the methods they employed, but ask that there efforts should be seen as prompting discussions of end of life issues. We are fully aware of the limits of our own analysis here and put forth our report in the same spirit. This is our first pass at a difficult topic. We intend to revise our report as our investigation of these issues proceeds in future years. We welcome comments on how we have done and suggestions of how to correct our reasoning and improve our inquiry into how well people die in Tennessee.

Jim Peterman
Teacher and Research Collaborator
Philosophy 235, Medical Ethics
Department of Philosophy
The University of the South
Sewanee, TN 37383
jpeterma@sewanee.edu

• The statistics Last Acts used to generate its report cards are sometimes incomplete. (See Question 3.)

•Even when the statistics are complete, they do not show what Last Acts claims they show. (See Questions 2, 4, 5, 6, and 7.)

•Last Acts presupposes a substantial, but overly simple picture of what a good death consists of. (See Questions 2, 4, 5, and 8.)

•In attempting to arrive at a nationwide evaluation scheme, Last Acts ignores possible differences between rural and urban medical practice that may affect the outcome of evaluations of local practices. (See Questions 4, 5, and 8.)

•An important determinant of whether people die well may be better examined in terms of how far they understand their options about how and where to die and exercised their autonomy in choosing what would be for them the best way to die given their preferences and life circumstances. (See Questions 2, 3, and 5.)

•An important determinant of whether people die well is whether their medical care givers understand the various options available to their patients and the best practices for caring for dying patients. (See Questions 3, 5, 6, 7, and 8.)

•Policy may have no direct relationship to success of practices. (See Question 7.)

•Public opinion polls are inadequate measures of preference about location and circumstances for one's death and dying. (See Question 2.)

What does all of this mean?

These issues need much additional investigation. Nevertheless, if these findings are reasonable, it may be that Last Acts has approached the problem of evaluating how well people die in the United States in the wrong way. Whether a person dies well cannot be addressed simply in terms of the laws and policies in the state, specific outcomes, formal programs, and public opinion polls. The question of whether someone dies well is a question about a complex set of particular circumstances and facts. Key to this success is whether or not the dying person dies in, what is for him or her, the right place and the right way. In order to maximize the chances for such success, communities must engage in ongoing education of the community about end of life issues and help patients and families find their own best path. Central to those discussions will be the question--that Last Acts does not adequately address--of what makes for a good death for an individual in the specific circumstances he or she finds herself in at the point at dying--and what makes for a community that helps its members achieve this.

Of course, it does not follow from this analysis that it is unimportant to address the specific problems that Last Acts clarifies. Our point is just that they may have caused us to focus too much an tangential questions: The central question they should have asked is how many communities in each state support sustained education and reflection about end of life issues and in doing so improve the chances that dying patients and their families will be able to choose the circumstances for their dying that is, all things considered, optimal for them. In fact, only when most communities support this type of discussion can we even start to address most of the rest of their questions. For until we know what is optimal in each case, we cannot begin to determine if the location of death data for a in particular reveal a problem.

In the section, "Last Acts Update" (accessed by clicking on the "Last Acts Update" button in the left margin), we report on the eight different aspects of end of life featured in Lat Acts' "Means to a Better End." By clicking on the link, you will see a report on the Tennessee data provided in the Last Acts' report card, along with the more recent data we have provided, and a summary of our analysis of Last Acts' evaluation.

Each analysis contains additional links that provide detailed argumentation that supports our findings.

In the section, "Advance Directives," we provide links to useful web sites on what advance medical directives are, why they are important, and how to access advance medical directives that are legally valid in Tennessee.

In the section, "DNR Basics," we provide useful links for making decisions about "Do Not Resuscitate" orders.