Death Comes As The End

There's been a lot of talk about end-of-life counseling, but what does it mean?  Helping people to write a living will, or doing something a little blunter, like highlighting the downsides of aggressive treatment?  This New York Times article follows a palliative care doctor.  It's good, but also troubling.  It's not clear to me that the patient is better informed about their disease; indeed, the main patient the article follows is never informed that she's dying.  The palliative care doctors listens to what the patient is "really" saying, which sounds uncomfortably like old-style 1950s paternalism.

I wonder if it's possible to do this sort of thing in any kind of a neutral way.  Doctors have clear preferences about what to do; some of them want to treat aggressively and optimistically, while others are horrified by the sight of people dying with tubes in them.  The problem is, the doctors who go into palliative care are sort of definitionally disposed against extreme intervention.  Maybe extreme interventions are useless.  But it seems like the sort of decision patients should make, not their doctors.

On the other hand, patients might well be better off in some utilitarian sense not knowing.  Some of the bias towards aggressive treatments comes from elderly patients who see medical dramas and think that, for example, people can easily be shocked back to life.  Telling them that this doesn't work as often in real life as it does on TV, and that it is less likely to work on an elderly patient than a young one, is valuable information.  But at what point does valuable information shade over into scaring the hell out of someone at an already emotionally vulnerable time?