Wednesday, October 9, 2013

A US Export: End-of-Life Guidelines

Name the American physician-author whose checklist has been adopted in the United Kingdom for end-of-life medical care.

Did you guess Atul Gawande? The Brigham & Women’s surgeon and author (“The Checklist Manifesto,” etc.) would have been my guess, especially as he’s collaborating on that subject with palliative specialist Dr. Susan Block, also of the Brigham.

But the correct answer is Monica Williams-Murphy. If that’s a surprise, it should be a pleasant surprise.

Indeed, it’s good to see that Williams-Murphy’s work is gaining recognition and influence.

Williams-Murphy co-authored the book “It’s OK to Die” (see review) and blogs at That is, when she’s not practicing emergency medicine in Huntsville, Alabama.

The essays and guidelines in both the book and blog are significant contributions to the literature of medical care at the end of life. Hers is an especially important voice for two reasons.

One, she’s an emergency physician, and for better or worse, the emergency room is where the poor and uninsured go for their care. Also, ER physicians regularly have the thankless task of diagnosing and treating urgent health problems with little or no knowledge of the patient or the patient’s values.

Perhaps more important, at least politically, is that Williams-Murphy is not from Massachusetts or another so-called Blue State. She practices in Alabama, politically as Red as a state can get. 

I’ve got nothing against Boston doctors. They’re among the best anywhere, and some of them saved my daughter’s life. I consider it a privilege of living in Brookline, Massachusetts that I’m in walking distance of Children’s Hospital Boston and several world-class centers of care and healing.

But there’s no denying that Harvard Medical carries elitist baggage with some of the American public. And maybe this exposes a bias on my part, but an elitist tag is not a problem for an emergency physician in Huntsville, Alabama. Geography gives Williams-Murphy credibility. That she has something important to say helps, too.

So I considered her place of practice notable when I first read “It’s OK to Die.” And I was glad to read this week that Norfolk & Suffolk Palliative Care Academy in the United Kingdom has adapted her guidelines in creating its online resource at

Be ready for it will help you to talk openly about dying and plan ahead so that you can make the right choices about end of life care,” the website says.

Another positive in this: The launch of follows by only a couple of months the demise of the Liverpool Care Pathway for the Dying Patient. That effective, hospice-inspired framework for end-of-life care in the United Kingdom was hurriedly implemented and poorly communicated in some locations and was blamed for patient neglect that led to early deaths. It is now being phased out, and dismissed by some as “tick-box medicine.” 

The solution to disputes over care is in more dialogue, not less, among families, communities, and doctors and patients. In this, a well-considered checklist can be helpful.

In her book, Williams-Murphy agrees with the American Medical Association “that there is no good reason to either allow or cause unnecessary suffering at the end of life. Sadly, we have arrived at a place in American history where this unnecessary suffering is too frequently occurring.”

The collaboration between and Dr. Williams-Murphy is a welcome sign that the checklist isn’t going away.


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