T h e subject of terminal care for any patient is a matter of acute concern. Human, moral, economic, and educational concerns are among the more obvious issues affecting the health-care system and society as a whole in the present stage of expanding technology and shrinking health-care dollars. The paper in this issue that investigates the problems of patients with terminal cancer of the head and neck is important both for the subject matter and for areas that are not discussed but should also be considered. In the process of gathering important data about the end of life for 60 people, the authors reported a number of significant facts. For example, the average survival time for the 60 patients was 17.2 months, 4 of which were spent in the hospital, and 86% of the patients died during a final hospitalization period which averaged 68 days. At initial diagnosis, 90% of the patients had advanced disease; after the onset of symptoms, patients delayed an average of 5 months before seeking treatment. The authors mention that emotional, cognitive, economic, and social factors may contribute to the reasons for potentially fatal delay in seeking treatment. Since they tabulated many aspects of the patients' disease with care, one might also wish to tabulate the costs, monetary and human, of 4 months of hospitalization, extensive treatment, and a preponderance of pain, mutilation, social isolation, and ultimate death. In the large, state-supported research and treatment facility where the study was done, the records show that ". . . emotional and psychologic problems were not well documented." However, depression was noted in 30% of the patients, nervousness was seen in 15%, and less frequent concerns such as "paranoia" and "fear of death" were also observed. My clinical experience suggests that 70% of the depressed and 85% of the anxious patients were misdiagnosed, ignored, or diagnosed but not recorded. Although surgery, radiation, and chemotherapy were carefully noted, specific attempts to treat the emotional, psychologic, social, and economic problems were not noted. They should have been included.
A t one time or another, 18.3% of the patients refused treatment. Surgical measures were the modality most often refused. The refusers, defined as "noncompliant," survived 4.3 months less than the compliant patients. Given the recorded pain and suffering and enormous additional costs generated by the compliant patients, it seems to me that the authors should raise the question of whether compliance with the treatment regimens offered is in either the patients' or the public's interest, since the state and probably the federal governments pay for the majority of the care. It would be important to know the patients' wishes for treatment given an informed understanding of what awaited them as a consequence of the efforts made in their behalf.