Seven legal barriers to end-of-life care: myths, realities, and grains of truth

Barriers to providing palliative care and priorities for future actions to advance palliative care in Japan: a nationwide expert opinion survey

OBJECTIVES

Palliative care specialists are faced with extensive barriers to providing effective palliative care. We carried out a survey to identify existing barriers from the point of view of palliative care experts in Japan and determine the priorities for future actions to overcome these barriers.

METHODS

We conducted a cross-sectional mail survey in December 2004. We sent out 2607 questionnaires to members of the Japanese Society of Palliative Medicine and Hospice Palliative Care Japan. We asked all respondents two open-ended questions regarding barriers and future actions in the context of palliative care in Japan. In total, 426 questionnaires were returned (response rate of 16%).

RESULTS

We identified 95 different answers concerning barriers to providing effective palliative care. The three most frequent answers were "general medical practitioners' lack of interest, knowledge, and skills" (n = 203), "general population's lack of knowledge and misunderstandings about palliative care" (n = 122), and "general medical practitioners' failure to provide information and lack of communication skills" (n = 89). We identified 136 different answers concerning future actions required to improve palliative care. The three most frequent answers were "organize study sessions on palliative care or case conferences in hospitals" (n = 122), "provide information about palliative care to the general population" (n = 117), and "in undergraduate education, make palliative care a compulsory course" (n = 88).

CONCLUSIONS

We identified numerous barriers to providing effective palliative care, related to not only medical practitioners, but also economic factors and the general population. These findings suggest that to overcome these barriers, we need to take action on many fronts, including increasing social awareness and effecting political change, as well as addressing problems relating to practitioners. We prioritized the future actions. The most frequent urgent problems were identified. We hope that collaborative efforts by the relevant organizations will improve palliative care in Japan.

Moral dilemmas associated with the withdrawal of artificial hydration

Withholding artificial hydration from unconscious terminally ill patients is a complex phenomenon identified as terminal dehydration. Towards the end of a terminal illness it is acknowledged that a patient's desire for fluid and food diminishes, followed by a period of unconsciousness (McAulay, 2001). Inconsistent care philosophies produce divergent opinions and often diametrically conflicting treatments (Craig, 1994). Additionally, literature disputes the detrimental effects of dehydration; therefore, decisions pivot on legal and ethical considerations. Consequently, the viewpoints of the medical and nursing staff can vary; furthermore, recognition must be made to the psychological impact of the relatives. As terminal illness is boundless, all areas of healthcare can be affected. Further investigation into this dilemma is required to identify the most appropriate care management plan.

Medically related legal needs and quality of life in cancer care: a structural analysis

BACKGROUND

This study investigated the interface of medical and legal systems by empirically identifying and evaluating the relation of medically related legal needs and patient quality of life and by assessing the degree to which these needs were addressed in standard patient care.

METHODS

Medically related legal needs were identified in a focus group setting. These needs were subsequently sorted and rated by a sample of 50 mixed-site cancer patients (22 men and 28 women; mean age, 52 years) and subjected to multidimensional scaling and cluster analyses. Participants also rated each need in terms of the extent to which it was met in their medical care and the impact on their quality of life.

RESULTS

Participants identified 30 medically related legal needs. Multivariate analyses identified 4 distinct medical-legal domains: Health Care Related, Estate Related, Financial, and Employment Related. Participants rated these domains as exerting a significant impact on quality of life. Patients reported that that these needs were not met by their current medical or supportive care.

CONCLUSIONS

The present study identified a range of medically related legal needs of cancer patients. Despite their importance to patient quality of life, these needs were not met by standard medical and supportive care. Findings underscored the need to integrate legal resources into cancer care as an important component of interventions that enhance patient quality of life.

Art Intervention With Family Caregivers and Patients With Cancer

PURPOSE/OBJECTIVES

To describe the implementation and preliminary evaluation of an art intervention at the bedsides of patients with cancer and their family caregivers.

DATA SOURCES

Field notes from ongoing encounters with family caregivers and patients with cancer, research literature, and descriptions of other programs.

DATA SYNTHESIS

An "Art Infusion" intervention was developed and offered to family caregivers and patients with cancer during treatment at a comprehensive cancer center. Training of interventionists, timing and delivery of the intervention, and the availability of art activity choices were key factors in the intervention's success.

CONCLUSIONS

Family caregivers and patients with cancer are interested in and responsive to art interventions. Additional research is needed to quantify the effects.

IMPLICATIONS FOR NURSING

Art interventions enhanced and extended the scope of care for family caregivers and patients with cancer. Nurses are in key positions to establish, supervise, and promote such interventions.

Nephrologists’ Changing Practices in Reported End-of-Life Decision-Making

Because the dialysis patient population is increasingly composed of older patients with high symptom burden, shortened life expectancy, and multiple comorbid conditions, nephrologists often engage in end-of-life decision-making with their patients. In the 1990s, reported practices of nephrologists' end-of-life decision-making showed much variability. In part as a reaction to that variability, the Renal Physicians Association (RPA) and the American Society of Nephrology (ASN) developed a clinical practice guideline on end-of-life decision-making. To determine whether nephrologists' attitudes and reported practices had changed over time, survey responses from 296 nephrologists completing an online survey in 2005 were compared with 318 nephrologists who completed a similar mailed survey in 1990. In 2005, less variability was noted in reported practices to withhold dialysis from a permanently unconscious patient (90% would withhold in 2005 versus 83% who would withhold in 1990, P < 0.001) and to stop dialysis in a severely demented patient (53% in 2005 would stop versus 39% in 1990, P < 0.00001). In 2005, significantly more dialysis units were reported to have written policies on cardiopulmonary resuscitation (86% in 2005 versus 31% in 1990, P < 0.0001) and withdrawal of dialysis (30% in 2005 versus 15% in 1990, P < 0.0002); nephrologists were also more likely to honor a dialysis patient's do-not-resuscitate order (83% in 2005 versus 66%, P < 0.0002) and to consider consulting a Network ethics committee (52% in 2005 versus 39%, P < 0.001). Nephrologists' reported practices in end-of-life care have changed significantly over the 15 years separating the two surveys, suggesting that the development of the clinical practice guideline was worthwhile.

Quality of Death: Implantable Cardioverter Defibrillators and Proactive Care

OBJECTIVES

The purpose of this paper is to discuss quality of death (QOD) among patients with congestive heart failure (CHF) and implantable cardioverter defibrillators. We outline recommendations that enhance QOD from the device patient and specialty cardiology perspectives.

BACKGROUND

Contemporary treatment of CHF patients routinely includes both pharmacologic therapy and the use of cardiac devices. The implantable cardioverter defibrillator prevents premature death in heart failure patients, though not death itself.

CONCLUSIONS

Active discussion and consideration of patient's QOD is indicated in implantable cardioverter defibrillator patients to prevent unnecessary treatment and to increase control over perceived quality of life by patients and family.

Can we know what Terri Schiavo would have wanted?

What would Terri Schiavo have wanted? That remains an unanswered question for many who followed the media frenzy that attended the extraordinary court and legislative battles that preceded her death 13 days after her feeding tube was removed for the last time. What would she have directed her physicians to do if she had “miraculously” regained capacity and awareness of the consequences of her cardiac arrest that left her in a persistent vegetative state? Who would she have wanted to make that decision for her if she were unable to do so? How are we to understand the meaning of statements that she purportedly made about life-sustaining treatments approximately 20 years ago, and how can we apply them to the current situation? This article reflects on those questions from the perspective of two small exploratory studies. These studies considered the meanings and interpretation of statements by terminally ill patients concerning desire for hastened death and the relevance of previously made statements to their current clinical situation.

Ethical, political, and social aspects of high-technology medicine: Eos and Care

OBJECTIVE

We discuss biosocial aspects of high-technology medicine (HTM) to provide a global view of the current model of medicine in the developed world and its consequences.

METHODS

We analyze changes in the concept of death and in the use and cost of HTM. The consequences of HTM on the delivery of basic medical care within and among countries are discussed. Concepts derived from Greek mythology are used to illustrate the problems associated with HTM.

RESULTS

HTM can be extremely effective in individual cases, but it poses important bioethical and biosocial problems. A major problem is related to the possibility of manipulating the process of dying and the consequent alteration in the social concept of death, which, if not carefully regulated, risks transforming medicine into an expensive way of pursuing pointless dreams of immortality (myth of Eos). Another problem is related to the extraordinary amount of resources necessary for HTM. This model of medicine (which is practiced daily) has limited sustainability, can work only in highly developed countries, may contribute to unequal access to health care, and has negligible positive impact on global health and survival.

CONCLUSIONS

HTM poses very important biosocial questions that need to be addressed in a wider and transparent debate, in the best interest of society and HTM as well.

Knowledge and beliefs about end-of-life care and the effects of specialized palliative care: a population-based survey in Japan

To clarify the knowledge and beliefs of the Japanese general population related to legal options, pain medications, communication with physicians, and hydration/nutrition in end-of-life care, and to explore the associations between end-of-life care they had experienced and these beliefs, a questionnaire survey was conducted on two target populations: 5000 general population subjects and 866 bereaved family members of cancer patents who died in 12 palliative care units in Japan. The respondents were requested to report the legal knowledge about end-of-life options, pain-related beliefs, communication-related beliefs, and hydration/nutrition-related beliefs, and their experiences with end-of-life care. A total of 3061 responses were analyzed (effective response rate, 54%). The respondents were classified into six groups: no bereavement experience (n = 949), those who had lost family members within the past 10 years from noncancer diseases at institutions (n = 673), those who lost family members from noncancer disease at home (n = 264), those who lost family members from cancer at institutions other than palliative care units (n = 525), those who lost family members from cancer at home (n = 86), and those who lost family members from cancer at palliative care units (n = 548). Across groups, 32-45% and 50-63% of the respondents stated that treatment withdrawal and double effect act were legal, respectively. Between 34% and 44% believed that cancer pain is not sufficiently relieved, 27-38% believed that opioids shorten life, and 24-33% believed that opioids cause addiction. Communication-related beliefs potentially resulting in barriers to satisfactory end-of-life discussion were identified in 31-40% ("physicians are generally poor at communicating bad news") and in 14-25% ("physicians are not comfortable discussing death"). The bereaved family members of the patients who died in palliative care units were significantly more likely than the other groups to believe that cancer pain is sufficiently relieved, and significantly less likely to believe that opioids shorten life, that opioids cause addiction, that physicians are generally poor at communicating bad news, and that physicians are uncomfortable discussing death. Between 33% and 50% of the respondents, including families from palliative care units, believed "artificial hydration should be continued as the minimum standard until death," while 15-31% agreed that "artificial hydration relieves patient symptoms." A significant proportion of the Japanese general population has beliefs about legal options, pain medications, and communication with physicians that potentially result in barriers to quality end-of-life care. As their experiences in specialized palliative care significantly influenced their belief, systematic efforts to spread quality palliative care activity are of value to lessen these barriers and achieve quality end-of-life care.

Who Is Dying in Our Critical Care Units?

Are deaths that occur in critical care expected or unexpected? The objective was to illustrate the incidence of deaths in adult critical care units. We also wanted to discover if our patient population fit the norm of those who die in these units in the United States. Are the patients with many comorbid conditions? Could they benefit from advance care planning? A prospective chart review was completed on all deaths that occurred in our 5 critical care units. Most deaths (76.6%) were expected. Patients had an average of 3.3 comorbidities. Greater public knowledge about advance care planning is needed and must include education about the full range of options in end-of-life care.

Medical and ethical aspects of long-term enteral tube feeding

Clinicians frequently care for patients in whom long-term enteral tube feeding is being considered. The substantial increase in the use of endoscopically placed tubes for long-term feeding reflects the aging population, advances in medicine and technology, and inadequate advance care planning. Physicians should address advance care planning with all patients at the earliest opportunity. Prospective randomized trials measuring clinical outcomes for patients receiving long-term tube feeding are understandably limited. In addition, confusion regarding medical and ethical guidelines for long-term tube feeding often exists among clinicians, patients, and surrogate decision makers. Therefore, we discuss the physiology and clinical tolerance of limited oral nutritional intake, the prevalence of and Indications for long-term tube feeding, the endoscopic procedures and their complications, the reported medical and quality-of-life outcomes, and the critical importance of advance care planning. We present our multidisciplinary approach that combines medical, nutritional, and ethical principles for the care of these patients.

Palliative and End-of-Life Care for Patients With Cardiopulmonary Diseases

Acute and chronic pulmonary and cardiac diseases often have a high mortality rate, and can be a source of significant suffering. Palliative care, as described by the Institute of Medicine, "seeks to prevent, relieve, reduce or soothe the symptoms of disease or disorder without effecting a cure... Palliative care in this broad sense is not restricted to those who are dying or those enrolled in hospice programs." The American College of Chest Physicians strongly supports the position that such palliative and end-of-life care of the patient with an acute devastating or chronically progressive pulmonary or cardiac disease and his/her family should be an integral part of cardiopulmonary medicine. This care is best provided through an interdisciplinary effort by competent and experienced professionals under the leadership of a knowledgeable and compassionate physician. To that end, it is hoped that this statement will serve as a framework within which physicians may develop their own approach to the management of patients requiring palliative care.

Beyond autonomy: diversifying end-of-life decision-making approaches to serve patients and families

Efforts to improve end-of-life decision-making quality have emphasized the principle of individual autonomy to better ensure that patients receive care consistent with their preferences. This principle has primarily been defined through court decisions during the past 3 decades as a patient's right to refuse medical technologies and avoid life-prolonging treatments. However, autonomy as traditionally defined only serves a small segment of dying patients. Patients might not value autonomy or consider autonomy important but define it differently than decision-making self-determination. Some patients also think in terms of their care goals rather than individual treatment preferences. Patients' functional and cognitive abilities, age, racial and ethnic backgrounds, and desire to avoid burdening loved ones may influence attitudes and definitions regarding autonomy. To improve end-of-life decision-making for an increasingly multicultural and aging population, the following priorities should be set: (1) Increase the flexibility of advance care planning and decision-making strategies used with capable patients to encompass diverse perceptions of autonomy; and (2) Improve communication between physicians and patients' families when patients lack decision-making capacity to facilitate decision-making and address families' emotional burdens. The goal of these priorities is to promote understanding of patients' and families' decision-making preferences and goals and to minimize decision-making burdens on families.

Withdrawal of life-sustaining low-burden care

A 90-year-old diabetic man with unreconstructable peripheral vascular disease, end-stage chronic obstructive pulmonary disease, relentless ischemic rest pain, and severe disability returns to your clinic asking you to deactivate his implanted pacemaker. To do so would likely precipitate his demise, and you ask him if he is aware of this. He tells you that he is and that he has been considering this request since he last saw you 3 months ago. Relief of his chronic pain would require bilateral hip-disarticulating amputations, procedures with a prohibitively high operative mortality rate, particularly with his age and comorbidities. He has been evaluated by a psychiatrist and found to be mentally competent. His treatment by a pain specialist, who used his full armamentarium of high-dose narcotics, electronic devices, nerve blocks, and psychological techniques, has been unsuccessful. You do not reside in Oregon. What is your most ethical course of action?

Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil

OBJECTIVES

To study the possible change on mode of deaths, medical decision practices, and family participation on decisions for limiting life-sustaining treatments (L-LST) over a period of 13 yrs in three pediatric intensive care units (PICUs) located in southern Brazil.

METHODS

A cross-sectional study based on a retrospective chart review (1988 and 1998) and on prospective data collection (from May 1999 to May 2000).

SETTING

Three PICUs in Porto Alegre, southern Brazilian region.

PATIENTS

Children who died in those PICUs during the years of 1988, 1998, and between May 1999 and May 2000.

RESULTS

The 3 PICUs admitted 6,233 children during the study period with a mortality rate of 9.2% (575 deaths), and 509 (88.5%) medical charts were evaluated in this study. Full measures for life support (F-CPR) were recognized in 374 (73.5%) children before dying, brain death (BD) was diagnosed in 43 (8.4%), and 92 (18.1%) underwent some limitation of life support treatment (L-LST) There were 140 (27.5%) deaths within the first 24 hrs of admission and 128 of them (91.4%) received F-CPR, whereas just 11 (7.9%) patients underwent L-LST. The average length of stay for the death group submitted to F-CPR was lower (3 days) than the L-LST group (8.5 days; p < .05). The rate of F-CPR before death decreased significantly between 1988 (89.1%) and 1999/2000 (60.8%), whereas the L-LST rose in this period from 6.2% to 31.3%. These changes were not uniform among the three PICUs, with different rates of L-LST (p < .05). The families were involved in the decision-making process for L-LST in 35.9% of the cases, increasing from 12.5% in 1988 to 48.6% in 1999/2000. The L-LST plans were recorded in the medical charts in 76.1% of the deaths, increasing from 50.0% in 1988 to 95.9% in 1999/2000.

CONCLUSION

We observed that the modes of deaths in southern Brazilian PICUs changed over the last 13 yrs, with an increment in L-LST. However, this change was not uniform among the studied PICUs and did not reach the levels described in countries of the Northern Hemisphere. Family participation in the L-LST decision-making process has increased over time, but it is still far behind what is observed in other parts of the world.

Ethical issues in palliative care

OBJECTIVES

To review important issues that address respect for patient autonomy, beneficnce, non-maleficence, and justice, which are included in communication surrounding the determination of decision-making capacity, informed consent, breaking bad news, and creating shared goals of care.

DATA SOURCES

Review articles, and government and organizational reports.

CONCLUSION

Palliative care and its proximity to end-of-life care issues frequently raises ethical issues for patients, their families, and the clinicians caring for them. Supporting the identification and honoring the patient's preferences for treatment are central components of ethical behavior.

IMPLICATIONS FOR NURSING PRACTICE

Advance care planning provides an important opportunity for respecting patient autonomy and may be helpful when discussing care options surrounding resuscitation, withholding or withdrawal of treatment, or the determination of medical futility.

Under what conditions is euthanasia acceptable to lay people and health professionals?

Euthanasia is legal only in the Netherlands and Belgium, but it is on occasion performed by physicians elsewhere. We recruited in France two convenience samples of 221 lay people and of 189 professionals (36 physicians, 92 nurses, 48 nurse's aides, and 13 psychologists) and asked them how acceptable it would be for a patient's physician to perform euthanasia in each of 72 scenarios. The scenarios were all combinations of three levels of the patient's life expectancy (3 days, 10 days, or 1 month), four levels of the patient's request for euthanasia (no request, unable to formulate a request because in a coma, some form of request, repeated formal requests), three of the family's attitude (do not uselessly prolong care, no opinion, try to keep the patient alive to the very end), and two of the patient's willingness to undergo organ donation (willing or not willing). We found that most lay people and health care professionals structure the factors in the patient scenarios in the same way: they assign most importance to the extent of requests for euthanasia by the patient and least importance (the lay people) or none (the health professionals) to the patient's willingness to donate organs. They also integrate the information from the different factors in the same way: the factors of patient request, patient life expectancy, and (for the lay people) organ donation are combined additively, and the family's attitude toward prolonging care interacts with patient request (playing a larger role when the patient can make no request). Thus we demonstrate a common cognitive foundation for future discussions, at the levels of both clinical care and public policy, of the conditions under which physician-performed euthanasia might be acceptable.

Parental role in medical decision-making: fact or fiction? A comparative study of ethical dilemmas in French and American neonatal intensive care units

Neonatal intensive care has been studied from an epidemiological, ethical, medical and even sociological perspective, but little is known about the impact of parental involvement in decision-making, especially in critical cases. We rely here on a comparative, case-based approach to study the parental role in decision-making within two technologically identical but culturally and institutionally different contexts: France and the United States. These contexts rely on two opposed models of decision-making: parental autonomy in the United States and medical paternalism in France. This paternalism model excludes parents from the decision-making process. We investigate whether parental involvement leads to different outcomes from exclusively medically determined decisions or whether "technological imperatives" outplay all other factors to shape a unique, 'medically optimal' outcome. Using empirical data generated from extensive ethnographic fieldwork, in-depth interviews with 60 clinicians and 71 parents and chart review over a year in two neonatal intensive care units (one in France and one in the US), we analyze the factors that can explain the observed differences in decision-making in medically identical cases. Parental involvement and the legal context play a less role than physicians' differential use of certainty versus uncertainty in prognosis, a conclusion that corroborates the fact that medical control over ethical dilemmas remains even in the context of autonomy. French physicians do not ask parents permission to withdraw care (as expected in a paternalistic context); but symmetrically, American neonatologists (despite the prevailing autonomy model) tend not to ask permission to continue. The study provides an analysis of the making of "ethics", with an emphasis on how decisions are conceptualized as ethical dilemmas. The final conclusion is that the ongoing medical authority on ethics remains the key issue.

Ethical issues in geriatrics: a guide for clinicians

Because of demographic trends, it is reasonable to expect that clinicians will care for an increasing number of elderly persons with challenging medical and psychosocial problems. These problems and issues, in turn, may lead to daunting ethical dilemmas. Therefore, clinicians should be familiar with ethical dilemmas commonly encountered when caring for elderly patients. We review some of these dilemmas, including ensuring informed consent and confidentiality, determining decision-making capacity, promoting advance care planning and the use of advance directives, surrogate decision making, withdrawing and withholding interventions, using cardiopulmonary resuscitation and do-not-resuscitate orders, responding to requests for interventions, allocating health care resources, and recommending nursing home care. Ethical dilemmas may arise because of poor patient-clinician communication; therefore, we provide practical tips for effective communication. Nevertheless, even in the best circumstances, ethical dilemmas occur. We describe a case-based approach to ethical dilemmas used by the Mayo Clinic Ethics Consultation Service, which begins with a review of the medical indications, patient preferences, quality of life, and contextual features of a given case. This approach enables clinicians to identify and analyze the relevant facts of a case, define the ethical problem, and suggest a solution.

The ethics of withholding/withdrawing nutrition in the newborn

The provision of nutrition and hydration to newborn infants is considered fundamental care. For premature and critically ill newborns, similar considerations generally hold true. Nutrition may be provided for these infants using assisted measures such as parenteral nutrition or tube feedings. However, for some newborn infants the provision of medically assisted nutrition may be a more complicated issue. In particular, the goals of nutrition need to be clearly elaborated for newborns with lethal conditions or for whom appropriately administered intensive care is unsuccessful in sustaining life. These infants may benefit from palliative measures of care and a limitation or withdrawal of burdensome or nonbeneficial interventions. This article explores issues pertinent to deciding and communicating the appropriate withdrawal of medically assisted nutrition and implementing palliative comfort measures.

Telephone Support for Caregivers of Patients With Cancer

Caregivers have complex needs as they care for a loved one with cancer at the end of life. The objective of this pilot study was to determine the feasibility of conducting a brief telephone intervention, Tele-Care II, for caregivers of hospice patients. Guided by Hogan's Model of Bereavement, nurse interventionists implemented Tele-Care II via teleconference calls with caregivers. Although 14 caregivers were recruited for the study, only 5 were able to complete the intervention before the patient's death. Those completing the intervention experienced decreased depression, despair, and disorganization although the patient's condition became more serious. Late enrollment in hospice continues to be problematic for patients, family caregivers, and hospice staff because it allows little time for completion of interventions with family caregivers before the patient's death.

Meaning and agency in discussing end-of-life care: a study of elderly veterans' values and interpretations

The authors of this exploratory study used textual analysis of transcribed interviews to examine the mental constructs that individuals form around advance care terminology and to learn how elderly veterans conceptualize the language used in the Veterans Administration advance directive. They found that respondents often negotiated meaning by drawing on rigid schemas, specific mental constructs already in place: The Lord's Will, Machine Talk, Being a Burden, and Being Productive. The authors also examined the transcripts for agency. In addition to assigning external agency for end-of-life care decisions, respondents often expressed a complex interaction of "self" and "other" agency. These results challenge us to develop communication methods that allow patients to claim agency and participate fully in decisions regarding their health care, especially at the end of life.

Ethical analysis of withdrawal of pacemaker or implantable cardioverter-defibrillator support at the end of life

OBJECTIVE

To describe a series of terminally ill patients who requested (or whose surrogates requested) withdrawal of pacemaker or implantable cardioverter-defibrillator (ICD) support and the ethical issues pertaining to these requests.

PATIENTS AND METHODS

We performed a retrospective review of the medical records of patients seen at the Mayo Clinic in Rochester, Minn, between January 1996 and June 2002 and identified 6 terminally ill patients who requested (or whose family members requested) withdrawal of pacemaker or ICD support. Potential interventions were an ethics consultation and subsequent withdrawal of pacemaker or ICD support. The study's main outcome measures were death and the context in which it occurred.

RESULTS

The mean age of the 6 patients (3 men, 3 women) was 75.5 years. Five had pacemakers, and 1 had an ICD. Five patients had advance directives that indicated a desire to withdraw medical interventions if death was inevitable. Two patients and 4 surrogates requested withdrawal of pacemaker or ICD support. One patient died without withdrawal of support despite an ethics consultation that endorsed its permissibility. Another died while an ethics consultation was in progress. The request to withdraw support was granted in 4 patients, all of whom died within 5 days of withdrawal of support.

CONCLUSIONS

Granting terminally ill patients' requests to withdraw unwanted medical support is legal and ethical. Death after withdrawal of support is attributable to the patient's underlying pathology and is not the same as physician-assisted suicide or euthanasia. Clinician familiarity with these concepts may lead to more expeditious withdrawal of unwanted medical support from terminally ill patients.

Update in palliative medicine and end-of-life care

Palliative medicine includes clinical palliative care, education, and research that focus on the quality of life of patients with advanced disease and their families. The domain of palliative medicine is the relief of suffering: physical, psychological, social, and spiritual. Palliative medicine and care for patients at the end of life and their families include the following key components: compassionate communication; exploration of patient and family values and goals of care; expert attention to relief of suffering; management of pain, depression, delirium, and other symptoms; awareness of the manifestations of grief; and sensitivity to the concerns of bereaved survivors.

Sedation in palliative care - a critical analysis of 7 years experience

BACKGROUND: The administration of sedatives in terminally ill patients becomes an increasingly feasible medical option in end-of-life care. However, sedation for intractable distress has raised considerable medical and ethical concerns. In our study we provide a critical analysis of seven years experience with the application of sedation in the final phase of life in our palliative care unit. METHODS: Medical records of 548 patients, who died in the Palliative Care Unit of GK Havelhoehe between 1995-2002, were retrospectively analysed with regard to sedation in the last 48 hrs of life. The parameters of investigation included indication, choice and kind of sedation, prevalence of intolerable symptoms, patients' requests for sedation, state of consciousness and communication abilities during sedation. Critical evaluation included a comparison of the period between 1995-1999 and 2000-2002. RESULTS: 14.6% (n = 80) of the patients in palliative care had sedation given by the intravenous route in the last 48 hrs of their life according to internal guidelines. The annual frequency to apply sedation increased continuously from 7% in 1995 to 19% in 2002. Main indications shifted from refractory control of physical symptoms (dyspnoea, gastrointestinal, pain, bleeding and agitated delirium) to more psychological distress (panic-stricken fear, severe depression, refractory insomnia and other forms of affective decompensation). Patients' and relatives' requests for sedation in the final phase were significantly more frequent during the period 2000-2002. CONCLUSION: Sedation in the terminal or final phase of life plays an increasing role in the management of intractable physical and psychological distress. Ethical concerns are raised by patients' requests and needs on the one hand, and the physicians' self-understanding on the other hand. Hence, ethically acceptable criteria and guidelines for the decision making are needed with special regard to the nature of refractory and intolerable symptoms, patients' informed consent and personal needs, the goals and aims of medical sedation in end-of-life care.

Ethical issues and the role of anesthesiologists in non-heart-beating organ donation

PURPOSE OF REVIEW

Demand for vital organs for transplantation continues to increase, and the supply of organs has not kept up with demand. The use of organs harvested immediately after death from patients who have requested withdrawal of life support may be one way to increase supply. Anesthesiologists frequently become involved with such 'non-heart-beating' organ donations when they are asked to withdraw life support from patients in the operating room and monitor them, providing terminal care, until death ensues.

RECENT FINDINGS

Despite thorough debate in the literature and reviews by the Institute of Medicine, ethical controversies remain concerning the use of non-heart-beating donors. Further, non-heart-beating organ donation has failed to produce the windfall of vital organs for transplant predicted by optimistic early estimates. There is agreement in the medical specialties of palliative care, intensive care medicine, internal medicine, and family practice that competency in end-of-life care requires specialty training. Most anesthesiologists are poorly qualified to carry out the tasks involved in non-heart-beating donation, and may even potentially compromise care.

SUMMARY

Ethical controversies in the use of non-heart-beating donors remain despite thorough review. No physician should be involved in withdrawal of life support in non-heart-beating donors, unless specialty trained in end-of-life care. Most anesthesiologists should not be involved in non-heart-beating organ donations; potential exceptions include those with specialty training or experienced in palliative care or intensive care medicine.

Dying in the intensive care unit: collaborative multicenter study about forgoing life-sustaining treatment in Argentine pediatric intensive care units

OBJECTIVE

Describe modes of death and factors involved in decision-making together with life support limitation (LSL) procedures.

DESIGN

Prospective, descriptive, longitudinal, and noninterventional study.

SETTING

Sixteen pediatric intensive care units in Argentina.

PATIENTS

Every patient who died during a 1-yr period was included.

MEASUREMENTS AND MAIN RESULTS

Age, sex, length of stay (LOS), primary and admission diagnosis, underlying chronic disease (CD), postoperative condition (PO). Deaths were classified in four groups: a) failed cardiopulmonary resuscitation (CPR); b) do-not-resuscitate (DNR) status; c) withholding or withdrawing life-sustaining treatment (WH/WD); and d) brain death (BD). Justifications were classified as a) imminent death; b) poor long-term prognosis; c) poor quality of life; and d) family request. Data were collected from medical records and interviews with the attending physicians. Descriptive statistics were performed. Differences among groups were analyzed through contingency tables and analysis of variance when required. Relative risks and confidence intervals of variables potentially related to LSL were analyzed, and logistic regression was performed. There were 6358 admissions and 457 deaths. CPR was performed in 52%, DNR in 16%, WH/WD in 20%, and BD in 11% of dead patients. BD patients were older, LOS and CD prevalence were higher in the WH/WD group. Inotropic drugs were the most frequently limited treatment in 110 patients (55%), CPR in 72 (35.6%), and mechanical ventilation in 63 (31%). Imminent death was the most frequently reported justification for LSL. CD and more staff were associated with a higher probability of LSL.

CONCLUSIONS

Most of the patients in Argentina underwent CPR before their death. We have a high proportion of patients with CD (65%) and low BD diagnosis. PO condition decreased LSL probability in chronically ill patients. Do-not-resuscitate orders and withholding new treatments were the most common LSL. Active withdrawal was exceptional. The Ethics Committee was consulted in 5% of the LSL population.

Managing respiratory symptoms at the end of life

Early and clear discussion and articulation of preferences about interventions with increasing burdens and diminishing benefits is helpful in identifying the goals of care and planning management for patients who have unremitting terminal illnesses. The development of respiratory symptoms such as dyspnea, cough, and hiccups is common and can often be anticipated. Aggressive evaluation and treatment should be pursued and offered to palliate symptoms at the end of life.

Pain relief, prescription drugs, and prosecution: a four-state survey of chief prosecutors

The experience of having to suffer debilitating pain is far too common in the United States, and many patients continue to be inadequately treated by their doctors. Although many physicians freely admit that their pain management practices may have been somewhat lacking, many more express concern that the prescribing of heightened levels of opioid analgesics may result in closer regulatory scrutiny, criminal investigation, or even criminal prosecution.

Although several researchers have examined the regulatory environment and the threat of sanction or harm it poses to physicians and patients, few have examined the likelihood of investigation or prosecution stemming from the aggressive use of opioids in physician-directed pain management. Accordingly, in an effort to assess whether the fear of prosecution is realistic and, if so, what factors contribute to its likelihood, we surveyed chief prosecutors in four states about their knowledge, opinions, and attitudes concerning opioids and the prosecution of physicians stemming from the treatment of patients who were either terminally ill or suffering from chronic noncancer pain.

On the Edge of Life, I: Assessment of, Reaction to, and Management of the Terminally Ill Recorded in an Intensive Care Unit Journal

BACKGROUND: In a general hospital, few clinical settings match the intensity of the intensive care unit (ICU) experience. Clinical rotations in ICUs elicit and emphasize the struggles house officers face on a daily basis throughout their training. METHOD: These struggles were recorded by hundreds of residents in a journal maintained in the Massachusetts General Hospital's Medical ICU for the past 20 years. We systematically reviewed these unsolicited entries to define and to illustrate how house officers respond to caring for terminally ill patients. The 3 overarching topics that surfaced repeatedly were assessment of terminally ill patients, reaction to their prognosis, and management of their disease or their eventual demise. RESULTS: House officers record affective reactions and cognitive assessments to cope with the stress and dysfunction associated with the care of the critically ill and to facilitate their management of these patients. Journal entries by residents reveal a deep concern for the welfare of their patients, conflict about the technological advances and limitations of the system, and reflection on how involved physicians should become with their patients. CONCLUSION: House officer journal entries reflect a combination of newly gained medical knowledge and coping strategies in managing terminally ill patients. House officers also demonstrate a deep concern for the welfare of their patients. Insight from years of reflection from past house officers can help prepare trainees and residency programs for the breadth and intensity of the ICU experience and for work in clinical practice settings that follow completion of training.

Ethical challenges in end-of-life therapies in the elderly

With the increasing numbers of elderly in the population of all western countries and the increasing life expectancy at birth, many seniors spend the last period of their life with various afflictions that may require the need for long-term institutional care. During the last period of life, many seniors and their families face decisions that challenge ethical principles and may cause conflict among family members as well as healthcare professionals. The commonly used ethical principles of autonomy, beneficence, nonmaleficence and justice, although forming a useful foundation for the evaluation of decision-making dilemmas, alone cannot resolve many clinically challenging situations. Healthcare professionals must clearly understand the clinical state of the patient for whom a difficult decision is being contemplated. Levels of function, clinical symptoms, the expected trajectory of change and possible treatment options have to be balanced against the person's values and wishes, either self-expressed directly or through an advance directive, or communicated by surrogate decision makers. At times, physicians face difficult treatment dilemmas when patients or families request treatments that are not legally sanctioned, such as when physician-assisted suicide is requested by a suffering patient. At other times conflicts occur when patients or surrogates wish to continue with therapies that are no longer considered necessary or suitable by the physician. At the societal level, sometimes an expensive drug that is deemed necessary by the physicians is not covered by a government-sponsored or private health plan. The issue of distributive justice must be considered in a situation such as when long-term facilities or acute hospitals treating frail, cognitively impaired elders consider withholding or withdrawing various treatments because of poor clinical outcomes coupled with excessive costs. The often controversial issue of nutrition and hydration in the end-of-life period frequently causes treatment conflicts and dilemmas among surrogates and staff, as does the highly charged issue of cardiopulmonary resuscitation in this frail and very vulnerable population. The real challenge for healthcare providers in the field of geriatric long-term care is to balance compassionate and appropriate care with respect for the choices and wishes of patients and their families. This should be accomplished while at the same time safeguarding the professional standards and ethical integrity of healthcare providers responsible for this care.

Guidelines for perioperative do-not-resuscitate policies

This paper reviews some of the difficulties in implementing perioperative reevaluation of do-not-resuscitate (DNR) orders and suggests several strategies for perioperative DNR policies. Policies should be written, designed and implemented at the level of the institution, and be sufficiently flexible to permit the tailoring of the perioperative DNR order to the individual patient. Policies should unambiguously state that reevaluation is required, delineate responsibilities for reevaluating the DNR order, state all the available options, define the necessary documentation, and list resources for help.

Artificial nutrition: dilemmas in decision-making

Artificial nutrition is a supportive medical therapy to attain pre-defined objectives, which should be adjusted to changing clinical situations. Optimal decision-making is based on the available scientific evidence blended with the science of probability and a spice of the art of uncertainty. Complex dilemmas in decision-making often occur given the paucity of solid scientific data to endorse precise indications and timing of prescription, whilst goals to be achieved may vary from clinical benefits to compassionate use. Hence, healthcare professionals must be aware and abide by the current norms of medical ethics, whereby eliciting and respecting patients' preferences is paramount. Patient-focused care implies: to respect patients' rights, to clearly inform and involve the patient in the decision-making process, to implement a therapeutic plan based on the best available care to suit patients' needs and informed options.

End-of-life care for the hospitalized patient

The majority of Americans die in hospitals where shortcomings in end-of-life care are endemic. Too often, patients die alone, in pain, their wishes unheeded by their physicians. Because hospitalists care for many of these dying patients, they can dramatically improve end-of-life care in hospitals. Hospitalists must first relieve distressing symptoms such as pain, dyspnea, nausea, vomiting, delirium, and depression. In addition, they should communicate clearly with patients and families, and provide them psychosocial support. Hospitalists can increase the number and the timeliness of hospice referrals, thereby allowing more patients to die at home. Finally, all physicians must attend to their own senses of grief and loss to avoid burnout and to continue to reap the rewards end-of-life care provides.

Sedation for comfort at end of life

Treatment for patients who are dying from cancer and are suffering with physiologic and existential symptoms is an important and valuable skill for health care providers. However, the treatment for suffering at the end of life and the use of sedation for comfort often are misunderstood. The following is a discussion of the clinical skills and ethical considerations that health care providers should have when treating terminal patients with cancer.

Legal and ethical issues in end-of-life care

Advances in medical technology during the past 3 decades altered the scenarios of our dying. It is now possible to prolong life, with the frightening reality that we also can extend death. This paper examines challenges to dying well in America, defines key end-of-life dilemmas faced by critical care nurses, and examines legal and ethical issues related to dying persons' care. These issues include patients' decision-making capacity and right to refuse treatment; withholding and withdrawing life-sustaining treatment, including nutrition and hydration; "no code" decisions; medical futility; and assisted suicide. Implications for critical care practice, education, research and public policy are identified.

Withdrawal of nutritional support in the terminally ill

The technological advances of recent years have placed an increasingly troublesome burden on healthcare practitioners. When the focus of patient care becomes supportive in nature and not curative, decisions to withhold or withdraw medical treatment become important. The purpose of this article is to allow the reader to explore their own personal reasoning for their continued use of or withdrawal of nutritional support. Legal/ethical principles and approaches to withdraw treatment will be discussed and help guide providers in care options.

Evaluating end-of-life care from the perspective of the patient's family

This article is written from personal experiences with the recent death of the authors' mother. It highlights the problems the authors encountered, while acknowledging the positive aspects of treatment during a difficult time. The overall purpose is to improve end-of-life care by advancing policy through research, legislation, and education. The impetus for writing this article is personal experience, but its larger purpose is to address issues that many readers will face in the future and suggest possible reforms, especially in the area of education.

Should there be a choice for cardiopulmonary resuscitation when death is expected? Revisiting an old idea whose time is yet to come

Since closed chest cardiac massage was introduced in 1960, the notion that cardiopulmonary resuscitation (CPR) attempts are not appropriate for all patients has been consistent. Over the years, leading authorities have clearly articulated that for patients who are dying irreversibly and expectedly medical decisions for do-not-resuscitate (DNR) orders should be made by physicians, because in such cases CPR attempts are not indicated. Physicians are not obligated to and should not offer or provide useless treatments, even in the name of patient autonomy. Despite this, physicians still seek and obtain patient or proxy consent when CPR is not indicated before writing a DNR order. Reasons include fear of legal repercussions/misconceptions, limited physician-patient relationships, time constraints, and institutional culture. End-of-life plans of care should be based on appropriate goals that focus on palliation and not on aggressive medical treatments that offer no benefit.