51
|
Decision-making in the end-of-life phase of high-grade glioma patients. Eur J Cancer 2011; 48:226-32. [PMID: 22153216 DOI: 10.1016/j.ejca.2011.11.010] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 11/03/2011] [Accepted: 11/07/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND During the disease course of high-grade glioma (HGG) patients, the goal of therapy eventually shifts from primarily life-prolongation to primarily sustaining the quality of life as good as possible. End-of-life care is aimed at prolongation of life with good quality, but inevitably also may require medical decisions for prevention and relief of suffering with a potential life shortening effect. Few data are available on this end-of-life decision (ELD) making process in HGG patients, with decreased consciousness, confusion or cognitive deficits preventing them to participate. In this study the ELD-making process in HGG patients is described. METHODS Physicians and relatives of a cohort of 155 deceased HGG patients were identified to fill in a questionnaire regarding the end-of-life conditions (patients' ELD preferences, patients' competence) and ELD-making (forgoing treatment and the administration of drugs with a potential life-shortening effect) for their patient or relative. Data were analysed with descriptive statistics. FINDINGS Of 101 patients, physicians completed surveys including questions about ELDs (62% response rate). More than half of the patients relatively early became incompetent to make decisions due to delirium, cognitive deficits and/or decreasing consciousness. In 40% of patients the physician did not discuss ELD preferences with his/her patient. At least one ELD was made in 72% of patients, most often this comprised the withdrawal of dexamethasone. Palliative sedation was performed in 30% of patients and physician assisted death in 7%. INTERPRETATION ELDs are common practises amongst HGG patients, although their preferences towards ELDs are frequently unknown to the physician. Because the majority of patients become incompetent towards death, participation in ELD-making is only possible with advanced care planning. Hence, timely discussion of ELD preferences is encouraged.
Collapse
|
52
|
Andersen PM, Abrahams S, Borasio GD, de Carvalho M, Chio A, Van Damme P, Hardiman O, Kollewe K, Morrison KE, Petri S, Pradat PF, Silani V, Tomik B, Wasner M, Weber M. EFNS guidelines on the clinical management of amyotrophic lateral sclerosis (MALS)--revised report of an EFNS task force. Eur J Neurol 2011; 19:360-75. [PMID: 21914052 DOI: 10.1111/j.1468-1331.2011.03501.x] [Citation(s) in RCA: 722] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The evidence base for the diagnosis and management of amyotrophic lateral sclerosis (ALS) is weak. OBJECTIVES To provide evidence-based or expert recommendations for the diagnosis and management of ALS based on a literature search and the consensus of an expert panel. METHODS All available medical reference systems were searched, and original papers, meta-analyses, review papers, book chapters and guidelines recommendations were reviewed. The final literature search was performed in February 2011. Recommendations were reached by consensus. RECOMMENDATIONS Patients with symptoms suggestive of ALS should be assessed as soon as possible by an experienced neurologist. Early diagnosis should be pursued, and investigations, including neurophysiology, performed with a high priority. The patient should be informed of the diagnosis by a consultant with a good knowledge of the patient and the disease. Following diagnosis, the patient and relatives/carers should receive regular support from a multidisciplinary care team. Medication with riluzole should be initiated as early as possible. Control of symptoms such as sialorrhoea, thick mucus, emotional lability, cramps, spasticity and pain should be attempted. Percutaneous endoscopic gastrostomy feeding improves nutrition and quality of life, and gastrostomy tubes should be placed before respiratory insufficiency develops. Non-invasive positive-pressure ventilation also improves survival and quality of life. Maintaining the patient's ability to communicate is essential. During the entire course of the disease, every effort should be made to maintain patient autonomy. Advance directives for palliative end-of-life care should be discussed early with the patient and carers, respecting the patient's social and cultural background.
Collapse
Affiliation(s)
-
- Umeå University, Umeå, Sweden.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
53
|
Cox FM, Titulaer MJ, Sont JK, Wintzen AR, Verschuuren JJGM, Badrising UA. A 12-year follow-up in sporadic inclusion body myositis: an end stage with major disabilities. ACTA ACUST UNITED AC 2011; 134:3167-75. [PMID: 21908393 DOI: 10.1093/brain/awr217] [Citation(s) in RCA: 134] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Sporadic inclusion body myositis is considered to be a slowly progressive myopathy. Long-term follow-up data are, however, not yet available. Follow-up data are important with a view to informing patients about their prognosis and selecting appropriate outcome measures for clinical trials. We performed a follow-up study of 64 patients with sporadic inclusion body myositis who participated in a national epidemiological study in the Netherlands. Case histories were recorded, and manual and quantitative muscle tests as well as laboratory tests were performed at baseline and 12 years (median) after the first out-patient visit. Date and cause of death were recorded for all deceased patients. Forty-six patients died during the follow-up period, two patients chose not to participate and one patient was lost to follow-up. The remaining 15 surviving patients had a mean disease duration of 20 years and were clinically evaluated at the second time point. The mean decline in strength was 3.5 and 5.4% per year according to the manual muscle testing and quantitative muscle testing, respectively. This decline was most pronounced in the lower legs, which were also the weakest extremities. Life expectancy was normal at 81 years, but activities of daily life were clearly restricted. At follow-up, all patients were found to be using a wheelchair, seven of them (47%) being completely wheelchair-bound. Disorders of the respiratory system were the most common cause of death. In three patients, euthanasia was requested and in another three, continuous deep sedation was applied. The fact that end-of-life care interventions were used in six patients (13%) reflects the severe disability and loss of quality of life at the end stage of this disease. Sporadic inclusion body myositis is a chronic progressive disorder, leading to major disabilities at the end stage of the disease due to extensive muscle weakness.
Collapse
Affiliation(s)
- Fieke M Cox
- Department of Neurology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands.
| | | | | | | | | | | |
Collapse
|
54
|
|
55
|
|
56
|
Monforte-Royo C, Villavicencio-Chávez C, Tomás-Sábado J, Balaguer A. The wish to hasten death: a review of clinical studies. Psychooncology 2010; 20:795-804. [DOI: 10.1002/pon.1839] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Revised: 07/07/2010] [Accepted: 07/15/2010] [Indexed: 11/12/2022]
|
57
|
|
58
|
Lou JS, Weiss MD, Carter GT. Assessment and management of fatigue in neuromuscular disease. Am J Hosp Palliat Care 2010; 27:145-57. [PMID: 20190203 DOI: 10.1177/1049909109358420] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Fatigue is a common and potentially debilitating symptom of neuromuscular disease (NMD). Studies show that patients with NMD subjectively report increased levels of fatigue. Laboratory testing has demonstrated that patients with NMD show objective physiological signs of increased fatigue, with both central and peripheral components. To date, no treatment has been proven to be truly effective through evidence-based medicine. Thus, the clinician must use a multimodality approach to treating fatigue in patients with NMD. Management interventions are generally based on a sequential approach including treatment of comorbid factors, with the goal of maximizing physical and psychological functioning. This might include low-intensity exercise training, cognitive therapy, treatment of associated depression, correction of risk factors such as obesity, poor nutrition, and inactivity (deconditioning). Optimizing cardiopulmonary function is also critical and measures such as noninvasive, positive pressure ventilation may reduce fatigue in patients with NMD. Novel medications such as modafinil, a nonamphetamine stimulant, may be a helpful pharmacological treatment. Nutraceutical agents, such as creatine monohydrate, coenzyme Q10 (CoQ10), and alpha-lipoic acid, may also improve neuromuscular function and reduce fatigue.
Collapse
Affiliation(s)
- Jau-Shin Lou
- Oregon Health and Science University, Portland, USA
| | | | | |
Collapse
|
59
|
Maessen M, Veldink JH, van den Berg LH, Schouten HJ, van der Wal G, Onwuteaka-Philipsen BD. Requests for euthanasia: origin of suffering in ALS, heart failure, and cancer patients. J Neurol 2010; 257:1192-8. [PMID: 20148336 DOI: 10.1007/s00415-010-5474-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 12/06/2009] [Accepted: 01/15/2010] [Indexed: 10/19/2022]
Abstract
In The Netherlands, relatively more patients (20%) with amyotrophic lateral sclerosis (ALS) die due to euthanasia or physician-assisted suicide (EAS) compared with patients with cancer (5%) or heart failure (0.5%). We wanted to gain insight into the reasons for ALS patients requesting EAS and compare these with the reasons of cancer and heart failure patients. Knowing disease-specific reasons for requesting EAS may improve palliative care in these vulnerable patients. The data used in the present study were derived from the Support and Consultation in Euthanasia in The Netherlands (SCEN) evaluation study. This study provided consultation reports and questionnaires filled out by the attending physicians from 3,337 consultations conducted by SCEN physicians in situations where a patient requested EAS. For this study we selected data on all ALS patients (n = 51), all heart failure patients (n = 61), and a random sample of 73 cancer patients. The most frequently reported reasons for unbearable suffering were: fear of suffocation (45%) and dependency (29%) in ALS patients, pain (46%) and fatigue (28%) in cancer patients, and dyspnea (52%) and dependency (37%) in heart failure patients. Somatic complaints were reported more frequently as a reason for EAS by cancer patients [odds ratio (OR) 0.20, 95% confidence interval (CI) 0.09-0.46] and heart failure patients [OR 0.16, 95% CI 0.05-0.46] than by ALS patients. ALS patients should be helped in a timely fashion to cope with psychosocial symptoms, e.g., by informing them about the low risk of suffocation in the terminal phase and the possible means of preventing this.
Collapse
Affiliation(s)
- Maud Maessen
- Department of Neurology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | | | | | | | | | | |
Collapse
|
60
|
Mitsumoto H, Bromberg M, Johnston W, Tandan R, Byock I, Lyon M, Miller RG, Appel SH, Benditt J, Bernat JL, Borasio GD, Carver AC, Clawson L, Del Bene ML, Kasarskis EJ, LeGrand SB, Mandler R, McCarthy J, Munsat T, Newman D, Sufit RL, Versenyi A. Promoting excellence in end‐of‐life care in ALS. ACTA ACUST UNITED AC 2009; 6:145-54. [PMID: 16183556 DOI: 10.1080/14660820510028647] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The type and quality of end-of-life care varies greatly in ALS; the time to initiate end-of-life care is not defined, and decision making is hampered by logistical and financial barriers. There has been no systematic review of these issues in ALS. The goals of this initiative are to: 1) improve end-of-life care for patients with ALS and families based on what limited evidence is available; 2) increase awareness, interest, and debate on the end-of-life care in ALS; and 3) identify areas needed for new prospective clinical research. The ALS Peer Workgroup reviewed the literature and 1) identified the current state of knowledge, 2) analysed the gaps in care, and 3) provided recommendations for standard of care and future research. It was shown that areas of investigation are needed on the incorporation of an interdisciplinary approach to care in ALS that includes: psychosocial evaluation and spiritual care; the use of validated instruments to assess patient and caregiver quality of life; and the establishment of proactive caregiver programs. Several public policy changes that will improve coverage for medical care, hospice, and caregiver costs are also reviewed. More clinical evidence is needed on how to provide optimal end-of-life care specifically in ALS.
Collapse
Affiliation(s)
- Hiroshi Mitsumoto
- The Elenor & Lou Gehrig MDA/ALS Research Center, Columbia University Neurological Institute, New York, NY 10032, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
61
|
Sathasivam S. Managing patients with amyotrophic lateral sclerosis. Eur J Intern Med 2009; 20:355-8. [PMID: 19524172 DOI: 10.1016/j.ejim.2008.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Revised: 08/28/2008] [Accepted: 09/03/2008] [Indexed: 12/14/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is the most common rapidly progressive adult-onset neurodegenerative disorder. There have been great advances in the management of patients with ALS over the past decade. It starts with the giving of the diagnosis and continues to the terminal phase of the disease. This review will examine the impact of medical and non-medical interventions on improving survival and quality of life in these patients, emphasizing the importance of a multidisciplinary approach.
Collapse
Affiliation(s)
- Sivakumar Sathasivam
- The Walton Centre for Neurology & Neurosurgery, Lower Lane, Liverpool, United Kingdom.
| |
Collapse
|
62
|
Mayadev AS, Weiss MD, Jane Distad B, Krivickas LS, Carter GT. The Amyotrophic Lateral Sclerosis Center: A Model of Multidisciplinary Management. Phys Med Rehabil Clin N Am 2008; 19:619-31, xi. [DOI: 10.1016/j.pmr.2008.04.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
63
|
|
64
|
Fang F, Valdimarsdóttir U, Fürst CJ, Hultman C, Fall K, Sparén P, Ye W. Suicide among patients with amyotrophic lateral sclerosis. Brain 2008; 131:2729-33. [PMID: 18669498 DOI: 10.1093/brain/awn161] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Studies on the suicide risk among patients with amyotrophic lateral sclerosis (ALS) in countries without legalized euthanasia or assisted suicide are important additions to data on the wish to die of these patients. We conducted a population-based cohort study in Sweden between 1965 and 2004, which comprised of 6,642 patients with incident ALS identified from the Swedish Inpatient Register. We calculated the standardized mortality ratios (SMRs) of suicide among the patients using the suicide rates of the general Swedish population as a reference. In total, 21 patients committed suicide during follow-up, compared to the predicted 3.6 suicides. Thus, we noted an almost 6-fold increased risk for suicide among ALS patients [SMR 5.8, 95% confidence interval (CI) 3.6-8.8]. Patients who committed suicide were, on average, around 7 years younger at the time of their first period of hospitalization than patients who did not commit suicide. The highest relative risk for suicide was observed within the first year after the patient's first period of hospitalization (SMR 11.2, 95% CI 5.8-19.6). After that, the relative risks decreased with time after hospitalization (P-value for trend = 0.006), but remained elevated 3 years later. The relative risks of suicide among ALS patients did not show a clear trend over time in contrast to the decreasing trend of relative risks for suicide among patients with cancer during the same period. Patients with ALS are at excess risk of suicide in Sweden and the relative risk is higher during the earlier stage of the disease.
Collapse
Affiliation(s)
- Fang Fang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | | | | | | | | | | | | |
Collapse
|
65
|
Kühnlein P, Kübler A, Raubold S, Worrell M, Kurt A, Gdynia HJ, Sperfeld AD, Ludolph AC. Palliative care and circumstances of dying in German ALS patients using non-invasive ventilation. ACTA ACUST UNITED AC 2008; 9:91-8. [PMID: 18428001 DOI: 10.1080/17482960701830495] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Non-invasive ventilation (NIV) is known to improve quality of life and to prolong survival in amyotrophic lateral sclerosis (ALS) patients. However, little is known about the circumstances of dying in ventilated ALS patients. In the light of the debate on legalizing euthanasia it is important to provide empirical data about the process of dying in these patients. In a structured interview, 29 family caregivers of deceased ALS patients were asked about their own and the patient's attitude toward physician-assisted suicide (PAS) and euthanasia, circumstances of dying, and the use of palliative medication. Quantitative and qualitative content analysis was performed on the data. Non-recurring suicidal thoughts were reported by five patients. Three patients and seven relatives had thought about PAS. Seventeen caregivers described the patients' death as "peaceful", while choking was reported in six bulbar patients. In final stages of dying, the general practitioner (GP) was involved in the treatment of 10 patients, with palliative medication including sedatives and opiates being administered in eight cases. In conclusion, in contrast to the Netherlands, where 20% of terminal ALS patients die from PAS or euthanasia, only a small minority of our patients seems to have thought about PAS. The legal situation in Germany (where euthanasia is illegal), a bias due to the selection of NIV patients as well as a high percentage of religious patients and those with good levels of social support from family and friends, might account for this. Most of our patients died peacefully at home from carbon dioxide narcosis, but choking was described in some bulbar patients. Thus, palliative care, especially the use of opiates, anxiolytics and sedatives should be optimized, and the involvement of GP should be strongly encouraged, especially in bulbar patients.
Collapse
|
66
|
Lulé D, Häcker S, Ludolph A, Birbaumer N, Kübler A. Depression and quality of life in patients with amyotrophic lateral sclerosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2008; 105:397-403. [PMID: 19626161 DOI: 10.3238/arztebl.2008.0397] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Accepted: 04/18/2008] [Indexed: 12/14/2022]
Abstract
INTRODUCTION There is increasing debate on the issue of whether to facilitate the end-of-life decisions of severely disabled patients with diseases such as amyotrophic lateral sclerosis (ALS). Our two studies were intended to explore the emotional state and quality of life of patients with ALS. METHODS Two studies were performed to investigate depression and the quality of life in ALS patients: one was a longitudinal study, the other a comparison of ALS patients to normal control subjects. RESULTS These studies found no correlation between physical disability in ALS and either depression or the quality of life. The severity of depression was found to be inversely related to educational status. In ALS patients the quality of life was comparable with healthy controls. DISCUSSION The rationale for not providing life-sustaining treatment to severely disabled patients is that a poor quality of life is expected after such treatment. Our studies have shown, however, that ALS patients can experience a satisfactory quality of life without depressive manifestations even if they are severely physically impaired, including in the terminal phase.
Collapse
Affiliation(s)
- Dorothée Lulé
- Neurologische Klinik der Universität Ulm im Rehabilitationskrankenhaus Ulm (RKU), Oberer Eselsberg 45, Ulm, Germany
| | | | | | | | | |
Collapse
|
67
|
Ogunbanjo GA, Knapp van Bogaert D. Voluntary active euthanasia: Is there a place for it in modern day medicine? S Afr Fam Pract (2004) 2008. [DOI: 10.1080/20786204.2008.10873714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
68
|
Abstract
The issue of quality of life is important for the patient with amyotrophic lateral sclerosis (ALS) and his or her family. Although initial thoughts frequently are that quality of life will be poor, there are strong data to support a relatively good quality of life despite the inexorable decline in strength and loss of function with disease progression. This article discusses how quality of life can be measured in ALS patients and caregivers, the results of studies, and factors affecting quality. It ends with 10 suggestions for clinicians who care for ALS patients and their caregivers.
Collapse
|
69
|
Abstract
Although amyotrophic lateral sclerosis and its variants are readily recognised by neurologists, about 10% of patients are misdiagnosed, and delays in diagnosis are common. Prompt diagnosis, sensitive communication of the diagnosis, the involvement of the patient and their family, and a positive care plan are prerequisites for good clinical management. A multidisciplinary, palliative approach can prolong survival and maintain quality of life. Treatment with riluzole improves survival but has a marginal effect on the rate of functional deterioration, whereas non-invasive ventilation prolongs survival and improves or maintains quality of life. In this Review, we discuss the diagnosis, management, and how to cope with impaired function and end of life on the basis of our experience, the opinions of experts, existing guidelines, and clinical trials. We highlight the need for research on the effectiveness of gastrostomy, access to non-invasive ventilation and palliative care, communication between the care team, the patient and his or her family, and recognition of the clinical and social effects of cognitive impairment. We recommend that the plethora of evidence-based guidelines should be compiled into an internationally agreed guideline of best practice.
Collapse
Affiliation(s)
- Aleksandar Radunović
- MRC Centre for Neurodegeneration Research, Department of Clinical Neuroscience, PO 41, Institute of Psychiatry, King's College London, London, UK
| | | | | |
Collapse
|
70
|
Averill AJ, Kasarskis EJ, Segerstrom SC. Psychological health in patients with amyotrophic lateral sclerosis. ACTA ACUST UNITED AC 2007; 8:243-54. [PMID: 17653923 DOI: 10.1080/17482960701374643] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive and fatal neurodegenerative disease with no known effective treatment or cure. Clinicians often expect that ALS patients will experience depression following the diagnosis because ALS is a terminal disease. The objective of the current study was to examine the evidence from the literature on psychological health in ALS patients in order to determine the prevalence and severity of depression in this population. Twenty-eight studies of ALS patients, conducted over the past 20 years, were reviewed and evaluated. The cumulative evidence suggests that clinically significant depression is neither as prevalent nor as severe as might be expected. Methodological limitations that are inherent to the measurement of depression in ALS, including the lack of appropriate instruments, small sample sizes, and reliance on cross-sectional data, have contributed to the wide range of reported results. We conclude that ALS patients are more likely to present with hopelessness and end-of-life concerns than clinically significant depression. It is important to assess a broad range of potential psychological distress early in the course of ALS, rather than focus specifically on depression, because the manner in which patients cope with their disease can affect their longevity.
Collapse
Affiliation(s)
- Alyssa J Averill
- Department of Psychology, University of Kentucky, Lexington, Kentucky 40506, USA
| | | | | |
Collapse
|
71
|
Abstract
OBJECTIVE The aim of this paper is to consider the history of human beings killing one another and reflect upon their reasons. Has it ever been altruistic? METHOD Important examples of large episodes of killing, such as wars, the Crusades, the Inquisition and genocides were examined. RESULTS Reasons are always advanced for killing large numbers of people who did not want to die. They were not based on logic nor on altruism but on moralities constructed from religious and political beliefs. Those who wanted to die because of unrelievable pain involved in the process of dying from an incurable illness are always preserved against their wishes. Once more, the reasons were usually religious and/or politically supported. CONCLUSION The belief that it is acceptable to kill those who do not want to die but unacceptable to kill those who want to die provides a curious paradox.
Collapse
Affiliation(s)
- John Ellard
- Mental Health Review Tribunal of New South Wales Balmoral Beach, NSW, Australia.
| |
Collapse
|
72
|
Abstract
Amyotrophic lateral sclerosis (known in the UK as motor neuron disease) is a devastating illness with uncertain pathogenesis. In this Seminar, we review its natural history, clinical features, diagnostic criteria, variant and mimic syndromes, genetic forms, and epidemiology. Several hypotheses about causes of the disorder are discussed, such as excitotoxicity and oxidant stress, and we review past and present putative disease-modifying treatments. Disease-management strategies, from telling the patient about their illness to end-of-life decisions and palliative care, are presented. We review options for control of the main symptoms of amyotrophic lateral sclerosis--including dysphagia, dysarthria, respiratory distress, pain, and psychological disorders--and care in the terminal phase. The need for good psychosocial and spiritual care of patients and families is emphasised. We conclude with an overview of some current major issues and future prospects, ranging from the search for disease markers to challenging developments such as stem-cell and gene therapy.
Collapse
Affiliation(s)
- J D Mitchell
- Motor Neurone Disease Care and Research Centre, Royal Preston Hospital, Fulwood, Preston PR2 9HT, UK.
| | - G D Borasio
- Interdisciplinary Centre for Palliative Medicine and Motor Neurone Disease Research Group, Department of Neurology, Munich University Hospital, Grosshadern, D-81366 Munich, Germany
| |
Collapse
|
73
|
Albert SM, Rabkin JG, Del Bene ML, Tider T, O'Sullivan I, Rowland LP, Mitsumoto H. Wish to die in end-stage ALS. Neurology 2006; 65:68-74. [PMID: 16009887 PMCID: PMC1201540 DOI: 10.1212/01.wnl.0000168161.54833.bb] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In retrospective studies, estimates of hastened dying among seriously ill patients range from <2% in one national survey to as much as 20% in end-stage disease cohorts. OBJECTIVE To examine, in prospective studies, dying patients in the months before death, in order to understand the wish to die. METHODS Patients with advanced ALS with a high likelihood of death or need for tracheostomy within 6 months were identified. Patients were assessed monthly with an extensive psychosocial interview, including a diagnostic interview for depression. Family caregivers were interviewed on the same schedule and also after patient deaths. RESULTS Eighty patients with ALS were enrolled, 63% of eligible patients; 53 died over follow-up. Ten (18.9%) of the 53 expressed the wish to die, and 3 (5.7%) hastened dying. Patients expressing the wish to die did not differ in sociodemographic features, ALS severity, or perceived burden of family caregivers. They were more likely to meet criteria for depression, but differences were smaller when suicidality was excluded from the depression interview. Patients who expressed the wish to die reported less optimism, less comfort in religion, and greater hopelessness. Compared with patients unable to act on the wish to die, patients who hastened dying reported reduction in suffering and increased perception of control over the disease in the final weeks of life. CONCLUSION These findings suggest caution in concluding that the desire to hasten dying in end-stage disease is simply a feature of depression.
Collapse
Affiliation(s)
- S M Albert
- The Eleanor and Lou Gehrig MDA/ALS Research Center, Department of Neurology, Columbia University, New York, NY 10032, USA.
| | | | | | | | | | | | | |
Collapse
|
74
|
Simmons Z. Management strategies for patients with amyotrophic lateral sclerosis from diagnosis through death. Neurologist 2005; 11:257-70. [PMID: 16148733 DOI: 10.1097/01.nrl.0000178758.30374.34] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disorder that is inevitably fatal. There are no effective treatments to stop or reverse the natural course of the disease. The role of the physician is to provide comfort and optimize quality of life. REVIEW SUMMARY Management of patients with ALS is a process extending over months to years. It begins with breaking the news of the diagnosis and extends through the terminal phase. Medication may extend lifespan by a small amount. However, most efforts are centered around symptom management. Areas of importance include respiration, nutrition, secretions, communication, pseudobulbar affect, therapy and exercise, spasticity and cramps, pain, depression and suicide, spirituality and religion, cognitive changes, the development of advance directives, and care at the end of life. Multidisciplinary ALS clinics provide much-needed support for patients with ALS and their caregivers. CONCLUSION Although physicians cannot cure ALS or even halt progression, there is much that can be done to manage the physical and emotional symptoms, thereby maintaining or enhancing quality of life.
Collapse
Affiliation(s)
- Zachary Simmons
- Department of Neurology, Penn State College of Medicine, Hershey, 17033, USA.
| |
Collapse
|
75
|
Nassar Junior AP, Pignataro DS, Fuzaro MM, Tilbery CP. [Ethical issues in multiple sclerosis under physicians and patients point of view]. ARQUIVOS DE NEURO-PSIQUIATRIA 2005; 63:133-9. [PMID: 15830079 DOI: 10.1590/s0004-282x2005000100024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
UNLABELLED Multiple sclerosis (MS) is a neurologic disorder that mostly affects young adults and can usually evolute to physical disability. Thus, caring patients with MS brings many ethic questions for the physician. OBJECTIVE To identify physicians and patients' perceptions about the illness and so improve doctor-patient relationship. METHOD It was made two different questionnaires, one for patients and another for physicians, 103 patients and 44 physicians answered them. RESULTS 96.1% of patients knew their diagnosis, all others would like to know it. From those, 74.7% thought that that way it was disclosured was correct and 90.9% said that the doctor should tell us it. The worst symptoms described were fatigue (29.1%) and motor deficits (28.1%). By other side, 68% of patients told they suffered because of the illness. The most important reason for doctors to tell the diagnosis to the patients was to improve adherence to treatment (56.8%). A familiar present at this moment was demanded for 54.6% of doctors. When asked about orientations in a pregnancy, 50% of physicians did not answer correctly. Finally, 50% of physicians were against complementary and alternative therapies. CONCLUSION Patients want to know their diagnosis and doctors should tell them in the most adequate moment and give more information. A debate about palliative care is also necessary.
Collapse
|
76
|
Foster C. Misrepresentations about palliative options and prognosis in motor neurone disease: some legal considerations. J Eval Clin Pract 2005; 11:21-5. [PMID: 15660533 DOI: 10.1111/j.1365-2753.2004.00487.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
If euthanasia were legalized, clinicians would be under a duty to explain to patients requesting euthanasia what the prognosis and palliative options were. Anecdotal evidence suggests that some patients suffering from motor neurone disease may request euthanasia because of a fear of choking to death. The literature indicates that with competent palliative care this is unlikely to occur. It is assumed, for the purposes of argument, that responsible clinicians would accordingly reassure patients that such a fear was unwarranted, and that such a reassurance would cause patients for whom choking was the main concern either to withdraw a request for euthanasia or not to make it in the first place. The legal consequences of both negligent and deliberate failure to represent the true prognostic and palliative situation are discussed. In the case of a deliberate failure, with the intention to induce the patient to consent to euthanasia, it is suggested that a verdict of murder would be ethically right. It is argued that such a failure is best regarded as an omission. The English law currently does not countenance the possibility of murder by omission. It is suggested that the distinction between acts and omissions, while sometimes convenient, can sometimes produce injustice, and that the distinction should not be allowed to prevent conviction for murder where this is clearly appropriate.
Collapse
|
77
|
Abstract
Tremendous debate surrounds the acceptability of physician-assisted suicide in the United States. Progress requires carefully mapping the relationship of this practice to termination of life-sustaining treatment, appropriate pain relief and palliative care, and euthanasia. Arguments that have been offered in favor of permitting physicians to aid suicide include the importance of patient autonomy, the claim that patients need this option to cope with symptoms at the end of life, and the assertion that practices already accepted involve intentionally ending life. Arguments that have been offered against include the potential for abuse, the claim that forbidding intentional killing is essential to the ethics of medicine, and the assertion that patients can be provided good and humane care at the end of life without assisting suicide. Addressing the demand for physician-assisted suicide requires improvement in end-of-life care and continued discussion attentive to emerging empirical data.
Collapse
Affiliation(s)
- Susan M Wolf
- University of Minnesota, 229 19th Avenue South, Minneapolis, MN 55455, USA.
| |
Collapse
|
78
|
Chiò A, Gauthier A, Montuschi A, Calvo A, Di Vito N, Ghiglione P, Mutani R. A cross sectional study on determinants of quality of life in ALS. J Neurol Neurosurg Psychiatry 2004; 75:1597-601. [PMID: 15489393 PMCID: PMC1738825 DOI: 10.1136/jnnp.2003.033100] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Understanding the determinants of quality of life (QoL) in amyotrophic lateral sclerosis (ALS) has become increasingly important with the recent emphasis on the comprehensive management of patients. OBJECTIVE To evaluate the determinants of QoL in ALS using two scales with different theoretical constructs: the Schedule for the Evaluation of QoL-Direct Weighting (SEIQoL-DW), which evaluates subjective aspects of QoL, and the McGill QoL Questionnaire (MQOL), which evaluates both health related and non-health related factors of QoL. METHODS Eighty consecutive patients with ALS underwent a battery of tests evaluating QoL and a series of physical, emotional, psychological, and socioeconomic predictor variables. A stepwise linear regression model was used to compare QoL scores and explicatory variables. RESULTS SEIQoL-DW score was related to social support, depression, religiosity, and socioeconomic status. Total MQOL score was related to social support, socioeconomic status, and clinical status. MQOL single item score (MQOL-SIS) was related to social support, depression, social withdrawal, and socioeconomic status. SEIQoL-DW score was not related to total MQOL score. Conversely, a significant correlation was found between SEIQoL-DW and MQOL-SIS. CONCLUSIONS With both QoL scales, the most important explicatory variable of QoL was the self perceived quality of social support. Physical status was not relevant in determining QoL. This study indicates that health related QoL measures are not adequate to assess QoL in patients with ALS, because their appreciation of QoL mainly relies on psychological, supportive, and spiritual factors. Therapeutic interventions should consider the psychological needs of patients and pay greater attention to caregivers' issues.
Collapse
Affiliation(s)
- A Chiò
- Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Torino, Italy.
| | | | | | | | | | | | | |
Collapse
|
79
|
Tolle SW, Tilden VP, Drach LL, Fromme EK, Perrin NA, Hedberg K. Characteristics and Proportion of Dying Oregonians Who Personally Consider Physician-Assisted Suicide. THE JOURNAL OF CLINICAL ETHICS 2004. [DOI: 10.1086/jce200415202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
80
|
Magnusson RS. "Underground euthanasia" and the harm minimization debate. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2004; 32:486-495. [PMID: 15490595 DOI: 10.1111/j.1748-720x.2004.tb00161.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
I have a hairstylist whose lover was very sick. I’d been seeing this stylist for ten years and we’re good friends. [His lover was] becoming an invalid, not able to get out of bed. He said “I hate to ask you this but would you mind writing a prescription to help us out?” [So] I wrote a prescription to a patient who I had never seen, and I sent it to him in the mail and I heard the next time I went in to get my hair cut that it was the most beautiful experience that my stylist had ever had. It was Valentine’s Day and they had a lovely meal with champagne. And they held each other and then, you know, his partner took his pills and was released.(Joseph, physician)
Collapse
|
81
|
Reagan P, Hurst R, Cook L, Zylicz Z, Otlowski M, Veldink JH, van den Berg LH, Wokke JHJ. Physician-assisted death: dying with dignity? Lancet Neurol 2003; 2:637-43. [PMID: 14505588 DOI: 10.1016/s1474-4422(03)00536-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
82
|
Chapter 5 Clinical Aspects of Sporadic Amyotrophic Lateral Sclerosis/Motor Neuron Disease. ACTA ACUST UNITED AC 2003. [DOI: 10.1016/s1877-3419(09)70106-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
|
83
|
Przedborski S, Mitsumoto H, Rowland LP. Recent advances in amyotrophic lateral sclerosis research. Curr Neurol Neurosci Rep 2003; 3:70-7. [PMID: 12507415 DOI: 10.1007/s11910-003-0041-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is the most common motor neuron disease in adults. Despite several genetic breakthroughs, the actual cause and mechanism of neurodegeneration in ALS remains a mystery. Nevertheless, recent scientific and clinical advances have led to the development of new therapeutic strategies for this progressive, fatal disorder. We review the progress of the most recent clinical trials in ALS, taking into account some of the hurdles encountered by these studies. We also discuss the potential role of retroviral infection as a cause or contributor to ALS, which is one of the most recent hypotheses for the pathogenesis of the disease. The genetic background of ALS is summarized and special attention is given to the newly identified ALS gene ALS2, and to those that are currently being investigated. The last part of this review is dedicated to the mutation in superoxide dismutase-1 (SOD1). The hypothesized deleterious mechanisms of mutant SOD1 are discussed, as well as the possibilities that the mutant protein activates the apoptotic cell death process and that these molecular alterations can be exploited to devise experimental neuroprotective therapies.
Collapse
Affiliation(s)
- Serge Przedborski
- Department of Neurology, Columbia University College of Physicians and Surgeons, 650 West 168th Street, BB 307, New York, NY 10032, USA.
| | | | | |
Collapse
|
84
|
Hecht M, Hillemacher T, Gräsel E, Tigges S, Winterholler M, Heuss D, Hilz MJ, Neundörfer B. Subjective experience and coping in ALS. AMYOTROPHIC LATERAL SCLEROSIS AND OTHER MOTOR NEURON DISORDERS : OFFICIAL PUBLICATION OF THE WORLD FEDERATION OF NEUROLOGY, RESEARCH GROUP ON MOTOR NEURON DISEASES 2002; 3:225-31. [PMID: 12710513 DOI: 10.1080/146608202760839009] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Amyotrophic lateral sclerosis is a rapidly progressive and fatal disease which has no known cure and limited symptomatic treatment. While coping strategies in more common diseases are widely assessed, coping is poorly understood in ALS. METHODS We examined 41 ALS patients using a standardised interview, a validated coping self-rating questionnaire and a self-rating depression scale. The evaluation was repeated after six months. RESULTS "Loss of speech", "loss of mobility" and "the poor prognosis" were the most frequent answers in the standardised interview to questions regarding the worst aspect of the disease. Pain was seldom mentioned. "Family members" were most helpful in coping with the disease, followed by "unspecific mechanisms" and "technical aids". None of our patients expressed a wish for assisted suicide. In comparison with other fatal diseases, patients with ALS had similar rankings in the coping mechanism of "rumination", but lower rankings in "search for social integration", "defence of fear", "search for information and communication". In contrast,* "search for hold in the religion" was of high importance for our ALS patients. In the follow-up examination the importance of "search for information and communication" increased. CONCLUSION The results emphasise the importance of "loss of speech" and the importance of the caring family as well as the availability of technical aids in ALS. Coping in ALS seems to be based mainly on "rumination" and *"hold in the religion", but the increasing importance of "search for information" indicates that the sustained offer of information is essential.
Collapse
Affiliation(s)
- Martin Hecht
- Department of Neurology, Centre of Neuromuscular diseases, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
85
|
Rousseau PC. Recent Literature. J Palliat Med 2002. [DOI: 10.1089/109662102320880688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Paul C. Rousseau
- Department of Geriatrics and Extended Care, VA Medical Center, Phoenix, AZ 85012
| |
Collapse
|
86
|
|
87
|
|