The use of opioids and sedatives at the end of life

[Attitudes towards patient care at the end of life. A survey of directors of neurological departments]

In view of the increasing importance of palliative medicine and end-of-life care of neurological patients, a survey from the American Academy of Neurology was translated in a validated fashion and sent to all medical directors of neurological departments in Germany. The topics of the survey comprised-based on clinical scenarios-the withdrawal or withholding of life-sustaining measures, physician-assisted suicide (PAS) and euthanasia, advance directives and health care proxies, principles of palliative care, and ethical and legal questions in end-of-life care. Of 411 directors of departments, 152 participated in the survey. Almost all respondents support a patient's right to refuse life-sustaining treatment. Thirty-two percent think it is illegal to administer analgesics in doses that risk respiratory depression. Forty-five percent believe that treating terminal dyspnea with morphine is the same as euthanasia. Despite the fact that 88% of the respondents regard advance directives as helpful, only an average of 4% of their patients have completed one. About one third of the respondents have been confronted with a request by patients for PAS or euthanasia. Thirty-five percent believe that PAS should be made explicitly legal for terminally ill patients. Forty-six percent of the respondents believe that their training in end-of-life care was insufficient, and 91% express interest in education programs on palliative care.

Physician-Assisted Suicide

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.

A comparison of the resources used in advanced cancer care between two different strong opioids: an analysis of naturalistic practice in the UK

OBJECTIVE

To assess the resource implications of using strong opioids in patients with advanced cancer in the UK, based on naturalistic practice, in order to develop the evidence base supporting better management.

DESIGN AND SETTING

A modelling study performed from the perspective of the UK's National Health Service (NHS). Study participants and interventions: A data set was created from the DIN-link database comprising 986 patients with advanced cancer who were prescribed either 12-hourly sustained release morphine (SR morphine; MST Continuous) ( n = 784) or transdermal fentanyl (Durogesic) (n = 202) as their first strong opioid between 1st January 1998 and 30th September 2000 and died during that period.

METHODS

Palliative care-related resource use data were obtained from the DIN-link database. Unit costs at 2000/2001 prices were applied to the resource use values to determine the mean NHS cost of palliative care from the start of treatment until death.

RESULTS

Patients initially treated with transdermal fentanyl started their strong opioid regime 8.5 years after diagnosis compared to 6.4 years after diagnosis in those who started SR morphine. This equates to an overall survival period from diagnosis of 8.8 years and 7.4 years respectively. Nevertheless, the total NHS cost of palliative care was similar between treatment groups, ranging from a mean 3087-3462 pounds per patient. Hospitalisation accounted for up to 71% of the total cost and opioids accounted for up to a further 17%. Less than one-third of patients received 4-hourly morphine as part of their initial opioid treatment despite UK guidelines recommending that moderate-to-severe pain should always be managed initially with an immediate-release preparation. Additionally, patients who received transdermal fentanyl as part of their initial treatment received significantly more laxative prescriptions than patients who started with SR morphine.

CONCLUSIONS

SR morphine and transdermal fentanyl seem to be used in different situations. The results also confirm previous findings that pain management in cancer patients is often sub-optimal. The low contribution of opioids to the overall costs indicates that this should not be an obstacle to starting this aspect of palliative care earlier in disease progression. This characterisation of the resource implications of using SR morphine and transdermal fentanyl should enable purchasers and providers to optimise the availability of strong opioids for cancer patients on medical, economic and humanitarian grounds.

Last hours of living

The last hours of living can be one of the most important times in the life of any patient and his/her family. With appropriate preparation and careful management of the process by skilled clinicians, dying and death can be a comfortable and even rewarding experience for everyone involved. After death, careful attention to the grief of survivors can help them cope with their loss and rebuild their lives.

Responding to persistent requests for assistance in dying: a phenomenological inquiry

Little is known about how American nurses understand and respond to requests made by decisionally capable patients for assistance in dying. This article is based on a broader qualitative study first reported elsewhere (Schwarz, 2003). The study used phenomenological interpretation and analysis of stories told by 10 nurses who worked in home hospice, critical care, and HIV/AIDS care settings. Persistent requests for assistance in dying were relatively uncommon, but when heard, participants provided the following responses: refusing assistance, administering palliative drugs that might secondarily hasten dying, tacitly permitting and not interfering with patient or family plans to hasten death, and actively providing direct assistance in dying. Nurses' responses were context-driven; they did not seek guidance from professional codes of ethics or colleagues. Secrecy and collusion were routinely practised. Few participants unequivocally agreed or refused to help patients die; most struggled to find morally and legally acceptable ways to help patients die well. Regardless of how they responded, nurses who believed they had hastened death described feelings of guilt and moral distress. Healthcare professionals who provide care for symptomatic dying patients need opportunities to meet with supportive colleagues, to share the experience of troubling cases and of moral conflict, and to be supported and heard in a 'safe' environment.

Palliative care in the intensive care unit: barriers, advances, and unmet needs

The concept that critical illness and terminal illness are necessarily distinct entities has given way to the understanding that they often exist on the same spectrum. Consequently, there is growing consensus that palliative treatment must coexist with attempts at restorative treatment in the intensive care unit (ICU). Palliative care in the ICU has evolved from a relatively one-dimensional construct of terminal sedation in dying patients to a multidisciplinary field addressing symptom control, physician-patient-family communication,spiritual needs, and the needs of health care providers. As ongoing research efforts yield new insights, our ability to practice evidence-based palliative care in the ICU will grow, and new avenues for improvement will become evident.

Advances in palliative care relevant to the wider delivery of healthcare

The availability of a variety of opioids, together with the discovery of new uses for old drugs (such as ketamine), assists individualised pain management in palliative care. Experience in palliative care provides reassurance that the effective use of opioids and sedatives does not accelerate the approach of death. In taking patient histories, recognising the spiritual component of life experience enlarges the focus of care. Interdisciplinary care brings many different insights to care situations in a prospective and cooperative way. Models of bereavement care established in palliative care units deserve wider implementation in medicine. An "experiential" model of medical student education encourages a focus on the whole experience of patients and their journey with their carers.