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Rholl EL, Baughman KR, Leuthner SR. Withdrawing and Withholding Life-Sustaining Medical Therapies in the Neonatal Intensive Care Unit: Case-Based Approaches to Clinical Controversies. Clin Perinatol 2022; 49:127-135. [PMID: 35209995 DOI: 10.1016/j.clp.2021.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In cases whereby the continuation of life-sustaining medical therapies is not in the infant's best interest and does not align with the parents' goals, it is ethically and morally advisable to withhold/withdraw life-sustaining medical therapies. Withdrawing/withholding artificial nutrition hydration is not morally or ethically different from other medical treatments. Determination of what and when to withdraw should occur through shared decision-making considering the parents' values and the infant's physiology and comfort. The practice of physician recommendations followed by parental informed nondissent should be considered in these instances.
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Affiliation(s)
- Erin L Rholl
- Division of Hospital Medicine, PANDA Palliative Care Team, Children's National Medical Center, 111 Michigan Avenue, Washington, DC 20010, USA
| | - Katie R Baughman
- Department of Pediatrics, Children's Wisconsin, Medical College of Wisconsin, 8915 W. Connell Court, Milwaukee, WI 53226, USA
| | - Steven R Leuthner
- Department of Pediatrics, Children's Wisconsin, Medical College of Wisconsin, 999 North 92nd Street, Suite C410, Wauwatosa, WI 53226, USA.
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2
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Bozzetti F. Nutritional Support in Terminal Cancer Patients. Am J Med 2021; 134:e473. [PMID: 34340761 DOI: 10.1016/j.amjmed.2020.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 10/20/2022]
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Nutrition and gastroenterological support in end of life care. Best Pract Res Clin Gastroenterol 2020; 48-49:101692. [PMID: 33317794 DOI: 10.1016/j.bpg.2020.101692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/25/2020] [Accepted: 10/06/2020] [Indexed: 01/31/2023]
Abstract
Malnutrition and the broad spectrum of cancer cachexia frequently occur in patients with malignant disease of all tumour stages and impact on survival and quality of life of patients. Structured screening for the risk of malnutrition with validated tools and nutritional assessment are the prerequisite for adequate nutritional support in cancer patients. In patients receiving tumour directed therapy, the patients diet should meet the requirements to give optimal support, while later on comfort feeding is part of symptom focused palliation. The basis of nutritional support in a malnourished patient is nutritional counselling, and nutritional support can be offered within a step-up approach meeting the patient's needs. A combination of nutritional support with interventions targeting metabolic changes and physical exercise is suggested to treat cancer cachexia.
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Torregrosa Almonacid L, Gómez M, Cuadrado Franco DM, Gempeler Rueda FE, Rugeles Quintero S. Futilidad en cirugía: el caso de la gastrostomía. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La nutrición se ha considerado tradicionalmente una necesidad básica y el garantizarla se ha asumido como una responsabilidad médica. Se cuestiona la utilización de procedimientos que permitan la nutrición artificial en situaciones clínicas limítrofes, en las cuales su beneficio puede ser limitado o nulo. En el presente estudio se busca determinar el éxito de un procedimiento quirúrgico, la gastrostomía, desde la perspectiva del beneficio para el paciente y, así, aproximarse a una definición de gastrostomía fútil.
Métodos. Se llevó a cabo un estudio observacional, retrospectivo y analítico, basado en la revisión de las historias clínicas de los pacientes sometidos a gastrostomía abierta o endoscópica en el Hospital Universitario San Ignacio. El grupo de investigadores principales analizaron los datos para determinar si las gastrostomías practicadas fueron fútiles o no lo fueron.
Resultados. Se incluyeron 145 pacientes tratados durante el periodo del 2015 al 2018 y en el 53 % de los cuales se cumplieron los criterios para considerar el procedimiento como fútil. Los procedimientos –108 endoscópicos y 37 abiertos–fueron practicados principalmente en pacientes con neoplasias de cabeza y cuello, y enfermedades neurológicas. Si bien no hubo mortalidad asociada con el procedimiento, 26 de los pacientes fallecieron en los primeros 15 días después de la intervención.
Discusión. El determinar en qué condiciones se debe considerar la gastrostomía una intervención realmente beneficiosa es un desafío. Es necesario incorporar un análisis ético, antes de ofrecer este procedimiento, con el fin de minimizar las gastrostomías innecesarias que actualmente constituyen un problema global.
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Bhattacharya S. Dilemmas faced by health professionals surrounding life-sustaining treatment. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2019; 28:1262-1263. [PMID: 31680578 DOI: 10.12968/bjon.2019.28.19.1262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Sayantan Bhattacharya
- Senior Fellow, Upper Gastro-intestinal Surgery, Aintree University Hospital, Liverpool
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Gastric Emptying of Elemental Liquid Diets Versus Semisolid Diets in Bedridden Gastrostomy-fed Patients. J Clin Gastroenterol 2019; 53:373-378. [PMID: 29570173 DOI: 10.1097/mcg.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Aspiration is a common problem in bedridden gastrostomy-fed patients. We compared gastric emptying of an elemental liquid diet and a commercial semisolid diet in bedridden gastrostomy-fed patients. METHODS Study 1: from January 2013 to December 2016, consecutive bedridden patients receiving percutaneous endoscopic gastrostomy (PEG) semisolid feeding hospitalized due to aspiration pneumonia were switched to elemental liquid diet feedings. The frequency of defecation, tube feed contents aspirated from the trachea, and aspiration pneumonia during hospitalization were retrospectively reviewed. Study 2 was a randomized, crossover trial comparing C sodium acetate gastric emptying of a commercial elemental liquid or a commercial semisolid diet in bedridden PEG patients and controls. RESULTS Study 1: 18 patients were enrolled. Elemental liquid diet was aspirated from the trachea in 1 (5.6%) (once in 24 observations); neither aspiration pneumonia nor diarrhea developed during elemental liquid diet feeding over 2 weeks observation. Study 2: 8 PEG patients and 8 healthy subjects were separately randomized to assess gastric emptying of the commercial elemental and semisolid diets. The elemental liquid diet was associated with a significant decrease of the 10%, 30%, or 50% emptying (excretion) time (P<0.05) and an increased the area under the curve (% dose/h) compared with the commercial semisolid diet (P<0.05). In healthy subjects there was no significant difference in gastric empting between the 2 diets. CONCLUSIONS Elemental liquid diets emptied more rapidly from the stomach than semisolid diets in bedridden PEG patients. They may prevent or reduce aspiration pneumonia compared with semisolid diets.
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Abstract
A large number of dying patients receive palliative care at home, and although palliative sedation (PS) may be indicated, literature describing PS at home is scarce. This study is a retrospective description of PS delivered to terminal patients at home from December 2000 to March 2006. A total of 36 patients (with a median age of 65) received home PS. Cancer was the diagnosis for 35 patients, and most patients suffered more than one symptom — most commonly, intractable pain, followed by agitation and existential suffering. Drugs used included midazolam, morphine, haloperidol, fentanyl TTS, and promethazine. Median duration of sedation was three days; median time to symptom control was 24 hours. Good symptom control was achieved in 28 out of 36 patients, and 34 of the patients died at home. In conclusion, PS was a feasible and successful treatment option, improving the care of terminal patients whose preference is to die at home.
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Affiliation(s)
- Ora S. Rosengarten
- Jerusalem Home Hospital Unit, Institute of Geriatric Medicine, Clalit Health Services, Jerusalem, Israel
| | - Yonat Lamed
- Jerusalem Home Hospital Unit, Institute of Geriatric Medicine, Clalit Health Services, Jerusalem, Israel
| | - Timna Zisling
- Jerusalem Home Hospital Unit, Institute of Geriatric Medicine, Clalit Health Services, Jerusalem, Israel
| | - Ayelet Feigin
- Jerusalem Home Hospital Unit, Institute of Geriatric Medicine, Clalit Health Services, Jerusalem, Israel
| | - Jeremy M. Jacobs
- Jerusalem Home Hospital Unit, Institute of Geriatric Medicine, Clalit Health Services, Jerusalem, Israel
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Abstract
From the time of Hippocrates, approximately 2500 years ago, medical ethics has been seen as an essential complement to medical science in pursuit of the healing art of medicine. This is no less true today, not only for physicians but also for other essential professionals involved in patient care, including clinical nutrition support practitioners. One aspect of medical ethics that the clinical nutritionist must face involves decisions to provide, withhold, or withdraw artificial nutrition and hydration. Such a decision is not only technical but often has a strong moral component as well. Although it is the physician who writes any such order, the clinical nutritionist as fellow professional should be a part not only of the scientific aspects of the order but of the moral discourse leading to such an order and may certainly be involved in counseling physicians, other healthcare providers, patients, and families alike. This paper is intended to give the clinical nutritionist a familiarity with the discipline of medical ethics and its proper relationship to medical science, politics, and law. This review will then offer a more specific analysis of the ethical aspects of decisions to initiate, withhold, or withdraw artificial nutrition and hydration (ANH) and offer particular commentary on the ethically significant pronouncements of Pope John Paul II in March of 2004 related to vegetative patients and artificial or "assisted" nutrition and hydration.
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Affiliation(s)
- Robert L Fine
- Office of Clinical Ethics, Baylor Health Care System; Director, Palliative Care Consultation Service, Baylor University Medical Center, 3434 Swiss Avenue, Suite 205, Dallas, TX 75204, USA.
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Fuhrman MP, Herrmann VM. Bridging the Continuum: Nutrition Support in Palliative and Hospice Care. Nutr Clin Pract 2017; 21:134-41. [PMID: 16556923 DOI: 10.1177/0115426506021002134] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Clinicians and patients in today's technically focused healthcare environment are often faced with decisions of what should be done vs what could be done. The decision to provide or not provide nutrition support during palliative care and hospice care requires an understanding of and respect for patient wishes, an appreciation for the expectations of the patient and family, and open and effective communication. There can be confusion and disagreement concerning what nutrition therapies should be continued and which ones stopped. These decisions can be facilitated by answering the question: When do the burdens of nutrition support outweigh the benefit to the patient? The patient, family members, and healthcare providers should openly discuss and agree upon the goals of nutrition support during palliative care and hospice care.
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Goto H, Yoshikawa S, Otsuka M, Omodaka T, Yoshimi K, Yoshida Y, Yamamoto O, Kiyohara Y. Symptom prevalence in patients with advanced skin cancer. J Dermatol 2016; 44:123-126. [PMID: 27451253 DOI: 10.1111/1346-8138.13527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 06/19/2016] [Indexed: 01/04/2023]
Abstract
Knowledge of the prevalence of symptoms in patients with incurable cancer in the terminal stage is important for clinicians. However, there has been no report on the prevalence of symptoms in patients with incurable skin cancer. We analyzed the prevalence of symptoms in 224 patients who died due to skin cancer in our center. These data were obtained from medical records compiled by a miscellaneous population of medical staff retrospectively. We evaluated the symptoms at 3 months, 1 month, 2 weeks, 1 week and 3 days before the patients died. Data for symptoms included Eastern Cooperative Oncology Group performance status and the presence or absence of the following 13 symptoms: (i) bleeding or exudate; (ii) pain or necessity for an analgesic; (iii) fatigue; (iv) anorexia; (v) nausea; (vi) dyspnea or need for oxygen administration; (vii) bloating; (viii) insomnia; (ix) delirium; (x) drowsiness; (xi) anemia; (xii) spasm; and (xiii) paralysis. The average performance status gradually progressed. Pain and anorexia were the most common symptoms in patients with advanced skin cancer. Dyspnea, anemia and drowsiness also tended to be frequent as death approached despite the fact that the frequencies of these symptoms were not high 3 months before death. We considered that frequencies of prevalence of pain and dyspnea were due to bone and lung metastases. Bleeding or exudate from lesions is a characteristic symptom in patients with skin cancer. Our results regarding the prevalence of symptoms in patients with advanced skin cancer will be helpful for medical professionals to assess patients' conditions and to plan treatment.
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Affiliation(s)
- Hiroyuki Goto
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan.,Division of Dermatology, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, Tottori University, Tottori, Japan
| | | | - Masaki Otsuka
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Kosuke Yoshimi
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yuichi Yoshida
- Division of Dermatology, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Osamu Yamamoto
- Division of Dermatology, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Yoshio Kiyohara
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan
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Sciubba JJ. End-of-life care in the head and neck cancer patient. Oral Dis 2016; 22:740-744. [DOI: 10.1111/odi.12506] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 01/10/2023]
Affiliation(s)
- JJ Sciubba
- The Milton J. Dance Head and Neck Center; The Johns Hopkins School of Medicine; Baltimore MD USA
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Wang X, Huang Y, Radha Krishna L, Puvanendran R. Role of the Nasogastric Tube and Lingzhi (Ganoderma lucidum) in Palliative Care. J Pain Symptom Manage 2016; 51:794-799. [PMID: 26891608 DOI: 10.1016/j.jpainsymman.2015.11.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 11/23/2015] [Accepted: 11/27/2015] [Indexed: 11/17/2022]
Abstract
Decision-making on behalf of an incapacitated patient at the end of life is a complex process, particularly in family-centric societies. The situation is more complex when attempts are made to accommodate Eastern concepts of end-of-life care with more conventional Western approaches. In this case report of an incapacitated 74-year-old Singaporean man of Malay descent with relapsed Stage 4 diffuse large B cell lymphoma who was without an established lasting power of attorney, we highlight the difficult deliberations that ensue when the patient's family, acting as his proxy, elected to administer lingzhi through his nasogastric tube (NGT). Focusing on the questions pertaining to end-of-life decision-making in Asia, we consider the issues surrounding the use of NGT and lingzhi in palliative care (PC) and the implementation of NGT for administering lingzhi in a PC setting, particularly in light of a dearth of data on such treatment measures among PC patients.
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Affiliation(s)
- Xiaohui Wang
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Youyi Huang
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Lalit Radha Krishna
- Duke-NUS Graduate Medical School, Singapore, Singapore; National Cancer Centre, Singapore, Singapore
| | - Rukshini Puvanendran
- Duke-NUS Graduate Medical School, Singapore, Singapore; KK Women's and Children's Hospital, Singapore, Singapore.
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Druml C, Ballmer PE, Druml W, Oehmichen F, Shenkin A, Singer P, Soeters P, Weimann A, Bischoff SC. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clin Nutr 2016; 35:545-56. [PMID: 26923519 DOI: 10.1016/j.clnu.2016.02.006] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 01/28/2016] [Accepted: 02/05/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient. METHODS The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members. RESULTS The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.
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Affiliation(s)
- Christiane Druml
- UNESCO Chair on Bioethics at the Medical University of Vienna, Collections and History of Medicine - Josephinum, Medical University of Vienna, Waehringerstrasse 25, A-1090 Vienna, Austria.
| | - Peter E Ballmer
- Department of Medicine, Kantonsspital Winterthur, Brauerstrasse 15, Postfach 834, 8401 Winterthur, Switzerland.
| | - Wilfred Druml
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Frank Oehmichen
- Department of Early Rehabilitation, Klinik Bavaria Kreischa, An der Wolfsschlucht 1-2, 01731 Kreischa, Germany.
| | - Alan Shenkin
- Department of Clinical Chemistry, University of Liverpool, Duncan Building, Daulby Street, Liverpool L69 3GA, UK.
| | - Pierre Singer
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Jean Leven Building, 6th Floor, Tel Aviv, Israel.
| | - Peter Soeters
- Department of Surgery, Academic Hospital Maastricht, Peter Debeyelaan 25, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
| | - Arved Weimann
- Department of General Surgery and Surgical Intensive Care, St Georg Hospital, Delitzscher Straße 141, 04129 Leipzig, Germany.
| | - Stephan C Bischoff
- Department of Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599 Stuttgart, Germany.
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Bragazzi NL, Briki W, Khabbache H, Rammouz I, Chamari K, Demaj T, Re TS, Zouhir M. Ramadan Fasting and Patients with Cancer: State-of-the-Art and Future Prospects. Front Oncol 2016; 6:27. [PMID: 26904505 PMCID: PMC4748028 DOI: 10.3389/fonc.2016.00027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 01/25/2016] [Indexed: 01/09/2023] Open
Abstract
Ramadan fasting represents one of the five pillars of the Islam creed. Even though some subjects (among which patients) are exempted from observing this religious duty, they may be eager to share this particular moment of the year with their family and peers. However, there are no guidelines or standardized protocols that can help physicians to properly address the issue of patients with cancer fasting in Ramadan and correctly advising them. Moreover, in a more interconnected and globalized society, in which more and more Muslim patients live in the Western countries, this topic is of high interest also for the general practitioner. For this purpose, we carried out a systematic review on the subject. Our main findings are that (1) very few studies have been carried out, addressing this issue, (2) evidence concerning quality of life and compliance to treatment is contrasting and scarce, and (3) generally speaking, few patients ask their physicians whether they can safely fast or not. For these reasons, further research should be performed, given the relevance and importance of this topic.
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Affiliation(s)
- Nicola Luigi Bragazzi
- Department of Health Sciences (DISSAL), School of Public Health, University of Genoa, Genoa, Italy; Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Walid Briki
- College of Arts and Sciences, Qatar University , Doha , Qatar
| | - Hicham Khabbache
- Laboratoire Etudes théologiques, Sciences Cognitives et Sociales, Faculty of Literature and Humanistic Studies, Sais, Sidi Mohamed Ben Abdellah University , Fez , Morocco
| | - Ismail Rammouz
- Psychiatric Centre Ibn Alhassan, CHU Hassan II, Fez, Morocco; Clinical Neuroscience Laboratory, Sidi Mohamed Ben Abdellah University, Fez, Morocco
| | - Karim Chamari
- Athlete Health and Performance Research Centre, Aspetar, Qatar Orthopaedic and Sports Medicine Hospital , Doha , Qatar
| | - Taned Demaj
- Emergency Department (Servizio di Emergenza Sanitaria Territoriale 118), Ospedale Maggiore della Carità , Novara , Italy
| | | | - Mohamed Zouhir
- Laboratoire Etudes théologiques, Sciences Cognitives et Sociales, Faculty of Literature and Humanistic Studies, Sais, Sidi Mohamed Ben Abdellah University , Fez , Morocco
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Tsiamis C, Tounta E, Poulakou-Rebelakou E. The "Endura" of The Cathars' Heresy: Medieval Concept of Ritual Euthanasia or Suicide? JOURNAL OF RELIGION AND HEALTH 2016; 55:174-180. [PMID: 25716628 DOI: 10.1007/s10943-015-0021-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The aim of the study is to explore the medieval concepts on the voluntary death of severely sick people, as they emerge through the endura (endurance) of the heresy of the Cathars in France (twelfth to fourteenth centuries). The endura was the prerequisite act of repentance that would allow the fallen soul to return to heaven. The endura was a necessary act of repentance, after the performance of a ceremonial purification of the soul (consolamentum), and consisted of the patients' voluntary abstention from vital food. The consolamentum and endura could be performed in the final stage of a disease with the consent of the patients or their relatives. The role of the Cathar physician was only to determine the severity of the disease and the forthcoming death of the patient. The physician was not allowed to take steps that would deprive the life of the patient, and the performance of the ritual endura was duty of the spiritual leaders of the community. The modern ethical approach to this subject is dictated by the medieval belief on the salvation of the soul and tries to answer the question of whether the endura could be seen as a medieval concept of a ritual euthanasia or fell within the theological sin of suicide.
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Affiliation(s)
- Costas Tsiamis
- Department of Microbiology, Athens Medical School, University of Athens, M. Asias 75, 115-27, Athens, Greece.
| | - Eleni Tounta
- Department of Ancient Greek, Roman, Medieval and Byzantine History, Faculty of History and Archaeology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Madden K, Wolfe J, Collura C. Pediatric Palliative Care in the Intensive Care Unit. Crit Care Nurs Clin North Am 2015; 27:341-54. [PMID: 26333755 DOI: 10.1016/j.cnc.2015.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The chronicity of illness that afflicts children in Pediatric Palliative Care and the medical technology that has improved their lifespan and quality of life make prognostication extremely difficult. The uncertainty of prognostication and the available medical technologies make both the neonatal intensive care unit and the pediatric intensive care unit locations where many children will receive Pediatric Palliative Care. Health care providers in the neonatal intensive care unit and pediatric intensive care unit should integrate fundamental Pediatric Palliative Care principles into their everyday practice.
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Affiliation(s)
- Kevin Madden
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1414, Houston, TX 77030, USA.
| | - Joanne Wolfe
- Pediatric Palliative Care, Pediatric Palliative Care Service, Department of Psychosocial Oncology and Palliative Care, Children's Hospital Boston, Dana-Farber Cancer Institute, Harvard Medical School, DA2-012, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Christopher Collura
- Division of Neonatal Medicine, Department of Pediatric & Adolescent Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55902, USA
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van de Vathorst S. Artificial nutrition at the end of life: ethical issues. Best Pract Res Clin Gastroenterol 2014; 28:247-53. [PMID: 24810185 DOI: 10.1016/j.bpg.2014.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 02/06/2014] [Accepted: 02/09/2014] [Indexed: 01/31/2023]
Abstract
Artificial nutrition is a medical treatment that first of all needs a sound scientific base before prescribing it. This base is absent for dying patients and patients in the end stage of dementia. Because feeding is a very emotional and symbolical issue, patient and family may request this treatment despite the lack of evidence. These issues should be addressed in good communication with patient and relatives. For comatose patients and patients in a persistent vegetative state artificial nutrition is a necessary support to bridge the time until either recovery is imminent or improbable. At that moment artificial nutrition no longer contributes to the life of the patient and should be ceased. Artificial nutrition has no place in patients that voluntary decide to stop eating and drinking in order to die.
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Affiliation(s)
- Suzanne van de Vathorst
- Department of Ethics and Philosophy, Na 2117, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands; Department of General Practice, J2-123, AMC, PO Box 22660, 1100 DD Amsterdam, The Netherlands.
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Horntvedt MET, Romøren M, Solvoll BA. Ethical problems related to intravenous fluids in nursing homes. Nurs Ethics 2014; 21:890-901. [DOI: 10.1177/0969733014521093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Intravenous fluids and/or antibiotics are applied to only a limited extent in Norwegian nursing homes, and the patients are often sent to hospital in these situations. A transfer and a stay in hospital may be unnecessary strains for frail older patients. Given this background, a collaborative research project was initiated in a Norwegian county in 2009. A teaching programme was developed, which aimed to strengthen the awareness of ethics, assessments and practical procedures related to intravenous fluid and/or antibiotics among healthcare professionals. Objectives: This qualitative study aimed to increase our knowledge of the ethical problems experienced by nursing home nurses in situations related to the administration of intravenous fluids and/or antibiotics. Research design: An exploratory design was used, and five focus group interviews were conducted with 26 registered nurses. A hermeneutic analytic approach was applied. Ethical considerations: This study was reported to the Norwegian Social Science Data Services in May 2010. The Regional Committee for Medical and Health Research Ethics approved the collaborative research project. Findings: The analysis showed that the nurses experienced difficult decision-making situations, which were interpreted as external pressure and internal pressure. External pressure emerged in interactions with patients and relatives. Organizational factors were also interpreted as external pressure. Internal pressure was interpreted as the nurses’ experience of feeling inadequate in situations where it was difficult to protect the dignity of patients. Discussion: These findings correspond with international studies, which show that ethical problems often arise during decision-making situations. Conclusion: In agreement with the definition of an ethical problem, we found that the nurses experienced uncertainty and disagreements about how situations should be managed. External and internal pressures related to intravenous fluids and/or antibiotics in nursing homes have not been reported in previous studies. Thus, these findings merit further exploration.
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Affiliation(s)
| | - Maria Romøren
- University of Oslo and Vestfold Hospital Trust, Norway
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Béranger A, Boize P, Viallard ML. [The practices of withdrawing artificial nutrition and hydration in the neonatal intensive care unit: a preliminary study]. Arch Pediatr 2013; 21:170-6. [PMID: 24374024 DOI: 10.1016/j.arcped.2013.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 06/28/2013] [Accepted: 11/19/2013] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Prematurity is one of the etiologies for severe neurological complications. Decisions to withdraw therapeutics, including artificial nutrition and hydration (ANH), are sometimes discussed. But can one withdraw ANH if the patient is a child suffering from severe neurological conditions, based on his best interests? The aim of this study was to further the understanding of the complexity of the withdrawal of ANH and its implementation in the neonatal intensive care unit (NICU). METHOD This qualitative preliminary study based on a questionnaire was conducted on the staff in the NICU of the Pontoise medical center (France) in February 2012. The results were compared with the current knowledge on this issue and sociological data. RESULTS Ten of the hospital staff members responded to the questionnaire: 60% considered ANH as a treatment, but the status of ANH (i.e., treatment or care) remained undefined for several respondents. Comparison with the withdrawal of mechanical ventilation or adult practices seemed to be inadequate. The staff had little experience in the domain and therefore few certainties on practices. Half of the respondents indicated that terminal sedation needed to be used. For the other half, it depended on the patient's pain. Timing was also an important notion given that the newborn is a being developing and evolving each in its own way. CONCLUSION The withdrawal of ANH remains controversial in the NICU. Humanity, culture, and the relationship to others are ever present in the decision-making process, creating a moral opposition above and beyond ethical reflection.
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MESH Headings
- Attitude of Health Personnel
- Brain Damage, Chronic/mortality
- Brain Damage, Chronic/therapy
- Ethics, Medical
- Ethics, Nursing
- Euthanasia, Active/ethics
- Fluid Therapy/ethics
- France
- Humans
- Infant, Newborn
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/therapy
- Intensive Care Units, Neonatal/ethics
- Nutritional Support/ethics
- Palliative Care/ethics
- Patient Care Team/ethics
- Pilot Projects
- Qualitative Research
- Surveys and Questionnaires
- Withholding Treatment/ethics
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Affiliation(s)
- A Béranger
- Laboratoire d'éthique médicale et de médecine légale, hôpitaux de Paris, université Paris-Descartes, 45, rue des Saints-Pères, 75006 Paris, France.
| | - P Boize
- Réanimation néonatale, centre hospitalier René-Dubos, 6, avenue de l'Île-de-France, BP 79, 95303 Cergy-Pontoise cedex, France
| | - M-L Viallard
- EA 4596 « politique, éthique, santé », Paris-Descartes, Sorbonne Paris Cité, 45, rue des Saints-Pères, 75006 Paris, France; Équipe mobile d'accompagnement et de soins palliatifs pédiatrique et adulte, Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
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Matsusaka K, Ohi A, Tahata K, Shimizu A, Numata M, Ohmiya R, Kubo H, Oikawa T, Yamaya M. Addition of oral cavity brushing and rehabilitation reduces fever in tube-fed patients. Geriatr Gerontol Int 2013; 13:1082-4. [DOI: 10.1111/ggi.12088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kaoru Matsusaka
- National Hospital Organization, Hachinohe National Hospital; Hachinohe; Japan
| | - Atsuko Ohi
- Department of Nursing; National Hospital Organization, Sendai Medical Center; Sendai; Japan
| | - Keita Tahata
- National Hospital Organization, Hachinohe National Hospital; Hachinohe; Japan
| | - Ayako Shimizu
- National Hospital Organization, Hachinohe National Hospital; Hachinohe; Japan
| | - Megumi Numata
- National Hospital Organization, Hachinohe National Hospital; Hachinohe; Japan
| | - Ruriko Ohmiya
- National Hospital Organization, Hachinohe National Hospital; Hachinohe; Japan
| | - Hiroshi Kubo
- Department of Advanced Preventive Medicine for Infectious Disease; Tohoku University Graduate School of Medicine; Sendai; Japan
| | - Takashi Oikawa
- National Hospital Organization, Hachinohe National Hospital; Hachinohe; Japan
| | - Mutsuo Yamaya
- Department of Advanced Preventive Medicine for Infectious Disease; Tohoku University Graduate School of Medicine; Sendai; Japan
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Therapeutic effects of mosapride citrate and lansoprazole for prevention of aspiration pneumonia in patients receiving gastrostomy feeding. J Gastroenterol 2013; 48:1105-10. [PMID: 23238778 DOI: 10.1007/s00535-012-0725-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 11/23/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Aspiration pneumonia is an emerging problem in patients receiving gastrostomy feeding. This study is designed to clarify the therapeutic effects of mosapride citrate and lansoprazole for prevention of aspiration pneumonia in patients receiving gastrostomy feeding. METHODS The study subjects were 119 patients with dysphasia who required gastrostomy feeding. They were randomly assigned to the control (without medication), lansoprazole (15 mg, 1/day), and mosapride (5 mg, 3/day) groups. The number of days with fever (≥37.8 °C), vomiting, and antibiotics administration, as well as the occurrence of pneumonia were investigated during the 6-month observation period. RESULTS The incidence of pneumonia during the observation period was significantly lower in the mosapride group as compared to the control (7/38 vs. 16/40, p = 0.038) and lansoprazole (vs. 20/41, p = 0.005) groups. The mosapride group also showed a significant decrease in days with fever and antibiotics administration as compared to the other groups. Multivariate analysis revealed that the presence of hiatal hernia was a significant risk factor and administration of mosapride was a significant preventive factor for pneumonia. CONCLUSION Mosapride has a preventive effect on occurrence of pneumonia in patients receiving gastrostomy feeding.
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Vesely C, Beach B. One Facility's Experience in Reframing Nonfeeding into a Comprehensive Palliative Care Model. J Obstet Gynecol Neonatal Nurs 2013; 42:383-9. [DOI: 10.1111/1552-6909.12027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Rapoport A, Shaheed J, Newman C, Rugg M, Steele R. Parental perceptions of forgoing artificial nutrition and hydration during end-of-life care. Pediatrics 2013; 131:861-9. [PMID: 23569099 DOI: 10.1542/peds.2012-1916] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Forgoing artificial nutrition and hydration (FANH) in children at the end of life (EOL) is a medically, legally, and ethically acceptable practice under specific circumstances. However, most of the evidence on FANH involves dying adults. There is a paucity of pediatric evidence to guide health care providers' and parents' decision-making around this practice. Objectives were (1) to explore the experiences of bereaved parents when a decision had been made to FANH during EOL care for their child and (2) to describe the perceived quality of death in these children, as reported by their parents. METHODS This was a qualitative study using in-depth interviews with parents whose children died after a decision to FANH. Parental perceptions about the experience and their child's quality of death were explored. Interviews were audiotaped and transcribed, then data were analyzed by using interpretive description methodology. RESULTS All parents were satisfied with their decision to FANH and believed that their child's death was generally peaceful and comfortable. The child's perceived poor quality of life was central to the decision to FANH, with feeding intolerance often contributing to this perception. Despite overall satisfaction, all parents had doubts and questions about the decision and benefited from ongoing assurances from the clinical team. CONCLUSIONS FANH in children at the EOL is an acceptable form of palliation for some parents and may contribute to a death that is perceived to be peaceful and comfortable. In situations in which FANH may be a reasonable possibility, physicians should be prepared to introduce the option.
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Affiliation(s)
- Adam Rapoport
- Paediatric Advanced Care Team, Hospital for Sick Children, Toronto, ON, Canada.
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25
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Holmdahl S, Sävenstedt S, Imoni R. Parenteral nutrition in home-based palliative care: Swedish district nurses experiences. Scand J Caring Sci 2013; 28:89-96. [DOI: 10.1111/scs.12038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 02/11/2013] [Indexed: 10/27/2022]
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Abstract
Introduction: The decision-making process underlying caregivers’ choice to continue feeding at the end of life is not well understood. Objectives: To provide a better understanding of the complex interplay of factors that influence the decision by caregivers to continue feeding. Methods: Palliative care patients and their main caregiver recruited at National Cancer Centre Singapore between May and July 2011 were included. Data were collected using an interviewer-administered questionnaire. Results: One hundred respondents were included. Three major prevailing themes were identified: filial piety, source of hope, and expression of affection. Nonparametric statistical testing showed that patients and caregivers shared similar views about feeding at the end of life. Discussion: The major themes identified above undergird the caregiver’s decision to continue feeding at the end of life.
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Affiliation(s)
- Hui Zhong Chai
- Department of Internal Medicine, Singapore General Hospital, Singapore
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27
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Cseko GC, Tremaine WJ. The Role of the Institutional Review Board in the Oversight of the Ethical Aspects of Human Studies Research. Nutr Clin Pract 2013; 28:177-81. [DOI: 10.1177/0884533612474042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Gary C. Cseko
- Office of Human Research Protection, Mayo Clinic, Rochester, Minnesota
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28
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Chantre N. Maintien/arrêt de l’alimentation artificielle : souffrances induites. Que peut-on en dire ? Arch Pediatr 2012. [DOI: 10.1016/s0929-693x(12)71163-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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29
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Irvin W, Muss HB, Mayer DK. Symptom management in metastatic breast cancer. Oncologist 2011; 16:1203-14. [PMID: 21880861 PMCID: PMC3228166 DOI: 10.1634/theoncologist.2011-0159] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 07/12/2011] [Indexed: 11/17/2022] Open
Abstract
Approximately 40,000 women die as a result of breast cancer each year and many more live with advanced disease. When breast cancer recurs, the goals of treatment often shift from one of cure to controlling the disease for as long as possible while palliating symptoms interfering with the patient's functional status and quality of life. This requires ongoing discussions with the patient and family about the goals of care. Many symptoms depend on the site of metastasis, with bone being the most frequent, and commonly occur with fatigue, depression, insomnia, and pain. The purpose of this paper is to identify and provide an overview of the management of the most common symptoms in patients with breast cancer metastases.
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Affiliation(s)
- William Irvin
- Lineberger Comprehensive Cancer Center; University of North Carolina–Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hyman B. Muss
- Lineberger Comprehensive Cancer Center; University of North Carolina–Chapel Hill, Chapel Hill, North Carolina, USA
| | - Deborah K. Mayer
- Lineberger Comprehensive Cancer Center; University of North Carolina–Chapel Hill, Chapel Hill, North Carolina, USA
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Abstract
The use of Nasogastric (NG) feeding in the provision of artificial nutrition and hydration at the end of life has, for the most part, been regarded as futile by the medical community. This position has been led chiefly by prevailing medical data. In Singapore, however, there has been an increase in its utilization supported primarily by social, religious and cultural factors expressly to prolong life of the terminally ill patient. Here this article will seek to review the ethical and clinical impact of this treatment and provide some understanding for such decisions in the light of the Duty of Palliative Care [DoPC]. Complemented by virtue ethics theory, the DoPC highlights and seeks to realize the individual case specific goals of care that maximize comfort and quality of life of the patient in the face of rapid attenuation of treatment options and the eminence of the final outcome by considering each of these factors individually in order to provide the best outcome for the patient and the family.
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Abstract
Pediatric surgeons can play an important role in offering procedures that may improve the quality of life for terminally ill children. As with all palliative interventions, surgical therapies should be evaluated in the context of explicitly defined treatment goals while weighing the risks and benefits of procedures in the context of a shortened life span. It is essential that pediatric surgeons become active members in the multidisciplinary team that provides palliative care.
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Affiliation(s)
- Julia Shelton
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-2730, USA
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32
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Buiting HM, Clayton JM, Butow PN, van Delden JJ, van der Heide A. Artificial nutrition and hydration for patients with advanced dementia: perspectives from medical practitioners in the Netherlands and Australia. Palliat Med 2011; 25:83-91. [PMID: 20870688 DOI: 10.1177/0269216310382589] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The appropriate use of artificial nutrition or hydration (ANH) for patients with advanced dementia continues to be a subject of debate. We investigated opinions of Dutch and Australian doctors about the use of ANH in patients with advanced dementia. We interviewed 15 Dutch doctors and 16 Australian doctors who care for patients with advanced dementia. We transcribed and analysed the interviews and held consensus meetings about the interpretation. We found that Dutch and Australian doctors use similar medical considerations when they decide about the use of ANH. In general, they are reluctant to start ANH. Disparities between the Dutch and Australian doctors are related to the process of decision-making: Dutch doctors seem to put more emphasis on a comprehensive assessment of the patient's actual situation, whereas Australian doctors are more inclined to use scientific evidence and advance directives. Furthermore, Dutch doctors take the primary responsibility themselves whereas Australian general practitioners seem to be more inclined to leave the decision to the family. It seems that Dutch and Australian doctors use somewhat different care approaches for patients with advanced dementia. Combining the Dutch comprehensive approach and the Australian analytic approach may serve the interest of patients and their families best.
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Affiliation(s)
- Hilde M Buiting
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands.
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33
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Olsen ML, Swetz KM, Mueller PS. Ethical decision making with end-of-life care: palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clin Proc 2010; 85:949-54. [PMID: 20805544 PMCID: PMC2947968 DOI: 10.4065/mcp.2010.0201] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Palliative sedation (PS) is the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. Although uncommon, some patients undergoing aggressive symptom control measures still have severe suffering from underlying disease or therapy-related adverse effects. In these circumstances, use of PS is considered. Although the goal is to provide relief in an ethically acceptable way to the patient, family, and health care team, health care professionals often voice concerns whether such treatment is necessary or whether such treatment equates to physician-assisted suicide or euthanasia. In this review, we frame clinical scenarios in which PS may be considered, summarize the ethical underpinnings of the practice, and further differentiate PS from other forms of end-of-life care, including withholding and/or withdrawing life-sustaining therapy and physician-assisted suicide and euthanasia.
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Affiliation(s)
| | - Keith M. Swetz
- Individual reprints of this article are not available. Address correspondence to Keith M. Swetz, MD, Division of General Internal Medicine, Palliative Medicine Program, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities. ACTA ACUST UNITED AC 2010; 110:1554-63. [DOI: 10.1016/j.jada.2010.08.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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35
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Sharp HM, Shega JW. Feeding tube placement in patients with advanced dementia: the beliefs and practice patterns of speech-language pathologists. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2009; 18:222-230. [PMID: 19106205 DOI: 10.1044/1058-0360(2008/08-0013)] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
PURPOSE To describe the beliefs and practices of speech-language pathologists (SLPs) about the use of percutaneous endoscopic gastrostomy (PEG) among patients with advanced dementia and dysphagia. METHOD A survey was mailed to a geographically stratified random sample of 1,050 medical SLPs. RESULTS The response rate was 57%, and 326 surveys met inclusion criteria. Fifty-six percent of SLPs recommended PEG for a patient with advanced dementia and dysphagia. Contrary to the evidence, many respondents believed that PEG improves nutritional status and increases survival. Relatively few SLPs believed that PEG improved patients' functional status or quality of life. Patient factors (e.g., age or prognosis) were more often identified as influences on recommendations for PEG than were extrinsic factors (e.g., cost). Nearly 40% believed that PEG was the standard of care, while 15% believed it should be. Very few SLPs (11%) would want a PEG themselves. Perceived standard of care was significantly related to both geographic region and population density (p < .05), but self-reported practices were not. CONCLUSIONS Discrepancies between SLPs' beliefs, the literature, and self-reported practices were observed. The findings suggest the need to connect the evidence base to clinical practice and to include SLPs in local and national discussions about end-of-life care protocols.
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Abstract
There is broad consensus that withholding or withdrawing medical interventions is morally permissible when requested by competent patients or, in the case of patients without decision-making capacity, when the interventions no longer confer a benefit to the patient or when the burdens associated with the interventions outweigh the benefits received. The withdrawal or withholding of measures such as attempted resuscitation, ventilators, and critical care medications is common in the terminal care of adults and children. In the case of adults, a consensus has emerged in law and ethics that the medical administration of fluid and nutrition is not fundamentally different from other medical interventions such as use of ventilators; therefore, it can be forgone or withdrawn when a competent adult or legally authorized surrogate requests withdrawal or when the intervention no longer provides a net benefit to the patient. In pediatrics, forgoing or withdrawing medically administered fluids and nutrition has been more controversial because of the inability of children to make autonomous decisions and the emotional power of feeding as a basic element of the care of children. This statement reviews the medical, ethical, and legal issues relevant to the withholding or withdrawing of medically provided fluids and nutrition in children. The American Academy of Pediatrics concludes that the withdrawal of medically administered fluids and nutrition for pediatric patients is ethically acceptable in limited circumstances. Ethics consultation is strongly recommended when particularly difficult or controversial decisions are being considered.
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Oriot D, Lassaunière JM. Physiopathologie et sémiologie de l’arrêt de nutrition et d’hydratation. MÉDECINE PALLIATIVE : SOINS DE SUPPORT - ACCOMPAGNEMENT - ÉTHIQUE 2008. [DOI: 10.1016/j.medpal.2008.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Nutritional support and risk status among cancer patients in palliative home care services. Support Care Cancer 2008; 17:153-61. [DOI: 10.1007/s00520-008-0467-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 04/30/2008] [Indexed: 10/22/2022]
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39
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Position of the American Dietetic Association: Ethical and Legal Issues in Nutrition, Hydration, and Feeding. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.jada.2008.03.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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40
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L’alimentation artificielle et l’hydratation chez la personne en état végétatif chronique : soin, traitement ou acharnement thérapeutique ? MEDECINE PALLIATIVE 2008. [DOI: 10.1016/j.medpal.2008.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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van der Riet P, Good P, Higgins I, Sneesby L. Palliative care professionals’ perceptions of nutrition and hydration at the end of life. Int J Palliat Nurs 2008; 14:145-51. [DOI: 10.12968/ijpn.2008.14.3.28895] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Phillip Good
- Calvary Mater Hospice, Calvary Mater Newcastle Hospital, Australia
| | - Isabel Higgins
- Research and Practice Development Unit, Division of Medicine, John Hunter Hospital, Hunter New England Health, New Lambton, Australia
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42
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Bernat JL. Ethical issues in the care of the patient with dementia. HANDBOOK OF CLINICAL NEUROLOGY 2008; 89:121-136. [PMID: 18631738 DOI: 10.1016/s0072-9752(07)01212-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- James L Bernat
- Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, Hanover, NH 03756, USA.
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43
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Bernat JL. Ethical issues in the management of patients with impaired consciousness. HANDBOOK OF CLINICAL NEUROLOGY 2008; 90:369-382. [PMID: 18631834 DOI: 10.1016/s0072-9752(07)01721-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Buiting HM, van Delden JJM, Rietjens JAC, Onwuteaka-Philipsen BD, Bilsen J, Fischer S, Löfmark R, Miccinesi G, Norup M, van der Heide A. Forgoing artificial nutrition or hydration in patients nearing death in six European countries. J Pain Symptom Manage 2007; 34:305-14. [PMID: 17606359 DOI: 10.1016/j.jpainsymman.2006.12.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Revised: 12/04/2006] [Accepted: 12/06/2006] [Indexed: 11/23/2022]
Abstract
Whether or not artificial nutrition or hydration (ANH) may be forgone in terminally ill patients has been the subject of medical and ethical discussions. Information about the frequency and background characteristics of making decisions to forgo ANH is generally limited to specific clinical settings. The aim of this study was to compare the practice of forgoing ANH in six European countries: Belgium, Denmark, Italy, The Netherlands, Sweden, and Switzerland. In each country, random samples were drawn from death registries. Subsequently, the reporting physician received a questionnaire about the medical decisions that preceded the patient's death. The total number of deaths studied was 20,480. The percentage of all deaths that were preceded by a decision to forgo ANH varied from 2.6% in Italy to 10.9% in The Netherlands. In most countries, decisions to forgo ANH were more frequently made for female patients, patients aged 80 years or older, and for patients who died of a malignancy or disease of the nervous system (including dementia). Of patients in whom ANH was forgone, 67%-93% were incompetent. Patients in whom ANH was forgone did not receive more potentially life-shortening drugs to relieve symptoms than other patients for whom other end-of-life decisions had been made. Decisions to forgo ANH are made in a substantial percentage of terminally ill patients. Providing all patients who are in the terminal stage of a lethal disease with ANH does not seem to be a widely accepted standard among physicians in Western Europe.
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Affiliation(s)
- Hilde M Buiting
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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He M, Ohrui T, Ebihara T, Ebihara S, Sasaki H, Arai H. MOSAPRIDE CITRATE PROLONGS SURVIVAL IN STROKE PATIENTS WITH GASTROSTOMY. J Am Geriatr Soc 2007; 55:142-4. [PMID: 17233710 DOI: 10.1111/j.1532-5415.2006.01026.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Parenteral nutrition is an expensive therapeutic modality that is used to treat patients with intestinal failure. The benefit it offers in terms of life prolongation needs to be weighed against its risks and burdens. Through the use of descriptive clinical vignettes, this article illustrates the ethical and legal principles that underpin decisions to administer and, more importantly, to withhold or withdraw parenteral nutrition.
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Affiliation(s)
- G M Sayers
- Department of General and Geriatric Medicine, Northwick Park Hospital, Harrow, UK
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48
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Abstract
BACKGROUND The care of patients in their last weeks of life is a fundamental palliative care skill, but few evidence-based reviews have focused on this critical period. METHOD A systematic review of published literature and expert opinion related to care in the last weeks of life. RESULTS The evidence base informing terminal care is largely descriptive, retrospective, or extrapolated. While home deaths and hospice use are increasing, medical care near death is becoming more aggressive and hospice lengths of stay remain short. Though the prediction of impending death remains imprecise, studies have identified several common terminal signs and symptoms. Decreased communication near death complicates the determination of patient wishes, and advanced directives prior to the terminal stage are recommended. Anorexia and cachexia are common in dying patients but there is no evidence that this process is painful or responsive to intervention. While there is general consensus that artificial nutrition is not beneficial in dying patients, the use of artificial hydration is controversial, especially in the setting of delirium. Breathlessness has been shown to benefit from oral and parenteral opioids but not anxiolytics. Accumulation of respiratory tract secretions (death rattle) is common and usually responds to antimuscarinics. Physical pain typically decreases toward death but its assessment in dying patients is difficult. Terminal delirium may occur in up to one-third of patients, may have a reversible cause, and may respond to antipsychotics or benzodiazepines. Palliative sedation is controversial but widely used, especially internationally. Caregiver stress and bereavement may benefit from improved communication and hospice involvement. CONCLUSION While the terminal care literature is characterized by varying quality, numerous knowledge gaps, and frequent inconsistencies, it supports several common clinical interventions. More research is needed to resolve controversies, define effective therapies, and improve the outcomes of dying patients.
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Affiliation(s)
- William M Plonk
- Division of General Medicine, Geriatrics, and Palliative Care, Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
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49
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Affiliation(s)
- Larry D Scott
- Division of Gastroenterology, Hepatology, and Nutrition, University of Texas Health Science Center at Houston, Houston, Texas, USA.
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50
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Nauck F, Klaschik E. [Cannabinoids in the treatment of the cachexia-anorexia syndrome in palliative care patients]. Schmerz 2004; 18:197-202. [PMID: 15221423 DOI: 10.1007/s00482-003-0277-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Loss of appetite and cachexia are frequent symptoms in palliative care patients. However, therapeutic regimens often prove ineffective, and the quality of life of many patients is significantly impaired by these symptoms. Causes and pathophysiology of anorexia and cachexia are complex and must be identified and treated. Symptomatic pharmacological therapy aims at metabolic, neuroendocrinological and catabolic changes. Prokinetic drugs, corticosteroids and gestagenes are used for symptomatic therapy. Recently, the use of cannabinoids for treatment of loss of appetite and cachexia has become the focus of interest. In cancer patients, cannabinoids proved more effective than placebo but less than gestagenes. Compared to placebo, higher efficacy of cannabinoids could be demonstrated in patients with AIDS as well as in patients with Morbus Alzheimer. However, side effects, such as dizziness, tiredness and daze led to discontinuation of the cannabinoid therapy in some patients.
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Affiliation(s)
- F Nauck
- Zentrum für Palliativmedizin, Malteser-Krankenhaus Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn.
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