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Luck G, Eggenberger TL, Bautista A, Peters D, Mellman RT, Keller KB, Jacomino M. Fearing Pain at the End of Life: A Review of Advance Directives. Am J Hosp Palliat Care 2024; 41:824-830. [PMID: 37491203 DOI: 10.1177/10499091231190063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Patients, caregivers, and healthcare professionals often describe a "good death" as a pain-free process. However, many patients experience pain during their last weeks of life. Advance directives (ADs) are legally binding documents that allow individuals to express their wishes for end-of-life care which should include management of their pain. METHODS An interprofessional team conducted a comprehensive analysis of ADs from all 50 states and the District of Columbia to assess the inclusion of language that reflects patients' wishes for pain relief at the end of life. RESULTS Thirty-seven (73%) of the 51 entities examined reflected the prototypical directive, containing explicit instructions for withholding or withdrawing interventions that may prolong suffering rather than options for treating pain. Of these, 12 (24%) did not include the word "pain". Only 14 states (27%) provided clear guidance for managing pain. Unexpectantly, researchers found that 13 (25%) addressed the common fears of patients, caregivers, and healthcare teams when using opioids to relieve suffering, such as addiction, sedation, appetite, or respiratory suppression, and hastening death. CONCLUSION The majority of ADs reviewed lacked clear and comprehensive measures for addressing pain relief. This deficiency may contribute to the undertreatment of pain and amplify the anxiety felt by patients, families, and healthcare providers when making end-of-life decisions. The results highlight the need for improvements in ADs to help ensure that patients' wishes regarding pain management are adequately addressed, documented and respected.
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Affiliation(s)
- George Luck
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Adriana Bautista
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Darian Peters
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Ross T Mellman
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Kathryn B Keller
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL, USA
| | - Mario Jacomino
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
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2
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Fredheim OMS, Torvund SK, Thoresen L, Magelssen M. How should respiratory depression and loss of airway patency be handled during initiation of palliative sedation? Acta Anaesthesiol Scand 2024; 68:675-680. [PMID: 38391048 DOI: 10.1111/aas.14396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Loss of airway patency has been reported during initiation of palliative sedation. In present guidelines the loss of airway patency during initiation of palliative sedation is not addressed. Airway patency can be restored by jaw thrust/chin lift or placing the patient in the recovery position. AIM A structured ethical analysis of how respiratory depression and loss of airway patency during initiation of palliative sedation should be handled. The essence of the dilemma is whether it is appropriate to apply simple non-invasive methods to restore airway patency in order to avoid the patient's immediate death. DESIGN A structured analysis based on the four principles of healthcare ethics and stakeholders' interests. RESULTS Beneficence and autonomy support a decision not to regain airway patency whereas non-maleficence lends weight to a decision to restore airway patency. Whether the proportionality criterion of the principle of double effect is met depends on the features of the individual case. The ethical problem appears to be a genuine dilemma where important values and arguments point to different conclusions. CONCLUSION Whether to restore airway patency when the airway is obstructed during initiation of palliative sedation will ultimately be based on clinical judgment taking into account both any known patient preferences and relevant clinical information. There are strong arguments favoring both options in this clinical and ethical dilemma. The fact that a clear and universal recommendation cannot be made does not imply indifference regarding what is the clinically and ethically best option for each individual patient.
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Affiliation(s)
- Olav Magnus S Fredheim
- Department of Palliative Medicine, Division of Surgery, Akershus University Hospital, Lørenskog, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Solveig K Torvund
- Department of Palliative Medicine, Division of Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Lisbeth Thoresen
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Magelssen
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
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3
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Gerber K, Willmott L, White B, Yates P, Mitchell G, Currow DC, Piper D. Barriers to adequate pain and symptom relief at the end of life: A qualitative study capturing nurses’ perspectives. Collegian 2022. [DOI: 10.1016/j.colegn.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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4
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Reed PA. Opioids, Double Effect, and the Prospects of Hastening Death. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2021; 46:505-515. [PMID: 34302349 DOI: 10.1093/jmp/jhab016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The relevance of double effect for end-of-life decision-making has been challenged recently by a number of scholars. The principal reason is that opioids such as morphine do not usually hasten death when administered to relieve pain at the end of life; therefore, no secondary "double" effect is brought about. In my article, I argue against this view, showing how the doctrine of double effect is relevant to the administration of opioids at the end of life. I contend that the prevailing view suffers from a misunderstanding of the nature of double effect, which includes application to risking a grave harm.
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Rinderle T, Willett J. Bioethical Distinctions of End-of-Life Care Practices #422. J Palliat Med 2021; 24:1400-1402. [PMID: 34469228 DOI: 10.1089/jpm.2021.0320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Takla A, Savulescu J, Kappes A, Wilkinson DJC. British laypeople's attitudes towards gradual sedation, sedation to unconsciousness and euthanasia at the end of life. PLoS One 2021; 16:e0247193. [PMID: 33770083 PMCID: PMC7997648 DOI: 10.1371/journal.pone.0247193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/02/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Many patients at the end of life require analgesia to relieve pain. Additionally, up to 1/5 of patients in the UK receive sedation for refractory symptoms at the end of life. The use of sedation in end-of-life care (EOLC) remains controversial. While gradual sedation to alleviate intractable suffering is generally accepted, there is more opposition towards deliberate and rapid sedation to unconsciousness (so-called "terminal anaesthesia", TA). However, the general public's views about sedation in EOLC are not known. We sought to investigate the general public's views to inform policy and practice in the UK. METHODS We performed two anonymous online surveys of members of the UK public, sampled to be representative for key demographic characteristics (n = 509). Participants were given a scenario of a hypothetical terminally ill patient with one week of life left. We sought views on the acceptability of providing titrated analgesia, gradual sedation, terminal anaesthesia, and euthanasia. We asked participants about the intentions of doctors, what risks of sedation would be acceptable, and the equivalence of terminal anaesthesia and euthanasia. FINDINGS Of the 509 total participants, 84% and 72% indicated that it is permissible to offer titrated analgesia and gradual sedation (respectively); 75% believed it is ethical to offer TA. Eighty-eight percent of participants indicated that they would like to have the option of TA available in their EOLC (compared with 79% for euthanasia); 64% indicated that they would potentially wish for TA at the end of life (52% for euthanasia). Two-thirds indicated that doctors should be allowed to make a dying patient completely unconscious. More than 50% of participants believed that TA and euthanasia were non-equivalent; a third believed they were. INTERPRETATION These novel findings demonstrate substantial support from the UK general public for the use of sedation and TA in EOLC. More discussion is needed about the range of options that should be offered for dying patients.
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Affiliation(s)
- Antony Takla
- Faculty of Medicine, Nursing and Health Science, Monash University, Clayton, Victoria, Australia
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, United Kingdom
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, United Kingdom
- Murdoch Children’s Research Institute, Melbourne, Australia
| | - Andreas Kappes
- School of Arts and Social Sciences, Department of Psychology, City University of London, London, United Kingdom
| | - Dominic J. C. Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, United Kingdom
- Murdoch Children’s Research Institute, Melbourne, Australia
- John Radcliffe Hospital, Oxford, United Kingdom
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7
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Trotter SA. Do you need compassion to work in palliative medicine? BMJ Support Palliat Care 2020; 11:422-426. [PMID: 32826271 DOI: 10.1136/bmjspcare-2020-002535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 07/06/2020] [Indexed: 11/03/2022]
Abstract
Compassion is deemed a "basic social emotion" (Nussbaum) and decreed a National Health Service core value-yet, what does 'compassion' really mean? Moreover, why is it so important, how can we deliver it best and how do we measure achievement here?This essay will argue that compassion stands apart from other forms of interpersonal engagement as a deeply human recognition of another's suffering which inherently motivates action to do something about this. There are two inextricable elements here: the role of suffering, and the resultant call to action it motivates.The role of compassion pivots on suffering, and thus, our interpretation of suffering and what we consider its upstream cause: the problem to be fixed. Palliative medicine here stands apart, priding itself on the holistic care of what is important to the patient; thus, the symptoms problematic to the patient are the problem, rather than the underlying cause per se.Compassion drives motivation to act; medicine equips us with the tools by which we can respond to this. Thus, compassion has been described as a 'calling' to healthcare for many who join the profession, and perhaps it is when these tools seem to fail that compassion fatigue takes hold. Though this is beyond the scope of this essay, compassion fatigue is considered a form of burnout directly related to the experiences of a caregiver.Thus, compassion is central, and its outcomes stem first from our perspective of the issue at hand and second from our ability to drive change. The ability to recognise suffering in another and be motivated to help has relevance far beyond work in palliative medicine; perhaps this form of interpersonal engagement extends to humanity itself.
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Affiliation(s)
- Sophie Anne Trotter
- Clinical School, University of Cambridge, Cambridge, UK .,University of Cambridge Gonville and Caius College, Cambridge, UK
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8
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Willmott L, White B, Yates P, Mitchell G, Currow DC, Gerber K, Piper D. Nurses' knowledge of law at the end of life and implications for practice: A qualitative study. Palliat Med 2020; 34:524-532. [PMID: 32031043 DOI: 10.1177/0269216319897550] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Some patients do not receive adequate pain and symptom relief at the end of life, causing distress to patients, families and healthcare professionals. It is unclear whether undertreatment of symptoms occurs, in part, because of nurses' concerns about legal and/or disciplinary repercussions if the patient dies after medication is administered. AIM The aim was to explore nurses' experiences and knowledge of the law relating to the provision of end-of-life pain and symptom relief. DESIGN Semi-structured interviews with nurses were assessed using a six-stage hybrid thematic analysis technique. SETTING/PARTICIPANTS Four face-to-face and 21 telephone interviews were conducted with nurses who routinely prescribed and/or administered pain and symptom relief to patients approaching the end of their lives in Queensland and New South Wales, Australia. RESULTS While many nurses had no personal experiences with legal or professional repercussions after a patient had died, the fear of hastening death and being held accountable was frequently discussed and regarded as relevant to the provision of inadequate pain and symptom relief. Concerns included potential civil or criminal liability and losing one's job, registration or reputation. Two-thirds of participants believed that pain relief was sometimes withheld because of these legal concerns. Less than half of the interviewed nurses demonstrated knowledge of the doctrine of double effect, the legal protection for health professionals who provide end-of-life pain and symptom relief. CONCLUSION Education is urgently required to strengthen nurses' knowledge of the legal protections supporting the provision of appropriate palliative medication, thereby improving their clinical practice with end-of-life patients.
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Affiliation(s)
- Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ben White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Geoffrey Mitchell
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - David C Currow
- IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Katrin Gerber
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, QLD, Australia.,Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, VIC, Australia
| | - Donella Piper
- Business School, University of New England, Armidale, NSW, Australia
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9
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Jeong IC, Bychkov D, Searson PC. Wearable Devices for Precision Medicine and Health State Monitoring. IEEE Trans Biomed Eng 2020; 66:1242-1258. [PMID: 31021744 DOI: 10.1109/tbme.2018.2871638] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Wearable technologies will play an important role in advancing precision medicine by enabling measurement of clinically-relevant parameters describing an individual's health state. The lifestyle and fitness markets have provided the driving force for the development of a broad range of wearable technologies that can be adapted for use in healthcare. Here we review existing technologies currently used for measurement of the four primary vital signs: temperature, heart rate, respiration rate, and blood pressure, along with physical activity, sweat, and emotion. We review the relevant physiology that defines the measurement needs and evaluate the different methods of signal transduction and measurement modalities for the use of wearables in healthcare.
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10
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Robert R, Le Gouge A, Kentish-Barnes N, Adda M, Audibert J, Barbier F, Bourcier S, Bourenne J, Boyer A, Devaquet J, Grillet G, Guisset O, Hyacinthe AC, Jourdain M, Lerolle N, Lesieur O, Mercier E, Messika J, Renault A, Vinatier I, Azoulay E, Thille AW, Reignier J. Sedation practice and discomfort during withdrawal of mechanical ventilation in critically ill patients at end-of-life: a post-hoc analysis of a multicenter study. Intensive Care Med 2020; 46:1194-1203. [PMID: 31996960 DOI: 10.1007/s00134-020-05930-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 01/10/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE Little is known on the incidence of discomfort during the end-of-life of intensive care unit (ICU) patients and the impact of sedation on such discomfort. The aim of this study was to assess the incidence of discomfort events according to levels of sedation. METHODS Post-hoc analysis of an observational prospective multicenter study comparing immediate extubation vs. terminal weaning for end-of-life in ICU patients. Discomforts including gasps, significant bronchial obstruction or high behavioural pain scale score, were prospectively assessed by nurses from mechanical ventilation withdrawal until death. Level of sedation was assessed using the Richmond Agitation-Sedation Scale (RASS) and deep sedation was considered for a RASS - 5. Psychological disorders in family members were assessed up until 12 months after the death. RESULTS Among the 450 patients included in the original study, 226 (50%) experienced discomfort after mechanical ventilation withdrawal. Patients with discomfort received lower doses of midazolam and equivalent morphine, and were less likely to have deep sedation than patients without discomfort (59% vs. 79%, p < 0.001). After multivariate logistic regression, extubation (as compared terminal weaning) was the only factor associated with discomfort, whereas deep sedation and administration of vasoactive drugs were two factors independently associated with no discomfort. Long-term evaluation of psychological disorders in family members of dead patients did not differ between those with discomfort and the others. CONCLUSION Discomfort was frequent during end-of-life of ICU patients and was mainly associated with extubation and less profound sedation.
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Affiliation(s)
- Rene Robert
- Université de Poitiers, Poitiers, France. .,Inserm CIC 1402, ALIVE, Poitiers, France. .,Service de Médecine Intensive Réanimation, CHU Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France.
| | | | - Nancy Kentish-Barnes
- Service de Médecine Intensive Réanimation, Groupe de Recherche Famiréa, CHU Saint-Louis, Paris, France
| | - Mélanie Adda
- APHM, URMITE, UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Aix-Marseille Université, Marseille, France
| | - Juliette Audibert
- Service de Réanimation Polyvalente, CH de Chartres, Chartres, France
| | | | - Simon Bourcier
- Université Paris-Descartes, Paris, France.,Service de Médecine Intensive Réanimation, Assistance Publique des Hôpitaux de Paris, CHU Cochin, Paris, France
| | - Jeremy Bourenne
- APHM, Hôpital La Timone, Réanimation et surveillance continue, Aix-Marseille Université, Marseille, France
| | - Alexandre Boyer
- Université de Bordeaux, Bordeaux, France.,Service de Réanimation Médicale, CHU Bordeaux, Bordeaux, France
| | - Jérôme Devaquet
- Service de Réanimation Polyvalente, Hôpital Foch, Suresnes, France
| | - Guillaume Grillet
- CH Bretagne Sud, Service de Réanimation Polyvalente, Lorient, France
| | - Olivier Guisset
- Université de Bordeaux, Bordeaux, France.,Service de Réanimation Médicale, CHU Bordeaux, Hôpital Saint-André, Bordeaux, France
| | - Anne-Claire Hyacinthe
- Service de Réanimation Polyvalente, Centre Hospitalier Annecy Genevois, Pringy, France
| | - Mercé Jourdain
- Université de Lille, Lille, France.,Service de Réanimation Polyvalente, Inserm U1190, CHRU de Lille - Hôpital Roger Salengro, Lille, France
| | - Nicolas Lerolle
- Université d'Angers, Angers, France.,Département de Réanimation médicale et Médecine hyperbare, CHU Angers, Angers, France
| | - Olivier Lesieur
- Service de Réanimation Polyvalente, CH de La Rochelle, La Rochelle, France
| | - Emmanuelle Mercier
- Université de Tours, Tours, France.,CHU de Tours, Service de Médecine Intensive Réanimation, Hôpital Bretonneau, Tours, France.,Réseau CRICS, Tours, France
| | - Jonathan Messika
- APHP; Nord-Université de Paris, Service de Réanimation médico-chirurgicale, Hôpital Louis Mourier, Colombes; Inserm U 1137, Paris, France, Colombes, France
| | - Anne Renault
- Université de Bretagne Occidentale, Brest, France.,Service de Réanimation Médicale, CHU de la Cavale Blanche, Brest, France
| | - Isabelle Vinatier
- Service de Réanimation Polyvalente, CHD de la Vendée, La Roche-sur-Yon, France
| | - Elie Azoulay
- Service de Médecine Intensive Réanimation, CHU Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France
| | - Arnaud W Thille
- Université de Poitiers, Poitiers, France.,Inserm CIC 1402, ALIVE, Poitiers, France.,Service de Médecine Intensive Réanimation, CHU Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France
| | - Jean Reignier
- Université de Nantes, Nantes, France.,Service de Médecine Intensive Réanimation, CHU de Nantes, Nantes, France
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Ziegler SJ. Euthanasia and the Administration of Neuromuscular Blockers without Ventilation: Should Physicians Fear Prosecution? OMEGA-JOURNAL OF DEATH AND DYING 2016. [DOI: 10.2190/7603-0605-1488-7577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A common dilemma among physicians who treat the dying is whether pharmacological paralysis should be reversed prior to removal of mechanical ventilation. But what if a physician were to administer a neuromuscular blocker without ever ventilating the patient in the first place? While there is evidence that euthanasia does occur in the United States, few physicians have been prosecuted. Could these infrequent prosecutions reflect a conscious desire by prosecutors not to pursue such matters? In an effort to explore this question, chief prosecutors in four U.S. states were presented with a vignette based on an actual event involving the administration of Succinylcholine to a dying patient. Response rates in this study were very acceptable (76.36% overall), and results indicated that not only was the likelihood of criminal prosecution low, almost half of the prosecutors believed that a physicianadministered lethal injection may be morally justified in some circumstances even though illegal.
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12
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LiPuma SH, DeMarco JP. Article Commentary: Palliative Care and Patient Autonomy: Moving beyond Prohibitions against Hastening Death. Health Serv Insights 2016; 9:37-42. [PMID: 27980420 PMCID: PMC5147517 DOI: 10.4137/hsi.s39013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 11/08/2016] [Accepted: 11/11/2016] [Indexed: 11/18/2022] Open
Abstract
The National Hospice and Palliative Care Organization (NHPCO) upholds policies prohibiting practices that deliberately hasten death. We find these policies overly restrictive and unreasonable. We argue that under specified circumstances it is both reasonable and morally sound to allow for treatments that may deliberately hasten death; these treatments should be part of the NHPCO guidelines. Broadening such policies would be more consistent with the gold standard of bioethical principles, ie, respecting the autonomy of competent adults.
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Affiliation(s)
- Samuel H. LiPuma
- Department of Philosophy, Cuyahoga Community College, Cleveland, OH, USA
| | - Joseph P. DeMarco
- Department of Philosophy, Cleveland State University, Cleveland, OH, USA
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13
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Rogers IR, Lukin B. Applying palliative care principles and practice to emergency medicine. Emerg Med Australas 2015; 27:612-615. [DOI: 10.1111/1742-6723.12494] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/13/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Ian R Rogers
- Department of Emergency Medicine; St John of God Murdoch Hospital; Perth Western Australia Australia
- The University of Notre Dame Australia; Fremantle Western Australia Australia
| | - Bill Lukin
- Department of Emergency Medicine; Royal Brisbane Hospital; Brisbane Queensland Australia,
- University of Queensland; Brisbane Queensland Australia
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14
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ten Cate K, van de Vathorst S, Onwuteaka-Philipsen BD, van der Heide A. End-of-life decisions for children under 1 year of age in the Netherlands: decreased frequency of administration of drugs to deliberately hasten death. JOURNAL OF MEDICAL ETHICS 2015; 41:795-798. [PMID: 26272986 DOI: 10.1136/medethics-2014-102562] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 07/23/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To assess whether the frequency of end-of-life decisions for children under 1 year of age in the Netherlands has changed since ultrasound examination around 20 weeks of gestation became routine in 2007 and after a legal provision for deliberately ending the life of a newborn was set up that same year. METHODOLOGY This was a recurrent nationwide cross-sectional study in the Netherlands. In 2010, a sample of death certificates from children under 1 year of age was derived from the central death registry. All 223 deaths that occurred in a 4-month study period were included. Physicians who had reported a non-sudden death (n=206) were sent a questionnaire on the end-of-life decisions made. 160 questionnaires were returned (response 78%). FINDINGS In 2010, 63% of all deaths of children under 1 year of age were preceded by an end-of-life decision-a percentage comparable to other times when this study was conducted (1995, 2001, 2005). These end-of-life decisions were mainly decisions to withdraw or withhold potentially life-sustaining treatment. In 2010, the percentage of cases in which drugs were administered with the explicit intention to hasten death was 1%, while in 1995 and 2001, this was 9% and in 2005, this was 8%. DISCUSSION AND CONCLUSION There has been a reduction of infant deaths that followed administration of drugs with the explicit intention to hasten death. One explanation for this reduction relates to the introduction of routine ultrasound examination around 20 weeks of gestation. In addition, the introduction of legal criteria and a review process for deliberately ending the life of a newborn may have left Dutch physicians with less room to hasten death.
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Affiliation(s)
- Katja ten Cate
- Department of General Practice, Section Medical Ethics, Academic Medical Centre/University of Amsterdam, Amsterdam, The Netherlands
| | - Suzanne van de Vathorst
- Department of General Practice, Section Medical Ethics, Academic Medical Centre/University of Amsterdam, Amsterdam, The Netherlands Department of Medical Ethics and Philosophy, Erasmus Medical Centre/Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute, VU Medical Centre/VU University Amsterdam, Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus Medical Centre/Erasmus University Rotterdam, Rotterdam, The Netherlands
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15
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MacKintosh D. Get the facts right: time for evidence-based ethics. JOURNAL OF MEDICAL ETHICS 2015; 41:830-831. [PMID: 26378198 DOI: 10.1136/medethics-2015-103052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 08/11/2015] [Indexed: 06/05/2023]
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16
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Lovell GP, Smith T, Kannis-Dymand L. Surrogate End-of-Life Care Decision Makers' Postbereavement Grief and Guilt Responses. DEATH STUDIES 2015; 39:647-653. [PMID: 26020736 DOI: 10.1080/07481187.2015.1047062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This article examined differences in familial/friend surrogate decision makers' (N = 93) postbereavement grief and guilt associated with decisions to either prioritize comfort or longevity in determining end-of-life care for decisionally incapacitated adult palliative loved ones. Results demonstrated that participants prioritizing the longevity of loved ones experienced significantly and meaningfully higher levels of grief, complicated grief, and trauma related guilt than those who prioritized comfort.
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Affiliation(s)
- Geoff P Lovell
- a School of Social Sciences , University of the Sunshine Coast , Maroochydore , Australia
| | - Trish Smith
- a School of Social Sciences , University of the Sunshine Coast , Maroochydore , Australia
| | - Lee Kannis-Dymand
- a School of Social Sciences , University of the Sunshine Coast , Maroochydore , Australia
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Minami S, Fujimoto K, Ogata Y, Yamamoto S, Komuta K. Opioids have no negative effect on the survival time of patients with advanced lung cancer in an acute care hospital. Support Care Cancer 2015; 23:2245-54. [PMID: 25564223 DOI: 10.1007/s00520-014-2592-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 12/21/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study is to determine whether or not opioid administration influenced the survival time of patients with advanced lung cancer in an acute care hospital setting. METHODS This was a single institutional and retrospective study. We reviewed patients with advanced lung cancer who had died from January 2008 to December 2013 at the Osaka Police Hospital. We compared survival times, calculated from the time of the last hospitalization or the last chemotherapy, between patients who had not used any opioids, those who had used a low dose of opioids (< 60 mg/day), and those who had used a higher dose of opioids (≥ 60 mg/day). RESULTS A total of 369 patients, of which 284 had received chemotherapy, were analyzed. Opioid users were generally younger than nonusers. There was no significant difference in survival time after the last hospitalization in terms of opioid dose at the last admission and mean daily opioid dose; there was also no significant difference in survival time after the last chemotherapy in terms of the mean daily opioid dose and the opioid dose at death. Univariate and multivariate Cox proportional hazard analysis regarding survival time after the last hospitalization or the last chemotherapy did not reveal any opioid-related variables as a significant predictive factor. CONCLUSIONS Opioids were found to have no negative influence on survival time even in an acute care hospital.
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Affiliation(s)
- Seigo Minami
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka-City, Osaka, 543-0035, Japan,
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Shearer FM, Rogers IR, Monterosso L, Ross-Adjie G, Rogers JR. Understanding emergency department staff needs and perceptions in the provision of palliative care. Emerg Med Australas 2014; 26:249-55. [PMID: 24713040 DOI: 10.1111/1742-6723.12215] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The primary aim of the present study was to investigate Australian ED staff perspectives and needs regarding palliative care provision. Secondary aims were to assess staff views about death and dying, and their awareness of common causes of death in Australia, particularly those where a palliative care approach is appropriate. METHODS All medical and nursing staff working in a private ED in Perth, Western Australia, were asked to complete a combined quantitative and qualitative survey. The survey tool uses a combination of Likert-type scales and open-ended questions. Descriptive statistics and intergroup comparisons were made for all quantifiable variables, whereas formal content analysis was used for text responses. RESULTS Surveys were returned by 22 doctors and 44 nurses, with most reporting only working knowledge of palliative care but clinical proficiency in symptom control. Confidence in palliative care provision was lower among nursing than medical staff but educational needs were similar. Cancer diagnoses were consistently overestimated, and dementia and COPD underestimated, as the most common causes of death. Only six of 63 (9.5%) of respondents identified the correct top five causes of death. CONCLUSIONS Our study suggests that although ED staff expressed confidence regarding symptom management in palliative care, they lacked understanding of the patients in whom a palliative approach could be applied and sought further education in areas, such as end-of-life communication and ethical issues. ED specific training and clinical interventions in palliative care provision would seem to be needed and justified.
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Affiliation(s)
- Freya M Shearer
- Emergency Department, St John of God Murdoch Hospital, Murdoch, Western Australia, Australia
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Jox RJ, Horn RJ, Huxtable R. European perspectives on ethics and law in end-of-life care. ETHICAL AND LEGAL ISSUES IN NEUROLOGY 2013; 118:155-65. [DOI: 10.1016/b978-0-444-53501-6.00013-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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20
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Roggendorf S, Eckart WU. [Indirect euthanasia : Medical and legal implications]. Anaesthesist 2012; 61:640-2, 644-5. [PMID: 22760674 DOI: 10.1007/s00101-012-2057-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- S Roggendorf
- Klinik für Neurologie, Klinikum Duisburg GmbH, Zu den Rehwiesen 9-11, 47055, Duisburg, Deutschland.
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Bennett R, Givens D. Easing suffering for a child with intractable pain at the end of life. J Pediatr Health Care 2011; 25:180-5. [PMID: 21514493 DOI: 10.1016/j.pedhc.2010.09.002] [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: 08/27/2010] [Accepted: 09/02/2010] [Indexed: 10/18/2022]
Affiliation(s)
- Rebecca Bennett
- Acute Pain Service, Rady Children's Hospital, San Diego, CA 92115, USA.
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Radha Krishna LK, Poulose JV, Tan BSA, Goh C. Opioid Use amongst Cancer Patients at the End of Life. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2010. [DOI: 10.47102/annals-acadmedsg.v39n10p790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: Concerns about the life shortening effect of opioids is a well known fact in the medical world when considering administration of these drugs for symptom alleviation at end of life. This study described the patterns of opioid use among cancer patients referred to a hospital-based specialist palliative care service for symptom management. This study also examined whether opioid use among terminally ill cancer patients during the last 2 days of life had any influence on survival. Materials and Methods: A retrospective review of case notes of patients who were diagnosed with terminal cancer and had passed away in a 95-bedded oncology ward between September 2006 and September 2007 was conducted. Data were collected on patients’ characteristics and patterns of opioid use including opioid doses and dose changes at 48 hours and 24 hours before death. Results: There were 238 patients who received specialist palliative care, of whom 132 (55.5%) were females. At 48 hours and 24 hours before death, 184 (77.3%) patients and 187 (78.6%) patients had received opioids, respectively. The median daily doses at 48 hours and 24 hours were 48 mg and 57 mg oral morphine equivalent doses (OME), respectively. Indications for opioid use were pain (41.1%), dyspnoea, (29.1%) and both dyspnoea and pain (30.8%). In the final 24 hours, 22.3% patients had a reduction in their mean opioid dose while 22.7% required an increase in their mean opioid dose. Increased age was associated with decreasing opioid doses (P = 0.003). Patients with spinal metastases required higher doses of opioids (P = 0.03) while those with lung metastases required lower doses (P = 0.011). Survival analysis using Kaplan-Meier survival curve revealed no significant survival difference between those who were on opioids and those who were not. Log rank test (Mantel-Cox) (P = 0.69). Conclusion: Our results showed that opioids are safe medications for symptom alleviation in terminally ill cancer patients during the last days of life and have no deleterious influence on survival.
Key words: Palliative care, Survival analysis, Terminal cancer
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van der Hoven B, de Groot YJ, Thijsse WJ, Kompanje EJO. What to do when a competent ICU patient does not want to live anymore but is dependent on life-sustaining treatment? Experience from The Netherlands. Intensive Care Med 2010; 36:2145-8. [PMID: 20689937 PMCID: PMC2981744 DOI: 10.1007/s00134-010-1953-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 06/21/2010] [Indexed: 11/26/2022]
Abstract
If patients on the intensive care unit (ICU) are awake and life-sustaining treatment is suspended because of the patients’ request, because of recovering from the disease, or because independence from organ function supportive or replacement therapy outside the ICU can no longer be achieved, these patients can suffer before they inevitably die. In The Netherlands, two scenarios are possible for these patients: (1) deep palliative (terminal) sedation through ongoing administration of barbiturates or benzodiazepines before withdrawal of treatment, or (2) deliberate termination of life (euthanasia) before termination of treatment. In this article we describe two awake patients who asked for withdrawal of life-sustaining measures, but who were dependent on mechanical ventilation. We discuss the doctrine of double effect in relation to palliative sedation on the ICU. Administration of sedatives and analgesics before withdrawal of treatment is seen as normal palliative care. We conclude that the doctrine of the double effect is not applicable in this situation, and mentioning it criminalised the practice unnecessarily and wrongfully.
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Affiliation(s)
- Ben van der Hoven
- Department of Intensive Care, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Nurses' Knowledge, Attitudes, and Practice Patterns Regarding Titration of Opioid Infusions at the End of Life. J Hosp Palliat Nurs 2010. [DOI: 10.1097/njh.0b013e3181cf791c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Palliation of symptoms to optimize QOL is the foundation of cancer care regardless of stage of disease or level of anticancer treatment. Patients commonly experience pain, constipation, nausea, vomiting, dyspnea, fatigue, and delirium. Many valid clinical tools are available to the primary care clinician to screen for symptoms, assess severity, measure treatment response, and elicit the patient's subjective symptom experience. Although there is limited evidence regarding the relative efficacy of symptom interventions from randomized controlled trials, clinical practice guidelines are available.
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Affiliation(s)
- Barbara Reville
- Palliative Care Service, Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Jansen LA. Disambiguating Clinical Intentions: The Ethics of Palliative Sedation. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2010; 35:19-31. [DOI: 10.1093/jmp/jhp056] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
The debate about the management of pain in the neonate has continued to evolve over the past 30 years. This controversy can be understood as evolving through now three eras of thought about the effect of pain and its management in newborns and infants. The first generation was characterized by a widespread belief that newborns lacked the complete development of the neuroanatomical and neuroendocrine components necessary to perceive pain. During this period, newborns often received inadequate anesthesia and analgesia for painful procedures, if not no treatment at all. The second generation was heralded by research that demonstrated that newborns did demonstrate similar or even exaggerated physiological and hormonal responses to pain compared with those observed in older children and adults and that exposure to prolonged or severe pain may increase neonatal morbidity. Controversy in this generation focused around the dosage of analgesia to newborns as well as the risks and benefits of pain management techniques. We are now in a third generation of thought about pain in the neonate, defined by intense debate over the significance of a growing number of studies in immature animal models that demonstrate degenerative effects of several anesthetics on neuronal structure. The challenge of this era is to integrate the advances in diagnosis and treatment achieved in previous generations with ongoing adaptation of clinical practice as dictated by research advances in the field. In this review, we examine the evolution of medical thought and ethical concerns regarding pain treatment in the neonate.
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Affiliation(s)
- Thomas Mancuso
- Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
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29
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Rabbi Weiss RB. Pain Management at the End of Life and the Principle of Double Effect: A Jewish Perspective. Cancer Invest 2009; 25:274-7. [PMID: 17612938 DOI: 10.1080/07357900701225380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Controlling the pain of patients at the end of life can be challenging both clinically and ethically. One ethical obstacle arises when analgesia has the potential to hasten the death of the patient, thus, invoking the principle of "double effect" to resolve such dilemmas. This article will develop, analyze, and apply that principle from a Jewish perspective. It is this writer's opinion, that pain management can be administered effectively from a Jewish perspective in most clinical scenarios.
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Spielthenner G. The principle of double effect as a guide for medical decision-making. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2008; 11:465-473. [PMID: 18330720 DOI: 10.1007/s11019-008-9128-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Accepted: 02/18/2008] [Indexed: 05/26/2023]
Abstract
Many medical interventions have both negative and positive effects. When health care professionals cannot achieve a particular desired good result without bringing about some bad effects also they often rely on double-effect reasoning to justify their decisions. The principle of double effect is therefore an important guide for ethical decision-making in medicine. At the same time, however, it is a very controversial tool for resolving complex ethical problems that has been criticized by many authors. For these reasons, I examine in this paper whether the principle of double effect can serve as a basis for ethical decisions in medicine. The conclusion reached in this article is that even though this principle has desirable effects on clinical conduct, it is only an unreliable guide and physicians and nurses cannot feel secure in continuing to use this principle for ethical guidance.
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Affiliation(s)
- Georg Spielthenner
- Department of Philosophy and Applied Ethics, The University of Zambia, P.O. Box 32379, Lusaka, Zambia.
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32
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Abstract
Critical care units are frequently the setting for the delivery of end-of-life care. A case study describing pain management for a terminally ill woman in an intensive care unit is used to illustrate conflicts that may be experienced by critical care nurses. The application of standards of professional organizations and regulatory bodies is described, as well as the ethical principles of autonomy, veracity, beneficence, nonmalfeasance, and double effect. Important legal and sociocultural considerations are included.
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33
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Douglas C, Kerridge I, Ankeny R. Managing intentions: the end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia. BIOETHICS 2008; 22:388-396. [PMID: 18547298 DOI: 10.1111/j.1467-8519.2008.00661.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
There has been much debate regarding the 'double-effect' of sedatives and analgesics administered at the end-of-life, and the possibility that health professionals using these drugs are performing 'slow euthanasia.' On the one hand analgesics and sedatives can do much to relieve suffering in the terminally ill. On the other hand, they can hasten death. According to a standard view, the administration of analgesics and sedatives amounts to euthanasia when the drugs are given with an intention to hasten death. In this paper we report a small qualitative study based on interviews with 8 Australian general physicians regarding their understanding of intention in the context of questions about voluntary euthanasia, assisted suicide and particularly the use of analgesic and sedative infusions (including the possibility of voluntary or non-voluntary 'slow euthanasia'). We found a striking ambiguity and uncertainty regarding intentions amongst doctors interviewed. Some were explicit in describing a 'grey' area between palliation and euthanasia, or a continuum between the two. Not one of the respondents was consistent in distinguishing between a foreseen death and an intended death. A major theme was that 'slow euthanasia' may be more psychologically acceptable to doctors than active voluntary euthanasia by bolus injection, partly because the former would usually only result in a small loss of 'time' for patients already very close to death, but also because of the desirable ambiguities surrounding causation and intention when an infusion of analgesics and sedatives is used. The empirical and philosophical implications of these findings are discussed.
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34
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Butts JB, Rich KL. Comment by Janie B Butts and Karen L Rich on: `Guilty but good: defending voluntary active euthanasia from a virtue perspective'. Nurs Ethics 2008. [DOI: 10.1177/0969733008090516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Janie B Butts
- University of Southern Mississippi, Hattiesburg, MS, USA
| | - Karen L Rich
- University of Southern Mississippi, Hattiesburg, MS, USA
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35
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Reuzel RPB, Hasselaar GJ, Vissers KCP, van der Wilt GJ, Groenewoud JMM, Crul BJP. Inappropriateness of using opioids for end-stage palliative sedation: a Dutch study. Palliat Med 2008; 22:641-6. [PMID: 18612030 DOI: 10.1177/0269216308091867] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To be able to distinguish end-stage palliative sedation from euthanasia without having to refer to intentions that are difficult to verify, physicians must be able to manage palliative sedation appropriately (i.e., see that death is not hastened as a result of disproportionate medication). In the present study, we assessed whether or not this requirement is met in the Netherlands. We sent a retrospective questionnaire to 1,464 medical specialists, general practitioners, and nursing home physicians in the Netherlands. Furthermore, we held two sets of 20 and 22 semi-structured in-depth interviews with general practitioners, internists, lung specialists, and nursing home physicians. Although most guidelines discourage the administration of opioids alone for purposes of palliative sedation, opioids alone were administered for 22% of all the patients reported upon. Those physicians who were more experienced, general practitioners, and physicians who had consulted a palliative care expert administered only opioids significantly less often than the other physicians. The interviewees reported difficulties in assessing the appropriateness of medication, feeling uncertain about the pharmacokinetics of drugs used in moribund patients. Given that no more than 2% of the respondents perceived palliative sedation to be used as a form of euthanasia and that the use of opioids alone was not associated with shorter survival rates, the inappropriate use of opioids can only be attributed to a lack of knowledge or skill and/or a tradition of alleviating refractory dyspnoea with the use of opioids and not as an intentional means of hastening death.
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Affiliation(s)
- R P B Reuzel
- Department of Epidemiology, Biostatistics and Health Technology Assessment, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
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Abstract
Despite advances in cancer survival rates, end of life care remains a vital aspect of cancer management. The use of integrated care pathways can facilitate effective care of dying patients in a generalist setting. However, it remains important that staff are able to recognise the onset of the dying process, not only in order to make symptom control provision, but also that appropriate communication can occur with patients and those close to them. This allows the exercise of choice over place and style of care. The key symptoms at the end of life are restlessness, agitation, breathlessness, pain and noisy respiration from retained airway secretions. Ethical tensions arise from the assumptions that the use of opioids and sedatives hastens dying, but this is contradicted by available evidence.
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Affiliation(s)
- Nigel Sykes
- Palliative Medicine, St. Christopher's Hospice, Lawrie Park Road, London, United Kingdom.
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37
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Reid C, Gooberman-Hill R, Hanks G. Opioid analgesics for cancer pain: symptom control for the living or comfort for the dying? A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer. Ann Oncol 2008; 19:44-8. [DOI: 10.1093/annonc/mdm462] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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38
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Abstract
Patients, families, and health care providers all face ethical issues at the end of life. Related to increased technology, decreased resources, and immense cultural diversity, these controversies are a common concern to providers in home care. Increased knowledge and skills related to ethical discussions are crucial tools for providers in home care. Providers'abilities to facilitate these discussions with families and patients at the end of life can ease the transition from aggressive care to hospice care. This article describes basic principles of an ethical discussion and discusses the common ethical dilemmas faced at the end of life.
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Wilcock A, Chauhan A. Benchmarking the use of opioids in the last days of life. J Pain Symptom Manage 2007; 34:1-3. [PMID: 17509815 DOI: 10.1016/j.jpainsymman.2007.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Accepted: 03/07/2007] [Indexed: 10/23/2022]
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Wuhrman E, Cooney MF, Dunwoody CJ, Eksterowicz N, Merkel S, Oakes LL. Authorized and Unauthorized ("PCA by Proxy") Dosing of Analgesic Infusion Pumps: position statement with clinical practice recommendations. Pain Manag Nurs 2007; 8:4-11. [PMID: 17336864 DOI: 10.1016/j.pmn.2007.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The American Society for Pain Management Nursing (ASPMN), in order to address sentinel alerts issued by JCAHO in 2004 and ISMP in 2005 concerning "PCA by Proxy", has developed a position statement and clinical practice recommendations on Authorized and Unauthorized (PCA by Proxy) Dosing of Analgesic Infusion Pumps, approved by the Board of Directors in June of 2006. In short, ASPMN does not support the use of "PCA by Proxy". ASPMN does, however, support the practice of Authorized Agent Controlled Analgesia in a variety of patient care settings when the agency has in place clear guidelines outlining the conditions under which this practice shall be implemented and outlining monitoring procedures that will insure safe use of the therapy. In addition to outlining this position, the paper clarifies and distinguishes between the unsafe practice of "PCA by Proxy", in which unauthorized individuals activate the dosing button of an analgesic infusion pump for a patient receiving Patient Controlled Analgesia, and the safe practice of Authorized Agent Controlled Analgesia (AACA). Furthermore, the paper examines the ethical and safety issues and outlines the necessary screening and patient/family education needed to implement AACA. The position statement describes criteria for the use of AACA, guidelines for selection and education of the authorized agent, key prescription and monitoring recommendations during therapy, and quality improvement activities to insure safety and effectiveness.
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Affiliation(s)
- Elsa Wuhrman
- Columbia University Medical Center, New York, New York, USA.
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41
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42
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Eine gesetzliche Regulierung des Umgangs mit Opiaten und Sedativa bei medizinischen Entscheidungen am Lebensende? Ethik Med 2006. [DOI: 10.1007/s00481-006-0424-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kompanje EJO. 'Death rattle' after withdrawal of mechanical ventilation: practical and ethical considerations. Intensive Crit Care Nurs 2006; 22:214-9. [PMID: 16551501 DOI: 10.1016/j.iccn.2005.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Revised: 05/23/2005] [Accepted: 06/13/2005] [Indexed: 11/20/2022]
Abstract
The noise produced by oscillatory movements of secretions in oropharynx, hypopharynx and trachea during inspiration and expiration in unconscious terminal patients is often described as 'the death rattle'. The reported incidence of death rattle in terminally ill patients varied between six and 92%. It is most commonly reported in patients dying from pulmonary malignancies, primary brain tumours or brain metastases, and predicts death within 48 hours in 75% of the patients. Clinical studies demonstrate that hyoscine hydrobromide is effective at improving symptoms. After withdrawal of artificial ventilation on the intensive care unit, excessive respiratory secretions resulting in rattling breathing, during the last hours of life, is not uncommon. Physicians and nurses experience considerable difficulties and frustrations in treating the death rattle. The distressing experience and negative influence in the bereavement process indicates an ethical demand to treat this symptom from the perspective of others merely than that of the patient. This article provides practical and ethical considerations in the management of this near-death symptom. The fact that relatives were relieved in almost all cases, in which a positive effect was obtained, makes treatment in anticipation of death rattle an ethical demand. In practice, injectable scopolamine is the reference drug for symptomatic treatment of death rattle.
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Affiliation(s)
- Erwin J O Kompanje
- Department of Intensive Care and Department of Medical Ethics, Erasmus MC University Medical Center, Room V-208, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
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Good PD, Ravenscroft PJ, Cavenagh J. Effects of opioids and sedatives on survival in an Australian inpatient palliative care population. Intern Med J 2005; 35:512-7. [PMID: 16105151 DOI: 10.1111/j.1445-5994.2005.00888.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS To assess whether opioid and sedative medication use affects survival (from hospice admission to death) of patients in an Australian inpatient palliative care unit. BACKGROUND Retrospective audit. Newcastle Mercy Hospice--a tertiary referral palliative care unit. All patients who died in the hospice between 1 February and 31 December 2000. METHODS Length of survival from hospice admission to death, and the median and mean doses of opioids and sedatives used in the last 24 h of life. Comparison of these with published studies outside of Australia. RESULTS In this study, the use of opioids, benzodiazepines and haloperidol did not have an association with shortened survival and the only statistical significant finding was an increased survival in patients who were on 300 mg/day or more of oral morphine equivalent (OME). The proportion of patients requiring greater than or equal to 300 mg OME/day (at 28%) was higher than published studies, but the mean dose of 371 mg OME/day was within the range of other studies. The proportion of patients receiving sedatives (94%) was higher than other studies, but the median dose of parenteral midazolam equivalent of 12.5 mg per 24 h was lower than other studies from outside Australia. CONCLUSIONS There was no association between the doses of opioids and sedatives on the last day of life and survival (from hospice admission to death) in this population of palliative care patients.
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Affiliation(s)
- P D Good
- Division of Palliative Care, Newcastle Mater Misericordiae Hospital, Waratah, New South Wales, Australia.
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Camps Herrero C, Gavilá Gregori J, Garde Noguera J, Caballero Díaz C, Iranzo González-Cruz V, Juárez Marroquí A, Safont Aguilera MJ, Blasco Cordellat A, Berrocal Jaime A, Sanz de Bremond MG. [Euthanasia in patients with cancer and the continuous-care providers]. Clin Transl Oncol 2005; 7:278-84. [PMID: 16185589 DOI: 10.1007/bf02710266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
During the clinical evolution of patients with cancer there are many occasions, or phases of the disease, when there are no specific treatments and, as such, we need to provide maximum comfort following appropriate symptom control; in this stage it is fundamental to respect personal autonomy together with the option to reject futile treatment. With appropriate control of symptoms it is possible to reach the stage where the majority of the patients do not continue to suffer. Continuous-care providers for cancer patients are those who are responsible for providing help to resolve these situations. In palliative medicine there are highly-efficacious procedures to the help in these last hours. Sedation is applied when it is impossible to control symptoms by other means. With appropriate Carer cover, it is not necessary to introduce laws on assisted suicide and/or active voluntary euthanasia, neither because of the magnitude of demand, nor because of the difficulties in achieving appropriate control of symptoms.
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Affiliation(s)
- Carlos Camps Herrero
- Servicio de Oncología Médica, Consorcio Hospital General Universitario de Valencia, España.
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Blacksher E. Hearing from pain: using ethics to reframe, prevent, and resolve the problem of unrelieved pain. PAIN MEDICINE 2004; 2:169-75. [PMID: 15102307 DOI: 10.1046/j.1526-4637.2001.002002169.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe three ways by which the field of medical ethics can be used to improve health professionals' capacity to assess and treat pain. CONCLUSIONS Three strategies could be used to sensitize health professionals to patients suffering chronic pain and improve their capacity to communicate with such patients: classroom opportunities to explore the biases and assumptions that guide our interpretation and response to pain, curriculum designed to enhance communications skills when interacting with and treating patients in pain, and more representative ethics cases that feature the issue of pain.
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Affiliation(s)
- E Blacksher
- Midwest Bioethics Center, Kansas City, Missouri 64105, USA.
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