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Terman SA, Steinberg KE, Hinerman N. Flaws in advance directives that request withdrawing assisted feeding in late-stage dementia may cause premature or prolonged dying. BMC Med Ethics 2022; 23:100. [PMID: 36203173 PMCID: PMC9535899 DOI: 10.1186/s12910-022-00831-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 08/26/2022] [Indexed: 11/23/2022] Open
Abstract
Background The terminal illness of late-stage (advanced) Alzheimer’s and related dementias is progressively cruel, burdensome, and can last years if caregivers assist oral feeding and hydrating. Options to avoid prolonged dying are limited since advanced dementia patients cannot qualify for Medical Aid in Dying. Physicians and judges can insist on clear and convincing evidence that the patient wants to die—which many advance directives cannot provide. Proxies/agents’ substituted judgment may not be concordant with patients’ requests. While advance directives can be patients’ last resort to attain a peaceful and timely dying consistent with their lifelong values, success depends on their being effective and acceptable. A single flaw can provide opponents justification to refuse the directive’s requests to cease assisted feeding. Aim This article considers 24 common advance directive flaws in four categories. Process flaws focus on how patients express their end-of-life wishes. Content flaws reflect drafters’ selection of conditions and interventions, and how they are described. Inherent flaws can make advance directives unacceptable to authorities concerned about premature dying. Strategies are needed to compel physicians to write needed orders and to prevent third parties from sabotaging these orders after they are implemented. The article includes excerpts from “dementia-specific” directives or supplements that exemplify each flaw—mostly from the US and Europe. No directive critiqued here included an effective strategy to resolve this long-debated bioethical conflict: the past directive requests “Cease assisted feeding” but the incapacitated patient apparently expresses the desire to “Continue assisted feeding.” Some opponents to the controversial request, cease assisted feeding, use this conflict as a conceptual wedge to practice hard paternalism. This article proposes a protocol to prevent this conflict from emerging. These strategies may prevent authorities from requiring patients to fulfill authorities’ additional clinical criteria as a prerequisite to honor the requests in patients directives. Conclusion This critique of flaws may serve as a guide to drafting and to selecting effective and acceptable advance directives for dementia. It also poses several bioethical and clinical questions to those in authority: Does your paternalistic refusal to honor patients’ wishes respect their self-determination? Protect vulnerable patients from harm? Force patients to endure prolonged suffering? Violate the principles of bioethics? Violate the very foundation of patient-centered care?
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Affiliation(s)
| | - Karl E Steinberg
- California State University Shiley Haynes Institute for Palliative Care, San Marcos, CA, USA
| | - Nathaniel Hinerman
- Department of Theology and Religious Studies and School of Nursing and Health Professions, University of San Francisco, San Francisco, USA
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Increasing our understanding of nonphysical suffering within palliative care: A scoping review. Palliat Support Care 2021; 20:417-432. [DOI: 10.1017/s1478951521001127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Objective
Nonphysical suffering is emotional, psychological, existential, spiritual, and/or social in nature. While palliative care is a discipline dedicated to the prevention and relief of suffering — both physical and nonphysical — little is known about existing research specific to nonphysical suffering within the context of palliative care. This scoping review helps to fill this gap.
Method
Three hundred and twenty-eight unique records were identified through a systematic search of three databases (MEDLINE, CINAHL, and PsycINFO). The following keywords were used: (suffering) AND (palliative OR “end of life” OR “end-of-life” OR hospice OR dying OR terminal* ill*). Thirty studies published between 1998 and 2019 met the inclusion criteria.
Results
Losses, worries, and fears comprise patients’ primary sources of nonphysical suffering. Patients face numerous barriers in expressing their nonphysical suffering to healthcare providers. The idea that patients can choose how they perceive their circumstances, thereby minimizing their nonphysical suffering, is pervasive in the research. The nature of nonphysical suffering experienced by family caregivers and palliative care clinicians is revealed in the review. The unique and sensitive interplay between nonphysical suffering and both palliative sedation and requests for hastened death is also evident. Overall, seven themes can be identified: (i) patients’ experiences of nonphysical suffering; (ii) patient coping mechanisms; (iii) efforts to measure nonphysical suffering; (iv) palliative sedation; (v) requests for hastened death; (vi) family suffering; and (vii) clinician suffering.
Significance of results
This is the first scoping review to map palliative care's research specific to suffering that is social, emotional, spiritual, psychological, and/or existential in nature. Its findings expand our understanding of the nature of nonphysical suffering experienced by patients, families, and palliative care clinicians. The review's findings have significant implications for front-line practice and future research.
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Marchand LR. Palliative and End-of-Life Care. Integr Med (Encinitas) 2018. [DOI: 10.1016/b978-0-323-35868-2.00082-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Krishna LKR. Addressing the Concerns Surrounding Continuous Deep Sedation in Singapore and Southeast Asia: A Palliative Care Approach. JOURNAL OF BIOETHICAL INQUIRY 2015; 12:461-475. [PMID: 26173777 DOI: 10.1007/s11673-015-9651-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 10/09/2014] [Indexed: 06/04/2023]
Abstract
The application of continuous deep sedation (CDS) in the treatment of intractable suffering at the end of life continues to be tied to a number of concerns that have negated its use in palliative care. Part of the resistance towards use of this treatment option of last resort has been the continued association of CDS with physician-associated suicide and/or euthanasia (PAS/E), which is compounded by a lack clinical guidelines and a failure to cite this treatment under the aegis of a palliative care approach. I argue that reinstituting a palliative care-inspired approach that includes a holistic review of the patient's situation and the engagement of a multidisciplinary team (MDT) guided by clearly defined practice requirements that have been lacking amongst many prevailing guidelines will overcome prevailing objections to this practice and allow for the legitimization of this process.
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Affiliation(s)
- Lalit Kumar Radha Krishna
- Department of Palliative Medicine, National Cancer Center Singapore, 11 Hospital Drive, Singapore, 169610, Singapore.
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Swart SJ, van der Heide A, van Zuylen L, Perez RSGM, Zuurmond WWA, van der Maas PJ, van Delden JJM, Rietjens JAC. Continuous palliative sedation: not only a response to physical suffering. J Palliat Med 2014; 17:27-36. [PMID: 24410419 DOI: 10.1089/jpm.2013.0121] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Palliative sedation is a medical intervention aimed at relieving symptoms that can no longer be controlled by conventional treatment. Ample knowledge is available regarding the nature of such symptoms, but there is no in-depth information regarding how health care workers decide about palliative sedation. OBJECTIVE The study objective was to investigate considerations concerning the indications for continuous palliative sedation (CPS) and issues that influence these considerations. DESIGN The study consisted of qualitative interviews regarding patients who had recently received CPS. SETTING/SUBJECTS The study involved physicians and nurses working in general practice, nursing homes, and hospitals. MEASUREMENT Analyses by a multidisciplinary research team used the constant comparative method. RESULTS Together with physical symptoms, psychological and existential suffering may combine to produce a refractory state for which other treatment options than CPS were not available or considered inappropriate. A limited life expectancy was by many considered crucial (e.g., to avoid hastening death) and by some less important (e.g., because the patient's suffering was considered to be key). Issues influencing the decision to use CPS related to patient preferences (e.g., dignity, not wanting to experience further suffering) or family issues (impact of suffering on family, family requesting CPS). CONCLUSIONS The indication for CPS typically originates from physical symptoms and nonphysical problems producing a refractory state in which a patient suffers unbearably. In such states, preferences of patients and families and the life expectancy criterion are weighed against the severity of refractory symptoms. Therefore the use of CPS is not only a response to the physical suffering of patients in the dying phase.
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Affiliation(s)
- Siebe J Swart
- 1 Department of Public Health, Erasmus Medical Centre , Rotterdam, the Netherlands
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Irwin SA, Pirrello RD, Hirst JM, Buckholz GT, Ferris FD. Clarifying delirium management: practical, evidenced-based, expert recommendations for clinical practice. J Palliat Med 2013; 16:423-35. [PMID: 23480299 PMCID: PMC3612281 DOI: 10.1089/jpm.2012.0319] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2013] [Indexed: 12/30/2022] Open
Abstract
Delirium is highly prevalent in those with serious or advanced medical illnesses. It is associated with many adverse consequences, including significant patient, family, and health care provider distress. This article suggests a novel approach to delirium assessment and management and provides useful, practical guidance for clinicians based on a complete review of the existing literature and the expert clinical opinion of the authors and their colleagues, derived from over a decade of collective bedside experience. Comprehensive assessment includes careful description of observed symptoms, signs, and behaviors; and an understanding of the patient's situation, including primary diagnosis, associated comorbidities, functional status, and prognosis. The importance of incorporating goals of care for the patient and family is discussed. The concepts of potential reversibility versus irreversible delirium and delirium subtype are proffered, with a description of how diagnostic and management strategies follow from these concepts. Pharmacological interventions that provide rapid, effective, and safe relief are presented. Employing both pharmacological and nonpharmacological interventions, including patient and family education, improves symptoms and relieves patient and family distress, whether the delirium is reversible or irreversible, hyperactive or hypoactive. All interventions can be provided in any setting of care, including patients' homes.
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Affiliation(s)
- Scott A Irwin
- San Diego Hospice and The Institute for Palliative Medicine, San Diego, CA 92103, USA.
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Patel B, Gorawara-Bhat R, Levine S, Shega JW. Nurses' attitudes and experiences surrounding palliative sedation: components for developing policy for nursing professionals. J Palliat Med 2012; 15:432-7. [PMID: 22500480 DOI: 10.1089/jpm.2011.0336] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nurses play an integral role in providing care for patients with end of life (EOL) symptoms refractory to conventional treatments and that may necessitate palliative sedation (PS). A paucity of research on nurses' attitudes, knowledge, and experience with PS exists, despite nurses being instrumental in evaluating its appropriateness and carrying out the care plan. OBJECTIVE The objective of the study was to elicit nurses' perspectives and conceptualizations of knowledge and skills needed to administer PS in order to inform development of a hospital policy that addresses identified concerns. METHODS Four focus groups were conducted with nurses likely to have had exposure to PS (oncology, intensive care, and hospice) at an academic medical center. Focus groups were audiotaped, transcribed verbatim, and coded for salient themes. Grounded theory principles were used for the analysis. RESULTS Among the four focus groups (n=31), 87% were female, 58% between the ages of 36 and 55, and more than 40% reported 10-plus years of providing patient care. Five domains emerged as important in developing a PS policy: 1) ability to define PS; 2) criterion for using PS; 3) skill set for administering PS; 4) policy and procedural guidelines; and 5) education on PS and EOL care. CONCLUSIONS Nurses identified knowledge, skills, and guidelines as key considerations for implementing PS. Comprehensive policies along with adequate training are needed to expand the availability of PS in acute care hospitals and hospice programs.
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Affiliation(s)
- Bansari Patel
- Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, IL 60637, USA.
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Hahn MP. Review of palliative sedation and its distinction from euthanasia and lethal injection. J Pain Palliat Care Pharmacother 2012; 26:30-9. [PMID: 22448939 DOI: 10.3109/15360288.2011.650353] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Palliative sedation evolved from within the practice of palliative medicine and has become adopted by other areas of medicine, such as within intensive care practice. Clinician's usually come across this practice for dying patients who are foregoing or having life support terminated. A number of intolerable and intractable symptom burdens can occur during the end of life period that may require the use of palliative sedation. Furthermore, when patients receive palliative sedation, the continued use of hydration and nutrition becomes an issue of consideration and there are contentious bioethical issues involved in using or withholding these life-sustaining provisions. A general understanding of biomedical ethics helps prevent abuse in the practice of palliative sedation. Various sedative drugs can be employed in the provision of palliative sedation that can produce any desired effect, from light sedation to complete unconsciousness. Although there are some similarities in the pharmacotherapy of palliative sedation, euthanasia, physician-assisted suicide, and lethal injection, there is a difference in how the drugs are administered with each practice. There are some published guidelines about how palliative sedation should be practiced, but currently there is not any universally accepted standard of practice.
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Affiliation(s)
- Michael P Hahn
- Respiratory Care, Loma Linda University Children's Hospital, Loma Linda, California 92354, USA.
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9
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Marchand LR. End-of-Life Care. Integr Med (Encinitas) 2012. [DOI: 10.1016/b978-1-4377-1793-8.00064-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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10
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Schuman-Olivier Z, Brendel DH, Forstein M, Price BH. The use of palliative sedation for existential distress: a psychiatric perspective. Harv Rev Psychiatry 2009; 16:339-51. [PMID: 19085388 DOI: 10.1080/10673220802576917] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article introduces a structure for standardization in the ongoing debate about the application of palliative sedation for psychological and existential suffering at the end of life. We differentiate the phenomenon of existential distress from the more general one of existential suffering, defining existential distress as a special case of existential suffering that applies to persons with terminal illness. We introduce both a clinical classification system of existential distress based on proximity to expected death and a decision-making process for considering palliative sedation (represented by the mnemonic, TIRED). Neuropsychiatric clinical cases will be used to demonstrate some of the concepts and ethical arguments.
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Affiliation(s)
- Zev Schuman-Olivier
- Department of Psychiatry, Harvard Medical School, Cambridge Health Alliance, Cambridge, MA 02139, USA.
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A call for simple and rational palliative medicine psychotropic prescribing guidelines: Response to Barnhorst et al. ( Palliative & Supportive Care, Volume 6, Number 1, 2008). Palliat Support Care 2009; 7:3-6. [DOI: 10.1017/s1478951509000029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
PURPOSE OF REVIEW Palliative care is a discipline that provides satisfactory symptom relief to most patients with advanced life-threatening disease. There remain circumstances, however, in which patients experience distressing symptoms and unbearable suffering that cannot be adequately relieved. In these situations palliative sedation may be valuable as a last resort. Palliative sedation is a controversial issue and research in this area is complex for ethical and practical reasons. A review of some critical aspects, giving special attention to those areas that require further research, is therefore timely. RECENT FINDINGS There is a dearth of evidence regarding sedation in the setting of palliative care. The literature contains many expert opinions and retrospective reports, but only a few prospective studies have been published. Terminology regarding sedation is confusing, indications and outcomes do not tend to be clearly reported, and no comparative studies to test drug effectiveness have been conducted. Consensus and innovative methodologies to enhance scientific knowledge are urgently needed in this area. SUMMARY This review addresses recent literature concerning definitions of palliative sedation and intolerable/refractory suffering, indications and drug use. The current state of the art is summarized and future lines of research are proposed.
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Cowan JD, Clemens L, Palmer T. Palliative sedation in a southern Appalachian community. Am J Hosp Palliat Care 2007; 23:360-8. [PMID: 17060303 DOI: 10.1177/1049909106292173] [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] [Indexed: 11/16/2022] Open
Abstract
Of 1200 palliative care patients, 28 received palliative sedation. They were more likely than patients without palliative sedation to have an Eastern Cooperative Oncology Group performance status of at least 3, a cancer diagnosis, an expected survival of weeks or less, to have been monitored by the palliative care team for at least 1 week, to have delirium as the cause of decreased communication, to have dyspnea as a non-pain symptom, and to be less able to communicate symptoms. Almost 90% received palliative sedation for at least 24 hours for a median of 3 days (range, 0 to 24 days). Home patients received palliative sedation longer. Symptoms were controlled in 82% and improved in the rest. Sedation developed in 79% but was not required for symptom control in 5. Patient survival from palliative care consultation was a median of 8 days (range, 0 to 32 days).
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Affiliation(s)
- John D Cowan
- Palliative Care and Hospice, Advanced Illness Assistance Team, Blount Memorial Hospital, Maryville, Tennessee.
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14
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End-of-Life Care. Integr Med (Encinitas) 2007. [DOI: 10.1016/b978-1-4160-2954-0.50085-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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15
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González Barón M, Gómez Raposo C, Vilches Aguirre Y. [The last phase in the progressive neoplasic disease: care at the end-of-life, refractory symptoms and sedation]. Med Clin (Barc) 2006; 127:421-8. [PMID: 17020687 DOI: 10.1157/13092768] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
End-of-life is one of the most stressful phases during course of a neoplasic disease. Frequently, death of patients with cancer comes after a continuous and progressive physical impairment. As death approaches, the medical team might redefine outcomes and treat as priority symptoms and relief suffering. That care encompasses the physical, psychological, social, spiritual, and existential needs of patients and their families. However, symptoms are frequently observed that are intolerable for the patient and which do not respond to usual palliative measures. The intolerable nature and being refractory to treatment indicates to the health-care team, on many occasions, the need for sedation of the patient. The medical team can take comfort in the knowledge that they did their best to provide safe passage to all their patients and that, although they did not always cure them, the patients often were healed.
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Affiliation(s)
- Manuel González Barón
- Cátedra de Oncología Médica y Medicina Paliativa, Universidad Autónoma de Madrid, Madrid, España
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Rousseau P. Palliative Sedation: The Author's Response. J Palliat Med 2005. [DOI: 10.1089/jpm.2005.8.702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Davis MP, Ford PA. Palliative Sedation Definition, Practice, Outcomes, and Ethics. J Palliat Med 2005; 8:699-701; author reply 702-3. [PMID: 16128638 DOI: 10.1089/jpm.2005.8.699] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
There is a continuum of the goals of comfort and function in palliative care that begins with comfort and function being equal priorities and sedation being unacceptable. As disease progresses, the goals and preferences of the patient turn to coping with the loss of function caused by the disease and acceptance of unintentional sedation from the disease, its therapies, or symptom relief interventions. As patients approach the end of life, they may need intentional sedation for the relief of refractory symptoms. Such sedation can be divided into three categories: routine, infrequent, and extraordinary with respect to the frequency, difficulty, and risks involved with the drugs and routes of administration required to induce and maintain a level of sedation that relieves the patient's physical and existential symptoms. Extraordinary sedation with continuous infusions of midazolam, thiopental, and propofol can relieve refractory symptoms in most patients in their final days of life. Palliative care clinicians should become comfortable with the ethical justification and technical expertise needed to provide this essential, extraordinary care to the small but deserving number of patients in whom routine and infrequent sedation does not adequately relieve their suffering.
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Affiliation(s)
- Michael H Levy
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA.
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