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LiPuma SH, Demarco JP. Expanding the Use of Continuous Sedation Until Death and Physician-Assisted Suicide. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2024; 49:313-323. [PMID: 38538066 DOI: 10.1093/jmp/jhae009] [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: 04/21/2024] Open
Abstract
The controversy over the equivalence of continuous sedation until death (CSD) and physician-assisted suicide/euthanasia (PAS/E) provides an opportunity to focus on a significant extended use of CSD. This extension, suggested by the equivalence of PAS/E and CSD, is designed to promote additional patient autonomy at the end-of-life. Samuel LiPuma, in his article, "Continuous Sedation Until Death as Physician-Assisted Suicide/Euthanasia: A Conceptual Analysis" claims equivalence between CSD and death; his paper is seminal in the equivalency debate. Critics contend that sedation follows proportionality protocols for which LiPuma's thesis does not adequately account. Furthermore, sedation may not eliminate consciousness, and as such LiPuma's contention that CSD is equivalent to neocortical death is suspect. We not only defend the equivalence thesis, but also expand it to include additional moral considerations. First, we explain the equivalence thesis. This is followed by a defense of the thesis against five criticisms. The third section critiques the current use of CSD. Finally, we offer two proposals that, if adopted, would broaden the use of PAS/E and CSD and thereby expand options at the end-of-life.
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2
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Furlan TJ. James Rachels and the morality of euthanasia. THEORETICAL MEDICINE AND BIOETHICS 2024; 45:69-97. [PMID: 38472568 DOI: 10.1007/s11017-024-09658-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 03/14/2024]
Abstract
My fundamental thesis is that Rachels dismisses the traditional Western account of the morality of killing without offering a viable replacement. In this regard, I will argue that the substitute account he offers is deficient in at least eight regards: (1) he fails to justify the foundational principle of utilitarianism, (2) he exposes preference utilitarianism to the same criticisms he lodges against classical utilitarianism, (3) he neglects to explain how precisely one performs the maximization procedure which preference utilitarianism requires, (4) his account of the sanctity of life is subject to the very criticism he levels against the traditional position, (5) he cannot justify the exceptions he makes to his interpretation of the sanctity of life, (6) his account could easily be used to justify murder, (7) his embrace of autonomy as an ethical principle undermines his preference utilitarianism, and (8) he cannot maintain the moral identification of acts of killing and letting die.
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3
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Bradley AS, Dalton A. Navigating ethical dilemmas in trauma, resuscitation, and critical care. Int Anesthesiol Clin 2023; 61:62-66. [PMID: 37551584 DOI: 10.1097/aia.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Affiliation(s)
- A Steven Bradley
- Department of Anesthesiology and Critical Care, University of Chicago Medical Center, Chicago, IL
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4
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Cherny NI, Ziff-Werman B. Ethical considerations in the relief of cancer pain. Support Care Cancer 2023; 31:414. [PMID: 37351702 DOI: 10.1007/s00520-023-07868-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/07/2023] [Indexed: 06/24/2023]
Abstract
The management of pain for patients with cancer and cancer survivors is a critical clinical task that involves a multitude of ethical issues at almost every phase of the cancer experience. This review is divided into three sections: In the first, we address rights and duties in the relief of pain from the perspective of patients, clinicians, health care institutions and organizations, and public policy. This section includes a detailed description of issues and duties in relation to opioid misuse and addiction. In the second section, we discuss the ethical consideration of therapeutic planning. The final section addresses ethical considerations in the management of pain at the end of life including a detailed discussion regarding ethical issues relating to the use of palliative sedation as a clinical intervention of last resort.
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5
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Kearns AJ. The principle of double effect and external whistleblowing in nursing. Nurs Outlook 2022; 70:807-819. [PMID: 36400577 DOI: 10.1016/j.outlook.2022.09.001] [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] [Received: 06/20/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022]
Abstract
Nurses are generally expected to raise concerns when a harm or wrongdoing is committed against patients. Should their concerns not be adequately addressed, then nurses may take the decision to engage in external whistleblowing. Given that it could have a negative effect on the health care organization or service, nurses may question whether they should engage in external whistleblowing. Consequently, is there an ethical criterion to discern whether the negative effect on the health care organization or service is ethically permissible? This paper argues for the suitability of the Principle of Double Effect as an ethical criterion. The position of this paper is that external whistleblowing by a nurse when understood as an advocacy act with two effects (i.e. the effect of defending a patient and the further negative effect on the health care organization or service) can be ethically permissible through meeting the conditions of the Principle of Double Effect.
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Affiliation(s)
- Alan J Kearns
- School of Theology, Philosophy, and Music, Dublin City University, Dublin, Ireland.
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6
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Wall AE, Fiedler A, Karp S, Shah A, Testa G. Applying the ethical framework for donation after circulatory death to thoracic normothermic regional perfusion procedures. Am J Transplant 2022; 22:1311-1315. [PMID: 35040263 DOI: 10.1111/ajt.16959] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 01/25/2023]
Abstract
The novel approach of thoracic normothermic regional perfusion (TA-NRP) for in-situ preservation of organs prior to removal presents a new series of ethical questions about donation after circulatory determination of death (DCD) procedures. This manuscript describes the framework used for the analysis of ethical acceptability of DCD donation and analyzes the specific practice of TA-NRP DCD within that framework to demonstrate that TA-NRP DCD can be performed within the ethical boundaries of DCD donation. We argue that TA-NRP DCD organ procurements meet the ethical standards of informed consent, non-maleficence, adherence to the dead donor rule, and irreversibility, and as such, are ethically acceptable. We also describe the potential benefits of TA-NRP DCD procedures that result from higher organ yields and better recipient outcomes. Finally, we call for open and transparent support of TA-NRP DCD by professional organizations as a necessary cornerstone for the advancement of TA-NRP DCD procedures.
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Affiliation(s)
- Anji E Wall
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Amy Fiedler
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Seth Karp
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish Shah
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Giuliano Testa
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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7
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Brenna CTA. Regulating Death: A Brief History of Medical Assistance in Dying. Indian J Palliat Care 2021; 27:448-451. [PMID: 34898940 PMCID: PMC8655630 DOI: 10.25259/ijpc_426_20] [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] [Received: 07/09/2021] [Accepted: 09/17/2021] [Indexed: 12/04/2022] Open
Abstract
Unique reports of suicide and euthanasia date back more than 2 millennia, reflecting evolving philosophies of death and dying as expressions of the mores dominating a given era. One longstanding theme in the history of decisions to die has been staunch opposition founded in religious claims that one’s body is a trust from the divine (and therefore not wholly in their ownership). The role of the physician has also been traditionally estranged from participation in such decisions, dating back to rudimentary conceptions of medical ethics in the Hippocratic notion primum non nocere (‘first, do no harm’). However, fundamental principles in the modern philosophy of medicine lend support to the idea that physicians can be justified in actions which cause some harm, in so far as they are acting to fulfil a greater ethical imperative. This brief historical review explores the inception of modern North American medical assistance in dying (MAiD) policy through a series of critical case studies in the unfolding of its practice. Medically assisted dying has presently been legalised in Canada and some United States jurisdictions, but with critical caveats surrounding circumstances of mature minors, advance directives and mental illness as participants’ sole underlying medical condition. While the modern regulations surrounding MAiD continue to take shape, the palliative care community is well-positioned to both guide and scrutinise the ethics of this practice.
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Affiliation(s)
- Connor T A Brenna
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
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8
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Stumpf A, Rogalski D. Getting Real About Killing and Allowing to Die: A Critical Discussion of the Literature. CANADIAN JOURNAL OF BIOETHICS 2021. [DOI: 10.7202/1084448ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
The moral significance of the distinction between killing and allowing to die has played a key role in debates about euthanasia and physician assisted suicide. Since the withdrawal of life-sustaining treatment is held as morally permissible in the medical community, it follows that if there is no morally significant difference between killing and allowing to die, then there is no morally significant difference between withdrawing life-sustaining treatment or administering a lethal injection to end a patient’s life. Consistency then requires that voluntary active euthanasia (VAE) is also morally permissible. The debates over whether the distinction is morally significant have carried on for decades with little hope of consensus. We begin by surveying the literature to identify common argumentative strategies used in defending or rejecting the distinction’s significance. We observe, based on our review, that many of these strategies operate in ways that are conceptually removed from the concrete clinical situation of physicians involved in practices that lead to patient death (by withdrawal of treatment or VAE). We conclude by arguing for a novel way of moving the debate forward indicated by our reading of the literature, namely, by paying careful attention to the moral experience of physicians involved in end-of-life interventions to understand how they experience these practices. Exploring physician experience can reveal how the distinction may or may not be useful for moral deliberation and can provide the needed context to theorize about the distinction in a more empirically informed and practically useful way.
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Affiliation(s)
- Andrew Stumpf
- Department of Philosophy, St. Jerome’s University, Waterloo, Canada
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9
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Floriani CA. Bioethical considerations on models for end-of-life care. CAD SAUDE PUBLICA 2021; 37:e00264320. [PMID: 34586171 DOI: 10.1590/0102-311x00264320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 06/25/2021] [Indexed: 11/22/2022] Open
Abstract
The article discusses contemporary societies' three institutionalized fields in end-of-life care and their respective models of death: euthanasia/assisted suicide; medical futility; and kalothanasia, the basis for the modern hospice movement. The article also analyzes how these models impact patients' lives and the conceptual weakness of some traditionally used banners such as that of human dignity. It also comments on orthothanasia, a widely used concept in the Brazilian bioethical literature, as well as rational suicide in the elderly. Questions are posed for the bioethical debate on the need to rethink some postulates, especially pertaining to euthanasia. Finally, the article presents and analyzes the ethical and philosophical basis for kalothanasia and its implications for the organization of good practices in end-of-life care.
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10
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Yip YY, Cheung JCH, Cheung EHL. Sedation and general anaesthesia in end-of-life care: the boundary has to be defined. Anaesthesia 2021; 76:1542. [PMID: 34044468 DOI: 10.1111/anae.15515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Y Y Yip
- Prince of Wales Hospital, Hong Kong, China
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11
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Potter J, Shields S, Breen R. Palliative Sedation, Compassionate Extubation, and the Principle of Double Effect: An Ethical Analysis. Am J Hosp Palliat Care 2021; 38:1536-1540. [PMID: 33657860 DOI: 10.1177/1049909121998630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Palliative sedation is a well-recognized and commonly used medical practice at the end of life for patients who are experiencing refractory symptoms that cannot be controlled by other means of medical management. Given concerns about potentially hastening death by suppressing patients' respiratory drive, traditionally this medical practice has been considered ethically justifiable via application of the ethical doctrine known as the Principle of Double Effect. And even though most recent evidence suggests that palliative sedation is a safe and effective practice that does not hasten death when the sedative medications are properly titrated, the Principle of Double Effect is still commonly utilized to justify the practice of palliative sedation and any risk-however small-it may entail of hastening the death of patients. One less common clinical scenario where the Principle of Double Effect may still be appropriate ethical justification for palliative sedation is when the practice of palliative sedation is pursued concurrently with the active withdrawal of life-sustaining treatment-particularly the practice of compassionate extubation. This case study then describes an unconventional case of palliative sedation with concurrent compassionate extubation where Principle of Double Effect reasoning was effectively employed to ethically justify continuing to palliatively sedate a patient during compassionate extubation.
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Affiliation(s)
- Jordan Potter
- Ethics Program, 5325Wellstar Health System, Atlanta, GA, USA
| | - Steven Shields
- Ethics Program, 5325Wellstar Health System, Atlanta, GA, USA
| | - Renée Breen
- Palliative Medicine, 1366Northside Hospital, Atlanta, GA, USA
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12
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Benedetti DJ, Marron JM. Ethical Challenges in Pediatric Oncology Care and Clinical Trials. Recent Results Cancer Res 2021; 218:149-173. [PMID: 34019168 DOI: 10.1007/978-3-030-63749-1_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The care of pediatric cancer patients is a vast departure from cancer care of adults. While the available treatment modalities-chemotherapy, radiation, and surgery-are the same, the diseases, care-delivery, and outcomes differ greatly. And just as 'children are not just little adults,' pediatric bioethics occupies a distinct place within the broader field of bioethics. In this chapter, we will begin with an introduction to fundamental principles and frameworks for understanding ethical issues in pediatrics, highlighting the triadic nature of medical decision-making between a physician, the child-patient, and the child's parent as the surrogate decision-maker. We will then delve into further details of how these principles and frameworks shape the care of children with cancer, examining specific ethical challenges commonly encountered by pediatric oncologists. We will traverse this landscape by examining issues involving (a) informed consent; (b) research involving children; (c) end of life; (d) genetic and genomic testing; and (e) professionalism. We also examine ethical challenges in clinical research, in children and more broadly. While not an exhaustive exploration of the myriad ethical issues one might encounter in pediatric cancer medicine and clinical trials, this chapter provides readers with a foundation for further reading.
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Affiliation(s)
- Daniel J Benedetti
- Division of Hematology-Oncology, Department of Pediatrics, Vanderbilt University Medical Center, 2220 Pierce Avenue 397 PRB, Nashville, TN, 37232-6310, USA.
| | - Jonathan M Marron
- Division of Pediatric Hematology/Oncology, Harvard Medical School, Center for Bioethics, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, 02215, USA
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13
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Murillo-Zamora E, García-López NA, de Santiago-Ruiz A, Chávez-Lira AE, Mendoza-Cano O, Guzmán-Esquivel J. Characterisation of palliative sedation use in inpatients at a medium-stay palliative care unit. Int J Palliat Nurs 2020; 26:341-345. [DOI: 10.12968/ijpn.2020.26.7.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Palliative sedation has been used to refer to the practice of providing symptom control through the administration of sedative drugs. The objective of this article was to characterise palliative sedation use in inpatients at a medium-stay palliative care unit. Material and methods A cross-sectional study was conducted on 125 randomly selected patients (aged 15 or older) who had died in 2014. The Palliative Performance Scale was used to evaluate the functional status. Results Palliative sedation was documented in 34.4% of the patients and midazolam was the most commonly used sedative agent (86.0%). More than half (53.5%) of those who recieved sedation presented with delirium. Liver dysfunction was more frequent in the sedated patients (p=0.033) and patients with heart disease were less likely (p=0.026) to be sedated. Conclusion Palliative sedation is an ethically accepted practice. It was commonly midazolam-induced, and differences were documented, among sedated and non-sedated patients, in terms of liver dysfunction and heart disease.
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Affiliation(s)
- Efrén Murillo-Zamora
- PhD, Departamento de Epidemiología, Unidad de Medicina Familiar No 19, Instituto Mexicano del Seguro Social, Colima, Mexico
| | - Nallely A García-López
- MPC, Departamento Clínico, Unidad de Medicina Familiar No. 19, Instituto Mexicano del Seguro Social, Colima, Mexico
| | - Ana de Santiago-Ruiz
- MD, Hospital Centro de Cuidados Laguna, Fundación Vianorte-Laguna, Madrid, Spain
| | | | | | - José Guzmán-Esquivel
- PhD, Unidad de Investigación en Epidemiología Clínica, Instituto Mexicano del Seguro Social, Colima, Mexico and Facultad de Medicina, Universidad de Colima, Colima, Mexico
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14
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Laserna A, Durán-Crane A, López-Olivo MA, Cuenca JA, Fowler C, Díaz DP, Cardenas YR, Urso C, O'Connell K, Fowler C, Price KJ, Sprung CL, Nates JL. Pain management during the withholding and withdrawal of life support in critically ill patients at the end-of-life: a systematic review and meta-analysis. Intensive Care Med 2020; 46:1671-1682. [PMID: 32833041 PMCID: PMC7444163 DOI: 10.1007/s00134-020-06139-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/26/2020] [Indexed: 01/08/2023]
Abstract
Purpose To review and summarize the most frequent medications and dosages used during withholding and withdrawal of life-prolonging measures in critically ill patients in the intensive care unit. Methods We searched PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Virtual Health Library from inception through March 2019. We considered any study evaluating pharmaceutical interventions for pain management during the withholding or withdrawing of life support in adult critically ill patients at the end-of-life. Two independent investigators performed the screening and data extraction. We pooled data on utilization rate of analgesic and sedative drugs and summarized the dosing between the moment prior to withholding or withdrawal of life support and the moment before death. Results Thirteen studies met inclusion criteria. Studies were conducted in the United States (38%), Canada (31%), and the Netherlands (31%). Eleven studies were single-cohort and twelve had a Newcastle–Ottawa Scale score of less than 7. The mean age of the patients ranged from 59 to 71 years, 59–100% were mechanically ventilated, and 47–100% of the patients underwent life support withdrawal. The most commonly used opioid and sedative were morphine [utilization rate 60% (95% CI 48–71%)] and midazolam [utilization rate 28% (95% CI 23–32%)], respectively. Doses increased during the end-of-life process (pooled mean increase in the dose of morphine: 2.6 mg/h, 95% CI 1.2–4). Conclusions Pain control is centered on opioids and adjunctive benzodiazepines, with dosages exceeding those recommended by guidelines. Despite consistency among guidelines, there is significant heterogeneity among practices in end-of-life care. Electronic supplementary material The online version of this article (10.1007/s00134-020-06139-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andres Laserna
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | | | - María A López-Olivo
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John A Cuenca
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cosmo Fowler
- Department of Medicine, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, USA
| | - Diana Paola Díaz
- Department of Critical Care, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Yenny R Cardenas
- Department of Critical Care, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Catherine Urso
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keara O'Connell
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Clara Fowler
- Research Services and Assessment, Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristen J Price
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joseph L Nates
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Divatia JV, Chawla R, Kapadia F, Myatra SN, Rajagopalan R, Amin P, Khilnani P, Prayag S, Todi SK, Uttam R. Guidelines for end-of-life and palliative care in Indian intensive care to units: ISCCM consensus Ethical Position Statement. Indian J Crit Care Med 2020. [DOI: 10.5005/ijccm-17-s1-26] [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] Open
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16
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Gruenewald DA, Vandekieft G. Options of Last Resort: Palliative Sedation, Physician Aid in Dying, and Voluntary Cessation of Eating and Drinking. Med Clin North Am 2020; 104:539-560. [PMID: 32312414 DOI: 10.1016/j.mcna.2020.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Some patients with terminal and degenerative illnesses request assistance to hasten death when suffering is refractory to palliative care, or they strongly desire to maximize their autonomy and dignity and minimize suffering. Palliative sedation (PS), voluntarily stopping eating and drinking (VSED), and physician-assisted death (PAD) are possible options of last resort. A decision to choose PS can be made by an informed surrogate decision maker, whereas intact decision-making capacity is required to choose VSED or PAD. For all palliative treatments of last resort, the risk of harm is minimized by the use of checklists, and establishment of policies and procedures.
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Affiliation(s)
- David A Gruenewald
- Palliative Care and Hospice Service, Geriatrics and Extended Care Service, Veterans Affairs Puget Sound Healthcare System, (S-182-GEC), 1660 South Columbian Way, Seattle, WA 98108, USA; Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA.
| | - Gregg Vandekieft
- Palliative Care Program, Providence St. Joseph Health Southwest Washington Region, Providence St. Peter Hospital, 413 Lilly Road Northeast, Olympia, WA 98506, USA; Palliative Practice Group, Institute for Human Caring at Providence St. Joseph Health, 879 W. 190th St., Suite 1000, Gardena, CA 90248, USA; Department of Family Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA. https://twitter.com/vandekieftg
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17
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Messika J, Boussard N, Guérin C, Michel F, Nseir S, Yonis H, Barbier CM, Rouzé A, Fouilloux V, Gaudry S, Ricard JD, Silverman H, Dreyfuss D. Strengths of the French end-of-life Law as Well as its Shortcomings in Handling Intractable Disputes Between Physicians and Families. New Bioeth 2020; 26:53-74. [PMID: 32065064 DOI: 10.1080/20502877.2020.1720421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
French end-of-life law aims at protecting patients from unreasonable treatments, but has been used to force caregivers to prolong treatments deemed unreasonable. We describe six cases (five intensive care unit patients including two children) where families disagreed with a decision to withdraw treatments and sued medical teams. An emergent inquiry was instigated by the families. In two cases, the court rejected the families' inquiries. In two cases, the families appealed the decision, and in both the first jurisdiction decision was confirmed, compelling caregivers to pursue treatments, even though they deemed them unreasonable. We discuss how this law may be perverted. Legal procedures may result in the units' disorganisation and give rise to caregivers' stress. Families' requests may be subtended by religious beliefs. French end-of-life law has benefits in theoretically constraining physicians to withhold or withdraw disproportionate therapies. These cases underline some caveats and the perverse effects of its literal reading.
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Affiliation(s)
- Jonathan Messika
- Université de Paris, Infection, Antimicrobials, Modelling, Evolution, IAME, UMR 1137, INSERM, Paris, France.,Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Louis Mourier, Colombes, France
| | - Noël Boussard
- CHRU Nancy-Brabois, Hôpital d'Enfants, Réanimation Pédiatrique Spécialisée, Vandoeuvre-Les-Nancy, France
| | - Claude Guérin
- Hospices civils de Lyon, Médecine intensive-Réanimation, Hôpital de la Croix-Rousse, Lyon, France.,Université de Lyon, Lyon, France.,INSERM 955, Créteil, France
| | - Fabrice Michel
- AP-HM Pediatric Anesthesia and Intensive Care Timone Hospital, Marseille, France.,Aix-Marseille Univ. CNRS, EFS, Marseille, France
| | - Saad Nseir
- CHU Lille, Critical Care Center, Lille, France.,School of Medicine, University of Lille, Lille, France
| | - Hodane Yonis
- Hospices civils de Lyon, Médecine intensive-Réanimation, Hôpital de la Croix-Rousse, Lyon, France
| | - Claire-Marie Barbier
- CHRU Nancy-Brabois, Hôpital d'Enfants, Réanimation Pédiatrique Spécialisée, Vandoeuvre-Les-Nancy, France
| | | | | | - Stephane Gaudry
- AP-HP Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, Bobigny, France.,French National Institute of Health and Medical Research (INSERM), UMR_S1155, Common and Rare Kidney Diseases: from Molecular Events to Precision Medicine, Sorbonne Université, Hôpital Tenon, Paris, France
| | - Jean-Damien Ricard
- Université de Paris, Infection, Antimicrobials, Modelling, Evolution, IAME, UMR 1137, INSERM, Paris, France.,Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Louis Mourier, Colombes, France
| | - Henry Silverman
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Didier Dreyfuss
- Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Louis Mourier, Colombes, France.,French National Institute of Health and Medical Research (INSERM), UMR_S1155, Common and Rare Kidney Diseases: from Molecular Events to Precision Medicine, Sorbonne Université, Hôpital Tenon, Paris, France.,Université de Paris, Paris, France
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18
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Abstract
The principle of double effect is widely used to permit the administration of narcotics and sedatives with the intent to palliate dying patients, even though the administration of these drugs may cause hastening of death. In recent medical literature, this principle's validity has been severely criticized, causing health care providers to fear providing good palliative care. Most of the criticisms levelled at the principle of double effect arise from misconceptions about its purpose and origins. This discussion will explore how virtue-based ethics can overcome the most important challenge to the principle of double effect's validity, that of its reliance on intention to determine whether the administration of analgesia is ethically acceptable.
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Barreth A, Fainsinger R, Oneschuk D, Pritchard Z. The Challenge of Communicating Intent of Sedation in Advanced Illness. J Palliat Care 2019. [DOI: 10.1177/082585970301900313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Angela Barreth
- Tertiary Palliative Care Program, Grey Nuns Community Hospital, Edmonton, Canada
| | - Robin Fainsinger
- Tertiary Palliative Care Program, Grey Nuns Community Hospital, Edmonton, Canada
| | - Doreen Oneschuk
- Tertiary Palliative Care Program, Grey Nuns Community Hospital, Edmonton, Canada
| | - Zinia Pritchard
- Tertiary Palliative Care Program, Grey Nuns Community Hospital, Edmonton, Canada
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20
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Blondeau D, Roy L, Dumont S, Godin G, Martineau I. Physicians’ and Pharmacists’ Attitudes toward the use of Sedation at the End of Life: Influence of Prognosis and Type of Suffering. J Palliat Care 2019. [DOI: 10.1177/082585970502100402] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Louis Roy
- Centre hospitalier universitaire de Québec
| | | | - Gaston Godin
- Faculté des sciences infirmières, Université Laval
| | - Isabelle Martineau
- Faculté des sciences infirmières Université Laval, Québec, Québec, Canada
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21
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Vogelstein E. Evaluating the American Nurses Association’s arguments against nurse participation in assisted suicide. Nurs Ethics 2019; 26:124-133. [DOI: 10.1177/0969733017694619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This discussion paper critically assesses the American Nurses Association’s stated arguments against nurse participation in assisted suicide, as found in its current (2013) position statement. Seven distinct arguments can be gleaned from the American Nurses Association’s statement, based on (1) the American Nurses Association’s Code of Ethics with Interpretive Statements and its injunction against nurses acting with the sole intent to end life, (2) the risks of abuse and misuse of assisted suicide, (3) nursing’s social contract or covenant with society, (4) the contention that nurses must not harm their patients, (5) the sanctity of life, (6) the traditions of nursing, and (7) the fundamental goals of nursing. Each of these arguments is evaluated, and none are found to be convincing. This is crucial because the American Nurses Association’s official stance on nurse participation in assisted suicide can have significant consequences for the well-being of nurses who care for patients in jurisdictions in which assisted suicide is legally available. The American Nurses Association should therefore have a strong and convincing justification for opposing the practice, if it is to take such a position. That it fails to evince such a justification in its official statement on the matter places a burden on the American Nurses Association to more strongly justify its position, or else abandon its stance against nurse participation in assisted suicide.
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22
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The role of end-of-life palliative sedation: medical and ethical aspects – Review. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 29776669 PMCID: PMC9391748 DOI: 10.1016/j.bjane.2018.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background and objective Palliative sedation is a medical procedure that has been used for more than 25 years to relieve refractory symptoms not responsive to any previous treatment in patients with no possibility of cure and near the end of life. Many uncertainties persist on the theme regarding definition, indications, decision making, most appropriate place to perform the procedure, most used drugs, need for monitoring, fluids and nutritional support, and possible ethical dilemmas. The objective of this review was to seek a probable consensus among the authors regarding these topics not yet fully defined. Method An exploratory search was made in secondary sources, from 1990 to 2016, regarding palliative sedation and its clinical and bioethical implications. Conclusions Palliative sedation is an alternative to alleviate end-of-life patient suffering due to refractory symptoms, particularly dyspnea and delirium, after all other treatment options have been exhausted. Decision making involves prior explanations, discussions and agreement of the team, patient, and/or family members. It can be performed in general hospital units, hospices and even at home. Midazolam is the most indicated drug, and neuroleptics may also be required in the presence of delirium. These patients’ monitoring is limited to comfort observation, relief of symptoms, and presence of adverse effects. There is no consensus on whether or not to suspend fluid and nutritional support, and the decision must be made with family members. From the bioethical standpoint, the great majority of authors are based on intention and proportionality to distinguish between palliative sedation, euthanasia, or assisted suicide.
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23
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Sulmasy DP. The last low whispers of our dead: when is it ethically justifiable to render a patient unconscious until death? THEORETICAL MEDICINE AND BIOETHICS 2018; 39:233-263. [PMID: 30132300 DOI: 10.1007/s11017-018-9459-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A number of practices at the end of life can causally contribute to diminished consciousness in dying patients. Despite overlapping meanings and a confusing plethora of names in the published literature, this article distinguishes three types of clinically and ethically distinct practices: (1) double-effect sedation, (2) parsimonious direct sedation, and (3) sedation to unconsciousness and death. After exploring the concept of suffering, the value of consciousness, the philosophy of therapy, the ethical importance of intention, and the rule of double effect, these three practices are defined clearly and evaluated ethically. It is concluded that, if one is opposed to euthanasia and assisted suicide, double-effect sedation can frequently be ethically justified, that parsimonious direct sedation can be ethically justified only in extremely rare circumstances in which symptoms have already completely consumed the patient's consciousness, and that sedation to unconsciousness and death is never justifiable. The special case of sedation for existential suffering is also considered and rejected.
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Affiliation(s)
- Daniel P Sulmasy
- The Pellegrino Center for Clinical Bioethics, The Kennedy Institute of Ethics, and the Departments of Medicine and Philosophy, Georgetown University, Washington, DC, USA.
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24
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Menezes MS, Figueiredo MDGMDCDA. [The role of end-of-life palliative sedation: medical and ethical aspects - Review]. Rev Bras Anestesiol 2018; 69:72-77. [PMID: 29776669 DOI: 10.1016/j.bjan.2018.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 02/28/2018] [Accepted: 03/31/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Palliative sedation is a medical procedure that has been used for more than 25 years to relieve refractory symptoms not responsive to any previous treatment in patients with no possibility of cure and near the end of life. Many uncertainties persist on the theme regarding definition, indications, decision making, most appropriate place to perform the procedure, most used drugs, need for monitoring, fluids and nutritional support, and possible ethical dilemmas. The objective of this review was to seek a probable consensus among the authors regarding these topics not yet fully defined. METHOD An exploratory search was made in secondary sources, from 1990 to 2016, regarding palliative sedation and its clinical and bioethical implications. CONCLUSIONS Palliative sedation is an alternative to alleviate end-of-life patient suffering due to refractory symptoms, particularly dyspnea and delirium, after all other treatment options have been exhausted. Decision making involves prior explanations, discussions and agreement of the team, patient, and/or family members. It can be performed in general hospital units, hospices and even at home. Midazolam is the most indicated drug, and neuroleptics may also be required in the presence of delirium. These patients' monitoring is limited to comfort observation, relief of symptoms, and presence of adverse effects. There is no consensus on whether or not to suspend fluid and nutritional support, and the decision must be made with family members. From the bioethical standpoint, the great majority of authors are based on intention and proportionality to distinguish between palliative sedation, euthanasia, or assisted suicide.
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Affiliation(s)
- Miriam S Menezes
- Universidade Federal de Santa Maria (UFSM), Santa Maria, RS, Brasil.
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25
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Salins N, Gursahani R, Mathur R, Iyer S, Macaden S, Simha N, Mani RK, Rajagopal MR. Definition of Terms Used in Limitation of Treatment and Providing Palliative Care at the End of Life: The Indian Council of Medical Research Commission Report. Indian J Crit Care Med 2018; 22:249-262. [PMID: 29743764 PMCID: PMC5930529 DOI: 10.4103/ijccm.ijccm_165_18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Indian hospitals, in general, lack policies on the limitation of inappropriate life-sustaining interventions at the end of life. To facilitate discussion, preparation of guidelines and framing of laws, terminologies relating to the treatment limitation, and providing palliative care at the end-of-life care (EOLC) need to be defined and brought up to date. METHODOLOGY This consensus document on terminologies and definitions of terminologies was prepared under the aegis of the Indian Council of Medical Research. The consensus statement was created using Nominal Group and Delphi Method. RESULTS Twenty-five definitions related to the limitations of treatment and providing palliative care at the end of life were created by reviewing existing international documents and suitably modifying it to the Indian sociocultural context by achieving national consensus. Twenty-five terminologies defined within the scope of this document are (1) terminal illness, (2) actively dying, (3) life-sustaining treatment, (4) potentially inappropriate treatment, (5) cardiopulmonary resuscitation (CPR), (6) do not attempt CPR, (7) withholding life-sustaining treatment, (8) withdrawing life-sustaining treatment, (9) euthanasia (10) active shortening of the dying process, (11) physician-assisted suicide, (12) palliative care, (13) EOLC, (14) palliative sedation, (15) double effect, (16) death, (17) best interests, (18) health-care decision-making capacity, (19) shared decision-making, (20) advance directives, (21) surrogates, (22) autonomy, (23) beneficence, (24) nonmaleficence, and (25) justice.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, India
| | - Roop Gursahani
- Department of Neurology, P.D. Hinduja National Hospital, Mumbai, India
| | - Roli Mathur
- ICMR Bioethics Unit, National Centre for Disease Informatics and Research (Indian Council of Medical Research), Bengaluru, Karnataka, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
| | - Stanley Macaden
- Palliative Care Program of the Christian Medical Association of India, India
- Coordinator of the Palliative Care Program of Christian Medical Association of India and Honorary Palliative Medicine Consultant at Bangalore Baptist Hospital, Bengaluru, Karnataka, India
| | - Nagesh Simha
- Medical Director, Karunashraya Hospice, Bengaluru, Karnataka, India
| | - Raj Kumar Mani
- CEO and Chairman, Department of Critical Care, Pulmonology and Sleep Medicine, Nayati Medicity, Mathura, Uttar Pradesh, India
| | - M. R. Rajagopal
- Chairman of Pallium India and Director of Trivandrum Institute of Palliative Sciences, Pallium, India
- Trivandrum Institute of Palliative Sciences, Thiruvananthapuram, Kerala, India
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26
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Hamano J, Morita T, Ikenaga M, Abo H, Kizawa Y, Tunetou S. A Nationwide Survey About Palliative Sedation Involving Japanese Palliative Care Specialists: Intentions and Key Factors Used to Determine Sedation as Proportionally Appropriate. J Pain Symptom Manage 2018; 55:785-791. [PMID: 29056564 DOI: 10.1016/j.jpainsymman.2017.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Although there has long been debate about physicians' intentions and what physicians consider to be proportionally appropriate when performing palliative sedation, few large studies have been performed. OBJECTIVES To identify physicians' intentions when starting continuous deep sedation and to clarify what factors determine whether physicians regard sedation as proportionally appropriate in relation to expected survival, the patients' wishes, and refractoriness. METHODS A nationwide questionnaire survey of Japanese palliative care specialists was performed from August to December 2016. We defined continuous deep sedation as the continuous use of sedatives to relieve intolerable and refractory symptoms with the loss of consciousness until death. RESULTS Of the 695 palliative care specialists enrolled, 440 were analyzed (response rate, 69%). A total of 95% and 87% of the physicians reported that they explicitly intended to perform symptom palliation and decrease consciousness levels, respectively. Moreover, 38% answered that they explicitly intended to maintain unconsciousness until death, and 11% reported that they intended to shorten survival to some extent. The respondents considered that continuous deep sedation is more appropriate when the predicted survival is shorter, the patients' wishes are consistent and clear, and confidence in the refractoriness of symptoms is higher. CONCLUSIONS Japanese palliative care specialists explicitly intend to control symptoms and reduce the level of consciousness when performing continuous deep sedation, but there are differences in their intentions with regard to maintaining unconsciousness until death. Predicted survival, patients' wishes, and confidence in refractoriness are associated with physicians' judgment that sedation is proportionally appropriate.
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Affiliation(s)
- Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
| | - Tatsuya Morita
- Palliative Care Team, Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Kita-ku, Hamamatsu, Shizuoka, Japan
| | - Masayuki Ikenaga
- Hospice Children's Hospice Hospital, Yodogawa Christian Hospital, Osaka, Japan
| | - Hirofumi Abo
- Department of Palliative Medicine, Rokko Hospital, Kobe, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Satoru Tunetou
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Kirby J. Morally-Relevant Similarities and Differences Between Assisted Dying Practices in Paradigm and Non-Paradigm Circumstances: Could They Inform Regulatory Decisions? JOURNAL OF BIOETHICAL INQUIRY 2017; 14:475-483. [PMID: 28983787 DOI: 10.1007/s11673-017-9808-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 03/12/2017] [Indexed: 06/07/2023]
Abstract
There has been contentious debate over the years about whether there are morally relevant similarities and differences between the three practices of continuous deep sedation until death, physician-assisted suicide, and voluntary euthanasia. Surprisingly little academic attention has been paid to a comparison of the uses of these practices in the two types of circumstances in which they are typically performed. A comparative domains of ethics analysis methodological approach is used in the paper to compare 1) the use of the three practices in paradigm circumstances, and 2) the use of the practices in paradigm circumstances to their use in non-paradigm circumstances. The analytical outcomes suggest that a bright moral line cannot be demonstrated between any two of the practices in paradigm circumstances, and that there are significant, morally-relevant distinctions between their use in paradigm and non-paradigm circumstances. A thought experiment is employed to illustrate how these outcomes could possibly inform the decisions of hypothetical deliberators who are engaged in the collaborative development of assisted dying regulatory frameworks.
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Affiliation(s)
- Jeffrey Kirby
- Department of Bioethics, Faculty of Medicine, Dalhousie University, C-320, 5849 University Avenue, Halifax, Nova Scotia, B3H 4H7, Canada.
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28
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Bernheim JL, Raus K. Euthanasia embedded in palliative care. Responses to essentialistic criticisms of the Belgian model of integral end-of-life care. JOURNAL OF MEDICAL ETHICS 2017; 43:489-494. [PMID: 28062650 DOI: 10.1136/medethics-2016-103511] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 10/25/2016] [Accepted: 12/01/2016] [Indexed: 06/06/2023]
Abstract
The Belgian model of 'integral' end-of-life care consists of universal access to palliative care (PC) and legally regulated euthanasia. As a first worldwide, the Flemish PC organisation has embedded euthanasia in its practice. However, some critics have declared the Belgian-model concepts of 'integral PC' and 'palliative futility' to fundamentally contradict the essence of PC. This article analyses the various essentialistic arguments for the incompatibility of euthanasia and PC. The empirical evidence from the euthanasia-permissive Benelux countries shows that since legalisation, carefulness (of decision making) at the end of life has improved and there have been no significant adverse 'slippery slope' effects. It is problematic that some critics disregard the empirical evidence as epistemologically irrelevant in a normative ethical debate. Next, rejecting euthanasia because its prevention was a founding principle of PC ignores historical developments. Further, critics' ethical positions depart from the PC tenet of patient centeredness by prioritising caregivers' values over patients' values. Also, many critics' canonical adherence to the WHO definition of PC, which has intention as the ethical criterion is objectionable. A rejection of the Belgian model on doctrinal grounds also has nefarious practical consequences such as the marginalisation of PC in euthanasia-permissive countries, the continuation of clandestine practices and problematic palliative sedation until death. In conclusion, major flaws of essentialistic arguments against the Belgian model include the disregard of empirical evidence, appeals to canonical and questionable definitions, prioritisation of caregiver perspectives over those of patients and rejection of a plurality of respectable views on decision making at the end of life.
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Affiliation(s)
- Jan L Bernheim
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussel, Belgium
| | - Kasper Raus
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussel, Belgium
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29
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Abstract
Heart failure presents unique challenges to the clinician who desires to provide excellent and humane care near the end of life. Accurate prediction of mortality in the individual patient is complicated by a chronic disease that is punctuated by recurrent acute episodes and sudden death. Health care providers continue to have difficulty communicating effectively with terminally ill patients and their caregivers regarding end-of-life care preferences, all of which needs to occur earlier rather than later. This article also discusses various means of providing palliative care, and specific issues regarding device therapy, cardiopulmonary resuscitation, and palliative sedation with concurrent discussion of the ethical ramifications and pitfalls of each.
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Affiliation(s)
- John Arthur McClung
- Division of Cardiology, Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA.
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30
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Kirby J. Organ donation after assisted death: Is it more or less ethically-problematic than donation after circulatory death? MEDICINE, HEALTH CARE, AND PHILOSOPHY 2016; 19:629-635. [PMID: 27263089 DOI: 10.1007/s11019-016-9711-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
A provocative question has emerged since the Supreme Court of Canada's decision on assisted dying: Should Canadians who request, and are granted, an assisted death be considered a legitimate source of transplantable organs? A related question is addressed in this paper: is controlled organ donation after assisted death (cDAD) more or less ethically-problematic than standard, controlled organ donation after circulatory determination of death (cDCDD)? Controversial, ethics-related dimensions of cDCD that are of relevance to this research question are explored, and morally-relevant distinctions between cDAD and cDCD are identified. In addition, a set of morally-relevant advantages of one practice over the other is uncovered, and a few potential, theoretical issues specifically related to cDAD practice are articulated. Despite these concerns, the analysis suggests a counterintuitive conclusion: cDAD is, overall, less ethically-problematic than cDCDD. The former practice better respects the autonomy interests of the potential donor, and a claim regarding irreversibility of cessation of the donor's circulatory function in the cDAD context can be supported. Further, with cDAD, there is no possibility that the donor will have negative sensory experiences during organ procurement surgery. Although the development of appropriate policy-decision and regulatory approaches in this domain will be complex and challenging, the comparative ethical analysis of these two organ donation practices has the potential to constructively inform the deliberations of relevant stakeholders, resource persons and decision makers.
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Affiliation(s)
- Jeffrey Kirby
- Department of Bioethics, Faculty of Medicine, Dalhousie University, C-320, 5849 University Avenue, Halifax, NS, B3H 4H7, Canada.
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31
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Abstract
Many patients nearing the end of life reach a point at which the goals of care change from an emphasis on prolonging life and optimizing function to maximizing the quality of remaining life, and palliative care becomes a priority. For some patients, however, even high-quality aggressive palliative care fails to provide relief. For patients suffering from severe pain, dyspnea, vomiting, or other symptoms that prove refractory to treatment, there is a consensus that palliative sedation is an appropriate intervention of last resort. In this report, the National Ethics Committee, Veterans Health Administration examines what is meant by palliative sedation, explores ethical concerns about the practice, reviews the emerging professional consensus regarding the use of palliative sedation for managing severe, refractory symptoms at the end of life, and offers specific recommendations for institutional policy.
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32
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Magelssen M, Kaushal S, Nyembwe KA. Intending, hastening and causing death in non-treatment decisions: a physician interview study. JOURNAL OF MEDICAL ETHICS 2016; 42:592-596. [PMID: 27255272 DOI: 10.1136/medethics-2015-103022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 05/11/2016] [Indexed: 06/05/2023]
Abstract
PURPOSE To explore how physicians analyse their non-treatment decisions in light of the concepts of hastening, causing and intending the patient's death. METHODS Sixteen Norwegian physicians from relevant specialties were interviewed and the results analysed by systematic text condensation, a qualitative analysis framework. RESULTS The physicians' chief dilemma in non-treatment decisions was the attempt to achieve the proper balance for the level of treatment at life's end. Respondents framed their challenges in medical and not ethical terms. They treated the concepts of intending, hastening and causing the patient's death as alien to their practical deliberations and, for many, irrelevant to the moral appraisal of their end-of-life practices. CONCLUSIONS The core concepts of traditional medico-ethical analyses of end-of-life decision-making do not map the practical terrain well. Research on physician intentions must be designed and interpreted in light of this.
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Affiliation(s)
| | - Sophia Kaushal
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
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34
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Gavaghan C, King M. Can facilitated aid in dying be permitted by 'double effect'? Some reflections from a recent New Zealand case. JOURNAL OF MEDICAL ETHICS 2016; 42:361-366. [PMID: 27030484 DOI: 10.1136/medethics-2016-103411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 02/15/2016] [Indexed: 06/05/2023]
Abstract
While the Doctrine of Double Effect (DDE) remains controversial in ethical circles, it continues to be recognised in common law courts. In 2015, the High Court of New Zealand became the latest to acknowledge the existence of the DDE, in a case that challenged the prohibition on physician assisted dying. In so doing, the possibility was raised that the DDE could potentially be used in an untraditional way to provide a prima facie justification of "facilitated aid in dying" (FAID) in some cases.In this article, we develop and offer justification for this line of reasoning. If it can be shown that FAID sometimes satisfies the conditions for DDE, this, we suggest, may have significant implications for the aid in dying debate, not only in New Zealand, but more widely. Even if all of the elements of the DDE are not met in such cases, though, we suggest that one of those elements - the doctor's intent in providing FAID - may not always be such as to attract moral blame or criminal culpability.
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Affiliation(s)
- Colin Gavaghan
- Faculty of Law, University of Otago, Dunedin, New Zealand
| | - Mike King
- Bioethics Centre, University of Otago, Dunedin, New Zealand
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35
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Kirby J. Managing Profound Suffering at the End-of-Life: Should expanding access to continuous deep sedation be the priority? BIOÉTHIQUEONLINE 2016. [DOI: 10.7202/1035489ar] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This paper argues that in addressing and managing profound suffering at the end-of-life, the priority should not be the legalization of physician-assisted suicide or voluntary active euthanasia in jurisdictions where these practices are not currently available. Rather, concerted efforts should be made by society and the healthcare provider community to expand patient access to proportionate distress-relieving sedation and continuous deep sedation.
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Affiliation(s)
- Jeffrey Kirby
- Professor, Department of Bioethics, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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36
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Abstract
Over the course of the last half-century, intensive care units have been the setting for many ethical and legal debates in medicine. This article outlines 3 important domains that lie at the intersection of critical care, palliative care, ethics, and the law: withholding and withdrawal of potentially life-sustaining therapies, making decisions for critically ill patients who lack decision-making capacity, and approaching cases of perceived futility when patients and families still request everything that is medically possible. Important principles and precedents that underlie our understanding of how nurses should approach critically ill patients are reviewed.
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38
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Abstract
Suicide is the deliberate act of causing death by self-directed injurious behavior with intent to die. Assisted dying, also known as assisted suicide, involves others to help hasten death. Physician-assisted dying specifically refers to the participation of a physician in facilitating one's death by providing a lethal means. Any decision to actively end a life has profound emotional and psychological effects on survivors. The article discusses the effects that older adults' deaths through suicide, assisted dying, and physician-assisted dying have on survivors and the implications for clinical practice.
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van Tol DG, Kouwenhoven P, van der Vegt B, Weyers H. Dutch physicians on the role of the family in continuous sedation. JOURNAL OF MEDICAL ETHICS 2015; 41:240-244. [PMID: 24595486 DOI: 10.1136/medethics-2013-101624] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In order to relieve intractable suffering of a terminal patient, doctors may decide to continuously sedate a patient until the end of life. Little research is done on the role the family plays during the process of continuous sedation. This study aims to get a view of doctors' experiences with continuous sedation, and the role of the family throughout that process. We held in-depth interviews with 48 doctors (19 general practitioners, 16 nursing home doctors and 18 medical specialists). Participants were selected varying in experience and opinions concerning end-of-life decisions. Dutch physicians experience the role of family in continuous sedation as important and potentially difficult. Difficulties may rise especially during the final stages when the patient is no longer conscious and family members are waiting for death to come. Disagreement may arise between physician and family, concerning the dignity of the dying process or the question whether the sedated patient is suffering or not. Some physicians report they hastened the dying process, in order to relieve the families' suffering.
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Affiliation(s)
- Donald G van Tol
- Department of General Practice, University Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Bea van der Vegt
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Heleen Weyers
- Deparment of Legal Theory, University of Groningen, Groningen, The Netherlands
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Boivin A, Marcoux I, Garnon G, Lehoux P, Mays N, Prémont MC, Chao YS, van Leeuwen E, Pineault R. Comparing end-of-life practices in different policy contexts: a scoping review. J Health Serv Res Policy 2015; 20:115-23. [DOI: 10.1177/1355819614567743] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives End-of-life policy reforms are being debated in many countries. Research evidence is used to support different assumptions about the effects of public policies on end-of-life practices. It is however unclear whether reliable international practice comparisons can be conducted between different policy contexts. Our aim was to assess the feasibility of comparing similar end-of-life practices in different policy contexts. Methods This is a scoping review of empirical studies on medical end-of-life practices. We developed a descriptive classification of end-of-life practices that distinguishes practices according to their legal status. We focused on the intentional use of lethal drugs by physicians because of international variations in the legal status of this practice. Bibliographic database searches were supplemented by expert consultation and hand searching of reference lists. The sensitivity of the search strategy was tested using a set of 77 articles meeting our inclusion criteria. Two researchers extracted end-of-life practice definitions, study methods and available comparisons across policy contexts. Canadian decision-makers were involved to increase the policy relevance of the review. Results In sum, 329 empirical studies on the intentional use of lethal drugs by doctors were identified, including studies from 19 countries. The bibliographic search captured 98.7% of studies initially identified as meeting the inclusion criteria. Studies on the intentional use of lethal drugs were conducted in jurisdictions with permissive (62%) and restrictive policies (43%). The most common study objectives related to the frequency of end-of-life practices, determinants of practices, and doctors’ adherence to regulatory standards. Large variations in definitions and research methods were noted across studies. The use of a descriptive classification was useful to translate end-of-life practice definitions across countries. A few studies compared end-of-life practice in countries with different policies, using consistent research methods. We identified no comprehensive review of end-of-life practices across different policy contexts. Conclusions It is feasible to compare end-of-life practices in different policy contexts. A systematic review of international evidence is needed to inform public deliberations on end-of-life policies and practice.
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Affiliation(s)
- Antoine Boivin
- Assistant Professor, Department of Family Medicine, Montreal University Hospital Research Center (CRCHUM), Canada
| | - Isabelle Marcoux
- Assistant Professor, Faculty of Health Science, University of Ottawa, Canada
| | | | - Pascale Lehoux
- Professor, Institut de recherche en santé publique de l’Université de Montréal, Canada
| | - Nicholas Mays
- Professor of Health Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, UK
| | | | | | - Evert van Leeuwen
- Professor of Medical Ethics, Scientific Institute for Quality of Healthcare, Radboud University, Netherlands
| | - Raynald Pineault
- Research Professor, Institut National de Santé Publique du Québec, Département de santé publique de Montréal, Canada
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Myatra SN, Salins N, Iyer S, Macaden SC, Divatia JV, Muckaden M, Kulkarni P, Simha S, Mani RK. End-of-life care policy: An integrated care plan for the dying: A Joint Position Statement of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Association of Palliative Care (IAPC). Indian J Crit Care Med 2014; 18:615-35. [PMID: 25249748 PMCID: PMC4166879 DOI: 10.4103/0972-5229.140155] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE The purpose was to develop an end-of-life care (EOLC) policy for patients who are dying with an advanced life limiting illness and to develop practical procedural guidelines for limiting inappropriate therapeutic medical interventions and improve the quality of care of the dying within an ethical framework and through a professional and family/patient consensus process. EVIDENCE The Indian Society of Critical Care Medicine (ISCCM) published its first guidelines on EOLC in 2005 [1] which was later revised in 2012.[2] Since these publications, there has been an exponential increase in empirical information and discussion on the subject. The literature reviewed observational studies, surveys, randomized controlled studies, as well as guidelines and recommendations, for education and quality improvement published across the world. The search terms were: EOLC; do not resuscitate directives; withdrawal and withholding; intensive care; terminal care; medical futility; ethical issues; palliative care; EOLC in India; cultural variations. Indian Association of Palliative Care (IAPC) also recently published its consensus position statement on EOLC policy for the dying.[3]. METHOD An expert committee of members of the ISCCM and IAPC was formed to make a joint EOLC policy for the dying patients. Proposals from the chair were discussed, debated, and recommendations were formulated through a consensus process. The members extensively reviewed national and international established ethical principles and current procedural practices. This joint EOLC policy has incorporated the sociocultural, ethical, and legal perspectives, while taking into account the needs and situation unique to India.
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Affiliation(s)
- Sheila Nainan Myatra
- From: Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Pune, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine, Tata Memorial Hospital, Pune, Maharashtra, India
| | - Shivakumar Iyer
- Department of Critical Care, Bharati Vidyapeeth, University Medical College, Pune, Maharashtra, India
| | - Stanley C. Macaden
- Palliative Care Program of Christian Medical Association of India, Bangalore, Karnataka, India
| | - Jigeeshu V. Divatia
- From: Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Pune, Maharashtra, India
| | - Maryann Muckaden
- Department of Palliative Medicine, Tata Memorial Hospital, Pune, Maharashtra, India
| | | | | | - Raj Kumar Mani
- Department of Pulmonology, Critical Care and Sleep Medicine, Saket City Hospital, New Delhi, India
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Gillett G, Chamberlain J. The clinician's dilemma: two dimensions of ethical care. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2013; 36:454-460. [PMID: 23830641 DOI: 10.1016/j.ijlp.2013.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
There is a continuing intense medico-ethico-legal debate around legalized euthanasia and physician assisted suicide such that ethically informed clinicians often agree with the arguments but feel hesitant about the conclusion, especially when it may bring about a change in law. We argue that this confusion results from the convergence of two continua that underpin the conduct of a clinician and are especially prominent in psychiatry. The two continua concern the duty of care and the importance of patient autonomy and they do not quite map into traditional divides in debates about sanctity of life, paternalism, and autonomy. As ethical dimensions, they come into sharp focus in the psychological complexities of end-of-life care and they form two key factors in most ethical and legal or disciplinary deliberations about a clinician's actions. Whereas both dimensions are important when a clinician reflects on what s/he has done or should do, they need careful balancing in a request for euthanasia or physician assisted suicide where the patient wants to take a decisive role in his or her own end-of-life care. However, end-of-life is also a situation where clinicians often encounter 'cries for help' so that both continua are importantly in play. Balancing these two continua without using blunt legal instruments is often required in psychiatric care in such a way as to problematize the idea that patient decisions should dominate the care options available. A simplistic approach to that issue arguably plays into what has been called an 'impoverished construction of life and death' and, some would say, devalues the basic commitments fundamental to medical care.
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Cherny NI. Palliative sedation for the relief of refractory physical symptoms. PROGRESS IN PALLIATIVE CARE 2013. [DOI: 10.1179/096992608x291234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abstract
Heart failure presents its own unique challenges to the clinician who desires to make excellent and humane care near the end of life a tangible reality. Accurate prediction of mortality in the individual patient is complicated by both the frequent occurrence of sudden death, both with and without devices, and the frequently chronic course that is punctuated by recurrent and more prominent acute episodes. A significant literature demonstrates that healthcare providers continue to have difficulty communicating effectively with terminally ill patients and their caregivers regarding end-of-life care preferences, and it is clear from the prognostic uncertainty of advanced heart failure that this kind of communication, and discussions regarding palliative care, need to occur earlier rather than later. This article discusses various means of providing palliative care, and specific issues regarding device therapy, cardiopulmonary resuscitation, and palliative sedation, with concurrent discussion of the ethical ramifications and pitfalls of each. A recent scientific statement from the American Heart Association begins to address some of the methodological issues involved in the care of patients with advanced heart failure. Above all, clinicians who wish to provide the highest quality of care to the dying patient need to confront the existential reality of death in themselves, their loved ones, and their patients so as to best serve those remanded to their care.
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Barathi B, Chandra PS. Palliative Sedation in Advanced Cancer Patients: Does it Shorten Survival Time? - A Systematic Review. Indian J Palliat Care 2013; 19:40-7. [PMID: 23766594 PMCID: PMC3680838 DOI: 10.4103/0973-1075.110236] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with advanced cancer often suffer from multiple refractory symptoms in the terminal phase of their life. Palliative sedation is one of the few ways to relieve this refractory suffering. OBJECTIVES This systematic review investigated the effect of palliative sedation on survival time in terminally ill cancer patients. MATERIALS AND METHODS Six electronic databases were searched for both prospective and retrospective studies which evaluated the effect of palliative sedation on survival time. Only those studies which had a comparison group that did not receive palliative sedation were selected for the review. Abstracts of all retrieved studies were screened to include the most relevant studies and only studies which met inclusion criteria were selected. References of all retrieved studies were also screened for relevant studies. Selected studies were assessed for quality and data extraction was done using the structured data extraction form. RESULTS Eleven studies including four prospective and seven retrospective studies were identified. Mean survival time (MST) was measured as the time from last admission until death. A careful analysis of the results of all the 11 studies indicated that MST of sedated and non-sedated group was not statistically different in any of the studies. CONCLUSION This systematic review supports the fact that palliative sedation does not shorten survival in terminally ill cancer patients. However, this conclusion needs to be taken with consideration of the methodology, study design, and the population studied of the included studies in this review.
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Affiliation(s)
- B Barathi
- Department of Pain and Palliative Care, St. John's Medical College Hospital, Bangalore, India
| | - Prabha S Chandra
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
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Mani RK, Amin P, Chawla R, Divatia JV, Kapadia F, Khilnani P, Myatra SN, Prayag S, Rajagopalan R, Todi SK, Uttam R. Guidelines for end-of-life and palliative care in Indian intensive care units' ISCCM consensus Ethical Position Statement. Indian J Crit Care Med 2012. [PMID: 23188961 PMCID: PMC3506078 DOI: 10.4103/0972-5229.102112] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- R K Mani
- Committee for the Development of Guidelines for limiting life-prolonging interventions and providing palliative care towards the end-of-life: Indian Society of Critical Care Medicine
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Abstract
Cardiac implantable electrical devices (CIEDs), including pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs), are the most effective treatment for life-threatening arrhythmias. Patients or their surrogates may request device deactivation to avoid prolongation of the dying process or in other settings, such as after device-related complications or with changes in health care goals. Despite published guidelines outlining theoretical and practical aspects of this common clinical scenario, significant uncertainty remains for both patients and health care providers regarding the ethical and legal status of CIED deactivation. This review outlines the ethical and legal principles supporting CIED deactivation, centered upon patient autonomy and authority over their own medical treatment. The empirical literature describing stakeholder views and experiences surrounding CIED deactivation is described, along with implications of these studies for future research surrounding the care of patients with CIEDs.
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Affiliation(s)
- Daniel B Kramer
- Hebrew SeniorLife Institute for Aging Research, Boston, MA, USA.
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Dean MM, Cellarius V, Henry B, Oneschuk D, Librach (Canadian Society of Pallia SL. Framework for Continuous Palliative Sedation Therapy in Canada. J Palliat Med 2012; 15:870-9. [DOI: 10.1089/jpm.2011.0498] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mervyn M. Dean
- Palliative Care, Western Memorial Regional Hospital, Corner Brook, Newfoundland and Labrador, Canada
| | - Victor Cellarius
- Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Blair Henry
- Ethics Centre, Sunnybrook Health Sciences Centre, Department of Family and Community Medicine, University of Toronto, University of Toronto, Toronto, Ontario, Canada
- Joint Centre for Bioethics, University of Toronto, Ontario, Canada
| | - Doreen Oneschuk
- Edmonton Regional Palliative Care Program, Grey Nuns Hospital, Edmonton, Alberta, Canada
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Chemotherapy at the end of life: up until when? Clin Transl Oncol 2012; 14:667-74. [PMID: 22855142 DOI: 10.1007/s12094-012-0847-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 12/06/2011] [Indexed: 12/25/2022]
Abstract
AIM The aim of this study is to analyze the use of CT in terminal stage cancer and the percentage of patients who received UCPD in 2009 and 2010 on the Medical Oncology and Palliative Home Care integrated service (UCPD) ward of the Marqués de Valdecilla University Hospital. METHOD Retrospective analysis of death rate registered on the Medical Oncology ward for 2009 and 2010 and the recorded date of the last CT given. The data are analyzed using the SPSS version 15.0 statistic package. Data were obtained from the Database Minimum Set for oncology admissions. RESULTS The death rate on the Medical Oncology ward is 22-24%. Total number of cases studied is 303. 47% of patients are aged 60 or younger. 81.8% (248) received active cancer treatment; of these, 138 (55.6%) in the last month, and 84 (33.8%) in the last 2 weeks. Only 66 patients out of those who died on the ward (21%) were previously sent to the UCPD. CONCLUSIONS Even when it is known that the majority of cancer patients become resistant to CT at the end of their lives, it is often given to patients of all ages. The request for palliative care is rare and often late.
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Billings JA, Churchill LR. Monolithic Moral Frameworks: How Are the Ethics of Palliative Sedation Discussed in the Clinical Literature? J Palliat Med 2012; 15:709-13. [DOI: 10.1089/jpm.2011.0157] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J. Andrew Billings
- Cambridge Health Alliance, Cambridge, Massachusetts, and Massachusetts General Hospital and the Harvard Medical School Center for Palliative Care, Boston, Massachusetts
| | - Larry R. Churchill
- Ann Geddes Stahlman Professor of Medical Ethics, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee
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