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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Mroz S, Deliens L, Cohen J, Chambaere K. Developments after the liberalization of laws concerning assisted dying—experience from Belgium and other countries. Deutsches Ärzteblatt international 2022. [DOI: 10.3238/arztebl.m2022.0378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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3
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Faris H, Dewar B, Dyason C, Dick DG, Matthewson A, Lamb S, Shamy MCF. Goods, causes and intentions: problems with applying the doctrine of double effect to palliative sedation. BMC Med Ethics 2021; 22:141. [PMID: 34666743 PMCID: PMC8527703 DOI: 10.1186/s12910-021-00709-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 10/05/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Palliative sedation and analgesia are employed in patients with refractory and intractable symptoms at the end of life to reduce their suffering by lowering their level of consciousness. The doctrine of double effect, a philosophical principle that justifies doing a "good action" with a potentially "bad effect," is frequently employed to provide an ethical justification for this practice. MAIN TEXT We argue that palliative sedation and analgesia do not fulfill the conditions required to apply the doctrine of double effect, and therefore its use in this domain is inappropriate. Furthermore, we argue that the frequent application of the doctrine of double effect to palliative sedation and analgesia reflects physicians' discomfort with the complex moral, intentional, and causal aspects of end-of-life care. CONCLUSIONS We are concerned that this misapplication of the doctrine of double effect can consequently impair physicians' ethical reasoning and relationships with patients at the end of life.
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Affiliation(s)
- Hannah Faris
- Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Brian Dewar
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Claire Dyason
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - David G Dick
- Department of Philosophy, University of Calgary, Calgary, Canada.,Canadian Centre for Advanced Leadership, Haskayne School of Business, University of Calgary, Calgary, Canada
| | | | - Susan Lamb
- Department of Innovation in Medical Education, University of Ottawa, Ottawa, Canada
| | - Michel C F Shamy
- Department of Medicine, University of Ottawa, Ottawa, Canada.,The Ottawa Hospital, Ottawa, Canada
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4
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Willmott L, White B, Feeney R, Chambaere K, Yates P, Mitchell G. Intentional hastening of death through medication: A case series analysis of Victorian deaths prior to the Voluntary Assisted Dying Act 2017. Intern Med J 2021; 51:1650-1656. [PMID: 34139049 DOI: 10.1111/imj.15435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 06/13/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Voluntary assisted dying is lawful in Victoria in limited circumstances and commences in Western Australia in mid-2021. There is evidence that in rare cases unlawful assisted dying practices occur in Australia. AIMS To determine whether assisted dying practices occurred in Victoria in the 12 months prior to the commencement of the Voluntary Assisted Dying Act 2017 (Vic) ('VAD Act'), and to examine features of any identified cases. METHODS Exploratory case series of adult patients in Victoria who died between May 2018 and 18 June 2019 as a result of medication administered with the primary intention of hastening death. Cases were identified from a self-administered survey about medical end-of-life decisions for adult patients, completed by Victorian specialists treating adults at the end of life. We examined reported use of medication with the primary intention of hastening the patient's death; characteristics of assisted dying cases, including doctors' classification of such practices. RESULTS Nine cases met the inclusion criteria. Death did not occur immediately after providing medication with the intention of hastening death. In eight cases, it was framed as palliative or terminal sedation and/or continuous deep sedation. Most doctors used language that distanced their practices from assisted dying. CONCLUSIONS Unlawful assisted dying practices seem to have occurred in a small number of deaths in Victoria prior to commencement of the VAD Act. These practices typically occurred within the context of palliative or terminal sedation and may be difficult to distinguish from lawful palliative care practice. Some survey responses possibly reflect ambiguity in doctors' intentions when providing medication. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology
| | - Ben White
- Australian Centre for Health Law Research, Queensland University of Technology
| | - Rachel Feeney
- Australian Centre for Health Law Research, Queensland University of Technology
| | - Kenneth Chambaere
- Sociology & Ethics of the End of Life, End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Belgium
| | - Patsy Yates
- Head of the School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Geoffrey Mitchell
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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5
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Willmott L, White B, Feeney R, Chambaere K, Yates P, Mitchell G, Piper D. Collecting data on end-of-life decision-making: Questionnaire translation, adaptation and validity assessment. Progress in Palliative Care 2021. [DOI: 10.1080/09699260.2021.1922795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ben White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Rachel Feeney
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Geoffrey Mitchell
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Donella Piper
- Business School, University of New England, Armidale, NSW, Australia
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6
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Fuscaldo G, Gwini SM, Larsen R, Venkataramani A. Do Health Service staff support the implementation of Voluntary Assisted Dying at their workplace? Intern Med J 2021; 51:1636-1644. [PMID: 33710752 DOI: 10.1111/imj.15285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 01/31/2021] [Accepted: 03/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND On 29 November 2017, the Victorian Parliament passed the Voluntary Assisted Dying (VAD) Act 2017, which came into effect from 19 June 2019. AIM To investigate whether staff from a large regional health service support the legalisation of Voluntary Assisted Dying (VAD) and the implementation of VAD at their workplace. METHODS Staff were invited to complete an anonymous online survey comprising both closed and open-ended questions. RESULTS 38% of the workforce (n = 1624) responded to the survey. Most participants supported the legalisation of VAD (88%), the provision of eligibility assessment and/or the administration of VAD within the health service (80%). There were negligible differences in support for VAD by role, however, specialist doctors were significantly less supportive (65%). Approximately half of the respondents expressed concern about monitoring (49%) or implementation (53%) of VAD. Concerns were also raised about assessment of eligibility, support for staff involved in VAD and pressure on both patients and staff to participate. Nearly three quarters (71%) of participants agreed that if the health service offers VAD services, a special unit or facility should be available. CONCLUSION This study found that health workers have concerns about the implementation of VAD at their workplace but are generally supportive. This paper provides information for health services considering the implementation of VAD, about staff concerns and issues that need to be addressed for the successful introduction of VAD. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- G Fuscaldo
- University Hospital Geelong Barwon Health, Geelong, Australia, 3220.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Box Hill, Australia, 3128
| | - S M Gwini
- University Hospital Geelong Barwon Health, Geelong, Australia, 3220.,iMPACT, Faculty of Health, Deakin University, Geelong, Australia, 3220
| | - R Larsen
- University Hospital Geelong Barwon Health, Geelong, Australia, 3220
| | - A Venkataramani
- University Hospital Geelong Barwon Health, Geelong, Australia, 3220
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7
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Stiel S, Nurnus M, Ostgathe C, Klein C. Palliative sedation in Germany: factors and treatment practices associated with different sedation rate estimates in palliative and hospice care services. BMC Palliat Care 2018. [PMID: 29534713 PMCID: PMC5851294 DOI: 10.1186/s12904-018-0303-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Clinical practice of Palliative Sedation (PS) varies between institutions worldwide and sometimes includes problematic practices. Little available research points at different definitions and frameworks which may contribute to uncertainty of healthcare professionals in the application of PS. This analysis investigates what demographic factors and characteristics of treatment practices differ between institutions with high versus low sedation rates estimates in Palliative and Hospice Care in Germany. Methods Data sets from 221 organisations from a prior online survey were separated into two sub-groups divided by their estimated sedation rate A) lower/equal to 16% (n = 187; 90.8%) and B) higher than 16% (n = 19; 9.2%) for secondary analysis. Demographic factors and characteristics of PS treatment practices between the two groups were compared using T-Tests and Chi2/ Fisher Exact Tests and considered significant (*) at two-sided p < .05. Results Organisations in group B report that they discuss PS for a higher proportion of patients (38.5%/10.2%, p < 0.000**), rate agitation more often as an indications for PS (78.9%/ 53.5%, p = 0.050*), and are more likely to use Lorazepam (63.2%/ 37.4%, p = 0.047*), Promethazin (26.3%/ 9.6%, p = 0.044*), and (Es-)Ketamin (31.6%/ 12.8%, p = 0.039*) than representatives in group A. Both groups differ significantly in their allocation of three case scenarios to different types of PS. Conclusions Both definitions and patterns of clinical practice between palliative and hospice care representatives show divergence, which may be influenced one by another. A comprehensive framework considering conceptual, clinical, ethical, and legal aspects of different definitions of PS could help to better distinguish between different types and nuances of PS.
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Affiliation(s)
- Stephanie Stiel
- Department of Palliative Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany. .,Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Mareike Nurnus
- Department of Palliative Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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8
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Cohen-Almagor R, Ely EW. Euthanasia and palliative sedation in Belgium. BMJ Support Palliat Care 2018; 8:307-313. [PMID: 29305500 DOI: 10.1136/bmjspcare-2017-001398] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 10/16/2017] [Accepted: 11/22/2017] [Indexed: 12/15/2022]
Abstract
The aim of this article is to use data from Belgium to analyse distinctions between palliative sedation and euthanasia. There is a need to reduce confusion and improve communication related to patient management at the end of life specifically regarding the rapidly expanding area of patient care that incorporates a spectrum of nuanced yet overlapping terms such as palliative care, sedation, palliative sedation, continued sedation, continued sedation until death, terminal sedation, voluntary euthanasia and involuntary euthanasia. Some physicians and nurses mistakenly think that relieving suffering at the end of life by heavily sedating patients is a form of euthanasia, when indeed it is merely responding to the ordinary and proportionate needs of the patient. Concerns are raised about abuse in the form of deliberate involuntary euthanasia, obfuscation and disregard for the processes sustaining the management of refractory suffering at the end of life. Some suggestions designed to improve patient management and prevent potential abuse are offered.
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Affiliation(s)
| | - E Wesley Ely
- Geriatric Research, VA Tennessee Valley Healthcare System, Education and Clinical Center (GRECC), Nashville, Tennessee, USA.,Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA.,Center for Health Services Research, Vanderbilt University, Nashville, Tennessee, USA
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9
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Cherny N. ESMO Clinical Practice Guidelines for the management of refractory symptoms at the end of life and the use of palliative sedation. Ann Oncol 2014; 25 Suppl 3:iii143-52. [DOI: 10.1093/annonc/mdu238] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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10
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11
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Allen F. Where are the Women in End-of-Life Research? Behav change 2012. [DOI: 10.1375/bech.19.1.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractThis article reviews research on attitudes towards, and the practice of, hastening death. The central aim of this review is to elucidate what is known about the role played by gender in shaping the behaviours of people in the diverse roles of healthcare provider, carer, and patient. It is concluded that, on the whole, researchers have neglected to acknowledge gender differences in the experience of dying. Also lacking is carefully conducted research which is contextualised so that the dying person is better understood as a member of society rather than an isolated individual.
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12
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Stewart CL. Law and cancer at the end of life: the problem of nomoigenic harms and the five desiderata of death law. Public Health 2011; 125:905-918. [PMID: 22054907 DOI: 10.1016/j.puhe.2011.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 09/29/2011] [Accepted: 10/04/2011] [Indexed: 11/29/2022]
Abstract
Good laws are a necessary, but not a sufficient, condition for the provision of good health care. At the end of life, there is a need for laws that foster and encourage the best possible outcomes for patients, their families and healthcare professionals. This article proposes five desiderata for laws at the end of life. It uses the emerging Australian jurisprudence of end-of-life decision making to test and examine the desiderata. The article also proposes that poorly drafted and confusing laws may have a deleterious effect on patient care. These nomoigenic (law-caused) harms can be avoided by adherence to the five desiderata of death law.
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Affiliation(s)
- C L Stewart
- Centre for Health Governance, Law and Ethics, University of Sydney, Sydney Law School, Sydney, NSW 2251, Australia.
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13
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14
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Alt-epping B, Sitte T, Nauck F, Radbruch L. Sedierung in der Palliativmedizin*: Leitlinie für den Einsatz sedierender Maßnahmen in der Palliativversorgung: European Association for Palliative Care (EAPC). Schmerz 2010; 24:342-54. [DOI: 10.1007/s00482-010-0948-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Abstract
The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review.
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Affiliation(s)
- Nathan I Cherny
- Shaare Zedek Medical Center, Department of Oncology, Jerusalem, Israel.
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16
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17
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White KM, Wise SE, Young RM, Hyde MK. Exploring the Beliefs Underlying Attitudes to Active Voluntary Euthanasia in a Sample of Australian Medical Practitioners and Nurses: A Qualitative Analysis. Omega (Westport) 2009; 58:19-39. [DOI: 10.2190/om.58.1.b] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A qualitative study explored beliefs about active voluntary euthanasia (AVE) in a sample ( N = 18) of medical practitioners and nurses from Australia, where AVE is not currently legal. Four behaviors relating to AVE emerged during the interviews: requesting euthanasia for oneself, legalizing AVE, administering AVE to patients if it were legalized, and discussing AVE with patients if they request it. Using thematic analysis, interviews were analyzed for beliefs related to advantages and disadvantages of performing these AVE behaviors. Medical practitioners and nurses identified a number of similar benefits for performing the AVE-related behaviors, both for themselves personally and as health professionals. Benefits also included a consideration of the positive impact for patients, their families, and the health care system. Disadvantages across behaviors focused on the potential conflict between those parties involved in the decision making process, as well as conflict between one's own personal and professional values.
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Affiliation(s)
| | - Susi E. Wise
- Queensland University of Technology, Brisbane, Australia
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18
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Douglas C, Kerridge I, Ankeny R. Managing intentions: the end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia. Bioethics 2008; 22:388-396. [PMID: 18547298 DOI: 10.1111/j.1467-8519.2008.00661.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
There has been much debate regarding the 'double-effect' of sedatives and analgesics administered at the end-of-life, and the possibility that health professionals using these drugs are performing 'slow euthanasia.' On the one hand analgesics and sedatives can do much to relieve suffering in the terminally ill. On the other hand, they can hasten death. According to a standard view, the administration of analgesics and sedatives amounts to euthanasia when the drugs are given with an intention to hasten death. In this paper we report a small qualitative study based on interviews with 8 Australian general physicians regarding their understanding of intention in the context of questions about voluntary euthanasia, assisted suicide and particularly the use of analgesic and sedative infusions (including the possibility of voluntary or non-voluntary 'slow euthanasia'). We found a striking ambiguity and uncertainty regarding intentions amongst doctors interviewed. Some were explicit in describing a 'grey' area between palliation and euthanasia, or a continuum between the two. Not one of the respondents was consistent in distinguishing between a foreseen death and an intended death. A major theme was that 'slow euthanasia' may be more psychologically acceptable to doctors than active voluntary euthanasia by bolus injection, partly because the former would usually only result in a small loss of 'time' for patients already very close to death, but also because of the desirable ambiguities surrounding causation and intention when an infusion of analgesics and sedatives is used. The empirical and philosophical implications of these findings are discussed.
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Parker MH, Cartwright CM, Williams GM. Impact of specialty on attitudes of Australian medical practitioners to end-of-life decisions. Med J Aust 2008; 188:450-6. [PMID: 18429710 DOI: 10.5694/j.1326-5377.2008.tb01714.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Accepted: 12/13/2007] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare attitudes and practices of Australian medical practitioners, by specialty, to a range of medical decisions at the end of life. DESIGN, SETTING AND PARTICIPANTS As part of an international study, in 2003, a structured questionnaire was mailed to 2964 medical practitioners drawn from membership registers of Australian and Australasian professional colleges. Data from 1478 questionnaires were statistically analysed using validated instruments. MAIN OUTCOME MEASURES Practitioners' willingness to comply with requests from patients and/or their relatives for symptom relief which might also hasten death; provision of terminal sedation and euthanasia, or willingness to provide these on their own initiative. RESULTS Respondents reported being much more willing to comply with a patient's request for increasing symptom relief, even at risk of hastening death, than for terminal sedation. Over a quarter of respondents would provide terminal sedation to competent patients on their own initiative. A small number of respondents would intentionally hasten death. There were significant differences by specialty for all three actions. Oncologists, palliative care physicians and geriatricians were least likely to actively hasten death, and more likely to act unilaterally to relieve symptoms as a medical necessity. CONCLUSIONS Perceptions about the causation of death and aspects of medical culture appear to influence physicians' attitudes towards medical decisions at the end of life. Our findings have implications for medical education, interprofessional communication and discussion between the medical profession and the community.
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Abstract
This article examines the evidence for the empirical argument that there is a slippery slope between the legalization of voluntary and non-voluntary euthanasia. The main source of evidence in relation to this argument comes from the Netherlands. The argument is only effective against legalization if it is legalization which causes the slippery slope. Moreover, it is only effective if it is used comparatively-to show that the slope is more slippery in jurisdictions which have legalized voluntary euthanasia than it is in jurisdictions which have not done so. Both of these elements are examined comparatively.
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Affiliation(s)
- Penney Lewis
- Centre of Medical Law and Ethics, School of Law, King's College London, London, UK
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21
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Abstract
Sedation in the context of palliative medicine is the monitored use of medications to induce varying degrees of unconsciousness to bring about a state of decreased or absent awareness (i.e. unconsciousness) in order to relieve the burden of otherwise intractable suffering. Sedation is used in palliative care in several settings: transient controlled sedation, sedation in the management of refractory symptoms at the end of life, emergency sedation, respite sedation, and sedation for refractory psychological or existential suffering. Sedation is controversial in that it diminishes the capacity of the patient to interact, function, and, in some cases, live. There is no distinct ethical problem in the use of sedation to relieve otherwise intolerable suffering in patients who are dying. Since all medical treatments involve risks and benefits, each potential option must be evaluated for its promise with regards to achieving the goals of care. When risks of treatment are involved, to be justified these risks must be proportionate to the gravity of the clinical indication. Some aspects of management, such as the need for hydration in patients undergoing sedation and the use of sedation in the management of psychological and spiritual suffering, remain controversial.
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Affiliation(s)
- Nathan I Cherny
- Department of Medical Oncology, Shaare Zedek Medical Center, PO Box 3235, Jerusalem 91031, Israel.
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Abstract
OBJECTIVE: The relationship between religiosity and mental health has been a perennial source of controversy. This paper reviews the scientific evidence available for the relationship between religion and mental health. METHOD: The authors present the main studies and conclusions of a larger systematic review of 850 studies on the religion-mental health relationship published during the 20th Century identified through several databases. The present paper also includes an update on the papers published since 2000, including researches performed in Brazil and a brief historical and methodological background. DISCUSSION: The majority of well-conducted studies found that higher levels of religious involvement are positively associated with indicators of psychological well-being (life satisfaction, happiness, positive affect, and higher morale) and with less depression, suicidal thoughts and behavior, drug/alcohol use/abuse. Usually the positive impact of religious involvement on mental health is more robust among people under stressful circumstances (the elderly, and those with disability and medical illness). Theoretical pathways of the religiousness-mental health connection and clinical implications of these findings are also discussed. CONCLUSIONS: There is evidence that religious involvement is usually associated with better mental health. We need to improve our understanding of the mediating factors of this association and its use in clinical practice.
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Affiliation(s)
- Alexander Moreira-Almeida
- Universidade de São Paulo, Brazil; João Evangelista Hospital, Brazil; Duke University Medical Center; VA Medical Center
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23
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Abstract
Health professionals do not always have the luxury of making "right" choices. This article introduces the "devil's choice" as a metaphor to describe medical choices that arise in circumstances where all the available options are both unwanted and perverse. Using the devil's choice, the paper criticizes the principle of double effect and provides a re-interpretation of the conventional legal and ethical account of symptom relief in palliative care.
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Abstract
I have a hairstylist whose lover was very sick. I’d been seeing this stylist for ten years and we’re good friends. [His lover was] becoming an invalid, not able to get out of bed. He said “I hate to ask you this but would you mind writing a prescription to help us out?” [So] I wrote a prescription to a patient who I had never seen, and I sent it to him in the mail and I heard the next time I went in to get my hair cut that it was the most beautiful experience that my stylist had ever had. It was Valentine’s Day and they had a lovely meal with champagne. And they held each other and then, you know, his partner took his pills and was released.(Joseph, physician)
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26
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Coombe FJ. "Death talk": debating euthanasia and physician-assisted suicide in Australia. Med J Aust 2003; 179:59-60; author reply 60. [PMID: 12899183 DOI: 10.5694/j.1326-5377.2003.tb05426.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2003] [Accepted: 05/01/2003] [Indexed: 11/17/2022]
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27
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Vitetta L, Kenner D, Sali A. The intention to hasten death of terminally ill patients. Med J Aust 2002; 177:166-7. [PMID: 12216544 DOI: 10.5694/j.1326-5377.2002.tb04714.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Piercy M, Fogarty GB, Jansz AW, Gawler DM. The intention to hasten death of terminally ill patients. Med J Aust 2002; 177:165-6. [PMID: 12149095 DOI: 10.5694/j.1326-5377.2002.tb04715.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2001] [Accepted: 01/07/2002] [Indexed: 11/17/2022]
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Flamm AL. Legal Trends in Bioethics. The Journal of Clinical Ethics 2002. [DOI: 10.1086/jce200213112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Affiliation(s)
- Roger W Hunt
- Palliative Care, Flinders University, Bedford Park, SA
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