Ethical decision-making in the care of the dying and its applications to clinical practice

Latimer, Elizabeth

doi:10.1016/0885-3924(91)90058-c

Cited by 58 publications

(29 citation statements)

References 10 publications

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“…Some of the treatment modalities used to manage such symptoms may cause decreased levels of consciousness as an unintended side-effect. 4 Such a side-effect is not always acceptable to the patient or family, but it may be seen as an inevitable trade-off for relief of particular symptoms.…”

Section: Introductionmentioning

confidence: 99%

Sedation for intractable distress in the dying–a survey of experts

Chater

Viola

Paterson³

et al. 1998

Palliat Med

219

185

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Terminal sedation is a phrase that has appeared in the palliative care literature in the last few years. There has not been a clear definition proposed for this term, nor has there been any agreement on the frequency with which the technique is used. A postal survey of 61 selected palliative care experts (59 physicians, two nurses) was carried out to examine their response to a proposed definition for 'terminal sedation', to estimate the frequency of this practice and the reasons for its use, to identify the drugs and dosages used, to determine the outcome, and to explore the decision-making process. Opinions on physician-assisted suicide and voluntary euthanasia were also sought. Eighty-seven per cent of the experts responded from eight countries, although predominantly from Canada and the United Kingdom. Forty per cent agreed unequivocally with the proposed definition, while 4% disagreed completely. Eighty-nine per cent agreed that 'terminal sedation' is sometimes necessary and 77% reported using it in the last 12 months--over half of these for up to four patients. Reasons for using this method included various physical and psychological symptoms. The most common drugs used were midazolam and methotrimeprazine. Decision making usually involved the patient or family, and varied with respect to the ease with which the decision was made. The use of sedation was perceived to be successful in 90 out of 100 patients recalled. Ninety per cent of respondents did not support legalization of euthanasia. In conclusion, sedating agents are used by palliative care experts as tools for the management of symptoms. The term 'terminal sedation' should be abandoned and replaced with the phrase 'sedation for intractable distress in the dying'. Further research into the management of intractable symptoms and suffering is warranted.

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Section: Introductionmentioning

confidence: 99%

Sedation for intractable distress in the dying–a survey of experts

Chater

Viola

Paterson³

et al. 1998

Palliat Med

219

185

View full text Add to dashboard Cite

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“…When facing these decisions, palliative medicine physicians often cite the doctrine of double effect in PS practice. 19,22,23 The doctrine of double effect is grounded in the ethical principle of proportionality. It originated from Thomas Aquinas in the 13th century.…”

Section: Ethical Issuesmentioning

confidence: 99%

Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments

Olsen

Swetz

Mueller³

2010

Mayo Clinic Proceedings

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Palliative sedation (PS) is the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. Although uncommon, some patients undergoing aggressive symptom control measures still have severe suffering from underlying disease or therapy-related adverse effects. In these circumstances, use of PS is considered. Although the goal is to provide relief in an ethically acceptable way to the patient, family, and health care team, health care professionals often voice concerns whether such treatment is necessary or whether such treatment equates to physician-assisted suicide or euthanasia. In this review, we frame clinical scenarios in which PS may be considered, summarize the ethical underpinnings of the practice, and further differentiate PS from other forms of end-of-life care, including withholding and/or withdrawing life-sustaining therapy and physician-assisted suicide and euthanasia. © 2010 Mayo Foundation for Medical Education and ResearchOn completion of this article, you should be able to (1) P alliative sedation (PS) refers to the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. The practice of PS has gained attention in the literature during the past 20 years. In 1994, Cherny and Portenoy 1 first offered an algorithm for determining appropriate indications for use of PS. During the late 1990s, several important court cases in the United States brought the issue of PS to the forefront and clarified the legality of the right to palliation at end of life. 2,3 Studies have shown that PS is effective, with efficacy rates ranging from 71% to 92%, 4 usually defined as the patient, family, or physician's perceived relief of refractory physical symptoms. In many settings, PS is uncommon, although a recent review revealed considerable variability in the prevalence of PS in the United States and other countries. 4 When PS is used, it is a measure of last resort rather than general care. Although required infrequently, PS is an important palliative tool with which clinicians should be familiar. PrActIcAl ISSueSThe following sections explore issues of the application of PS. Detailed guidelines for practicing PS, although beyond the scope of this article, have been published. 5

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“…For example, it prohibits physicians from performing euthanasia even if a patient wants it. 61 Justice also implies that physicians should not provide medically futile treatments just because the patient wants it. While patients have an almost absolute right to refuse treatment, they do not have a right to demand and receive treatment that is outside the standard of care.…”

Section: Autonomy and Justicementioning

confidence: 99%

Should There be a Choice for Cardiopulmonary Resuscitation When Death is Expected? Revisiting an Old Idea Whose Time is Yet to Come

Ditillo

2002

Journal of Palliative Medicine

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Since closed chest cardiac massage was introduced in 1960, the notion that cardiopulmonary resuscitation (CPR) attempts are not appropriate for all patients has been consistent. Over the years, leading authorities have clearly articulated that for patients who are dying irreversibly and expectedly medical decisions for do-not-resuscitate (DNR) orders should be made by physicians, because in such cases CPR attempts are not indicated. Physicians are not obligated to and should not offer or provide useless treatments, even in the name of patient autonomy. Despite this, physicians still seek and obtain patient or proxy consent when CPR is not indicated before writing a DNR order. Reasons include fear of legal repercussions/misconceptions, limited physician-patient relationships, time constraints, and institutional culture. End-of-life plans of care should be based on appropriate goals that focus on palliation and not on aggressive medical treatments that offer no benefit.

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Ethical decision-making in the care of the dying and its applications to clinical practice

Cited by 58 publications

References 10 publications

Sedation for intractable distress in the dying–a survey of experts

Sedation for intractable distress in the dying–a survey of experts

Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments

Should There be a Choice for Cardiopulmonary Resuscitation When Death is Expected? Revisiting an Old Idea Whose Time is Yet to Come

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