Distress during end-of-life: Ethical questions about sedation

Distress and suffering are words currently used in the medical vocabulary, the first carrying a more acute and dramatic feature, while suffering is more subjective. They may concern the somatic, psychic, social, and spiritual domains, with interactions such as excrutiating and unrelieved pain causing psychological distress. Distress during the end of life is induced by the threatening of an unavoidable death, more or less foreseen by the patient. It may correspond to an existential distress, with loss of the meaning of life, and of the social role, along with metaphysical anxiety. Patient's next of kin and carers can also be involved by the distress, either by empathic transmission, or due to specific factors. Palliative care and anticipation should allow to prevent or relieve distress and suffering. This imply to ask for palliative care on due time, and to anticipate the foreseeable situations, trying meanwhile to identify the patient's preferences. Pharmacologic sedation is becoming a frequent practice during terminal phase of diseases, raising ethical questioning on its motives and aims. Deep continuous sedation maintained until death may be viewed as a psychic and social euthanasia, ethically questionable, and should be foreseen only in case of intractable distress. A controlled and reversible sedation, when needed, should be preferred, always with the agreement of the patient or his/her proxy. Existential distress by itself should not justify a deep continuous sedation.     

Principle of double effect and sedation for intractable distress: Reflexion on survival in sedated patients

The effect of sedation for intractable distress on survival in terminally ill patients is a debated question. For certain people, this would limit the physician's intervention to the detriment of symptom alleviation for patients. The principle of double effect is traditionally used to overcome this ethical conflict. Studies conducted between 1990?and 2009?fail to show that the death of patients undergoing sedation for intractable distress is hastened. Some authors conclude that sedation does not hasten death and claim that principle of double effect is unnecessary in this debate. In our view, caution is required in the interpretation of studies results and absence of evidence of sedation effects on survival cannot be considered as an evidence of absence of sedation effects on survival. Furthermore, we consider obtaining a definitive answer as impossible in the future, as the required cannot be conducted for ethical reasons. Caution, we think, is necessary, especially as sedation is sometimes used with explicit intention of hastening the end of life. Physician's intention, key point of the principle of double effect, comes back into the foreground of ethical debate on sedation for intractable distress. Far from limiting the physician's action, the principle of double effect, which requires us to clarify our intentions, should allow us to make the distinction between sedation for intractable distress and euthanasia.     

Palliative Sedierung

Terminal illnesses can cause distressing symptoms such as severe pain, mental confusions, feelings of suffocation, and agitation. Despite skilled palliative care in some cases these symptoms may not respond to standard interventions. After all other means to provide comfort and relief to a dying patient have been tried and are unsuccessful, clinical caregivers and patients can consider palliative sedation.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 in order to relieve the burden of otherwise refractory suffering. Palliative sedation is not intended to cause death or shorten life. The patient and family should agree with plans for palliative sedation. Because cases involving palliative sedation are emotionally stressful, the patient, family, and health care workers can all benefit from talking about the complex medical, ethical, and emotional issues they raise.     

Terminal cancer patients and euthanasia — The church’s position

Aim-Background

Cancer patients at terminal stage, with no prospect of recovery, may commit suicide at any stage of the disease. With no hope of survival, these patients see euthanasia or physician-assisted suicide as the only way of relieving themselves of terminal illness symptoms, such as pain, dyspnoea, and depression. The dilemma that arises for devoted members of the church is immense, since it is at such a time that their faith and strength to comply with the gospel is seriously challenged. They are effectively being called upon to choose between life and death. The object of this paper is to show the Church’s position on euthanasia in terminal cancer patients.

Method

A review of the literature was made of relevant Greek and international articles. The search words that there were used for this purpose were: terminal cancer patients, church, euthanasia. Also questionnaires were completed by 350 cancer patients at different stages of their disease,(not only at terminal stage). These patients received radiotherapy treatment during the period 2010–2011.

Results

Seventy-six percent of patients were in favour of euthanasia but only at terminal disease stage, 15% of patients said they would most likely sanction it, 7% were against, and 2% did not respond. In the event that the patient was not in a position to give their consent, 62% of relatives would permit euthanasia. The difference presented by patients and their relatives (and from the bibliography) appears to be related to religious beliefs.

Conclusions

The Greek Orthodox Church prohibits suicide and euthanasia (physician assisted suicide). In Greece, both the medical and legal society have rejected the thought of legalizing euthanasia. Human care for the terminally ill is determined by the conscience and sensitivity of the doctors in attendance. The Greek Orthodox Church believes in euthanasia in the true sense of the word, and always prays for a peaceful and sanctified death granted by God and not man.     

The problem of euthanasia and dysthanasia in burns

The authors discuss basic approaches to the problem of defining euthanasia. The definition should maintain the distinction between active and passive and between voluntary and involuntary euthanasia. Some of the recent views of the ethical and moral aspects are mentioned, as well as the reasons for terminating resuscitation in persons who suffer ‘brain death’ (permanent central nervous system) dysfunction. This problem is a matter of great urgency particularly in the burn centres, dealing with old patients. The authors base the discussion on their clinical experience showing that it is sometimes better that a person should die than continue living in certain desperate states, such as unbearable suffering, severe debilitation, permanent coma etc.However, the problem of euthanasia is in conclusion considered as an open system of question, where the answers are not unanimous. They are complicated with respect to the ethical, forensic aspects and also to the peculiarities of psychology.     

Legal aspects of pain

Since years legal demands towards patients information are extensive and highly refined. Recently, however, pain--a permanent companion of human life since ever--was included by two sentences as an additional item. Following legal categories, the physician before diagnostic interventions is obliged to evaluate the ability of the severely suffering patient fully to understand and judge the given information. Additionally patients have to be informed on possibly appearing engraved pains. Concerning therapeutical interventions normally the same legal rules have to be considered. Furthermore doctors are obliged to inform the patient on the foreseen development of pain either with or without medical intervention.     

Euthanasia: the "good death"?

The changing attitude of some medical practitioners in certain countries condones the practice of euthanasia. This article examines the scope of attitudes toward life and death, suggesting moral and ethical considerations regarding euthanasia.     

Ethical issues at the end of life.

Providing good care for dying patients requires that physicians be knowledgeable of ethical issues pertinent to end-of-life care. Effective advance care planning can assure patient autonomy at the end of life even when the patient has lost decision-making capacity. Medical futility is difficult to identify in the clinical setting but may be described as an intervention that will not allow the intended goal of therapy to be achieved. Medical interventions, including artificial nutrition and hydration, can be withheld or withdrawn if this measure is consistent with the dying patient's wishes. Physicians caring for terminally ill patients receive requests for physician-assisted suicide. The physician should establish the basis for the request and work with the healthcare team to provide support and comfort for the patient. Physician-assisted suicide could negate the traditional patient-physician relationship and place vulnerable populations at risk. Physicians need to incorporate spiritual issues into the management of patients at the end of life. The integrity of the physician as a moral agent in the clinical setting needs to be recognized and honored. The physician has a moral imperative to assure good care for dying patients.     

Euthanasia in Europe--ten countries with special consideration of the Netherlands and Germany

This article presents an overview of the current situation of euthanasia in Europe. Emphasis is given to the positions discussed in the Netherlands and in Germany. The current situation, the development of the legal positions, and the resulting debate are established by analysing English and German anesthesiological and medical-ethical journals. It has to be noted that many physicians are not satisfied with the terminology of euthanasia. The traditional concepts of euthanasia do not cover the aspect of accompanying terminally ill persons until they have died. The differentiation of active, passive, and indirect euthanasia does not correspond to the practical handling of the problem. Many physicians are in need of an open discussion of euthanasia-related issues. The way euthanasia is practiced in the Netherlands has strongly influenced the further development of the debate in Europe. Even though the Dutch model is rejected by the jurisdications of virtually all other countries, and official statements of medical corporations stick to the disapproval of active euthanasia, studies examining the attitudes towards euthanasia and the treatment of it in daily routine show that active interventions to shorten life are performed to different degrees outside of the Netherlands as well.     

Ethical and practical considerations of withdrawal of treatment in the Intensive Care Unit

Purpose

To discuss the medical, ethical and legal basis of decisions to discontinue life-support therapy in the adult intensive care unit (ICU), and to provide practical guidelines for the discontinuation of life support therapy.

Source

Relevant articles were retrieved through Medline (1991-present; terms: ethics, life support discontinuation, double effect, beneficence, non-maleficence). Other sources include legal references, and personal files.

Principal Findings

Understanding the legal and ethical principles of autonomy, beneficence, non-maleficence and double effect are crucial when withdrawing life support therapy. The law respects a competent patient’s right to direct his/her healthcare but does not uphold his/her right to demand futile care. Surrogate decision makers can be used when the patient is incompetent, provided they are acting in the patient’s best interest, Euthanasia is illegal and the distinction between discontinuation of therapy and euthanasia is legally clear. Skilful administration of palliative therapy cannot be construed as euthanasia when the aforementioned ethical principals are respected. The various practical methods of discontinuing therapy are discussed. Every ICU should develop its own guidelines and a checklist to help caregivers during this difficult time. Caregivers must anticipate the mechanism of death and direct interventions at the symptoms that are likely to cause discomfort. Drugs and dosages must be individualized, and depend on the underlying disease, anticipated mechanism of death, and the patient’s pharmacological history. When prescribing a drug, the intention should be clear.

Conclusions

Appropriate discontinuation of therapy in the ICU allows patients a dignified and comfortable death.     

Intrathecal phenol block in a child with cancer pain--a case report

We present a case of a terminally ill child with cancer pain which was treated with intrathecal phenol block. A 13-year-old boy felt severe pain in the right buttock and leg due to osteosarcoma. Despite treatment with nonsteroidal anti-inflammatory drugs, intravenous injection of morphine, continuous infusion of ketamine or continuous lumbar epidural block, his pain increased progressively. Therefore, we performed intrathecal block with 10% phenol glycerine 0.2 ml. After the block, his pain was markedly relieved. He sometimes came back home and joined school events. He did not complain of the pain until his death. We suggest that intrathecal phenol block should be performed in terminally ill children with cancer pain if they do not respond to the usual therapeutic modalities including administration of morphine and continuous epidural block.     

Limits to the duty to treat in intensive care. 1. Explanation of the guidelines in the DGAI]

Every form of active euthanasia is a punishable offence under sections 216 of the Penal Code; nor is there any ethical justification for it from a medical point of view. The many strands of the movement in favour of making "death on demand" exempt from punishment in Germany as it is in The Netherlands cannot change this. In the area of passive euthanasia the limits of the intensive care team's duty to treat depends on various factors: The patient's declared or assumed wishes. It is not permissible to carry out procedures refused by the patient, even when these alone would make an extension of life possible. The indications for medical treatment. In the twilight zone between life and death, procedures with no prospect of success can no longer help the patient. In these circumstances they are pointless and are not medically indicated. According to Supreme Court rulings, the medical decision on whether to implement procedures designed to extend life or whether to withhold such procedures is based almost exclusively on the wishes or the assumed wishes of the patient, even though interpretation of the "assumed wishes" can be difficult and is quite often liable to subjective influences. The question of using the presence or absence of medical indications for treatment as an objective criterion, in contrast, has so far been disregarded in rulings. If no life-extending procedures are implemented the physician's duty to provide suitable basic care for the patient, in the sense of palliative care, remains. To make decisions easier, the authors discriminate between the essential "ordinary" remedies that must be provided to all patients and the "extraordinary" remedies of intensive care that are available for patients who can still benefit from them. There is some controversy over the correct assignment of artificial nutrition; according to German legislation it belongs in the category of extraordinary remedies. The palliative procedures that make up basic care include adequate pain relief, which can be a form of indirect euthanasia. The Supreme Court has ruled that it is the physician's duty to prescribe adequate pain relief even when it might have the unavoidable side effect of unintentionally accelerating the patient's death.     

Drug control of common symptoms in the terminally ill patient.

St Christophers' Hospice near London is now internationally known as a special centre for the care of terminally ill patients. In these cases, the relief of symptoms is paramount, and prominent among those symptoms is pain. Such pain can almost always be relieved without euphoria or lessening of consciousness. More than 60% of patients admitted to St Christopher's complain of pain, and the scheme of management outlined below results in substantial or complete relief of pain in all of them. Addiction does not occur when control of the patient's pain is part of the pattern of total care. The author considers management of pain of varying severity, together with associated symptoms such as vomiting, anorexia, dry mouth and hiccup, dyspnoea, cough, anxiety and depression, insomnia, constipation and diarrhoea.     

Percutaneous cervical cordotomy in the therapy of incidence pain

BACKGROUND: Incident pain does not respond to opioid treatment and it is not easily relieved with other therapeutic strategies (local intrapleural or spinal analgesia, phenol blocks etc.). For this reason cervical percutaneous cordotomy at C(1)-C(2) interspace is the only effective antalgic therapy in patients whose life expectancy is more than three to six months. METHODS: This study is a rectrospective review of 22 patients with cancer and incident pain from brachial, lumbar-sacral plexus injury and gluteal ulcer. RESULTS: Cordotomy provided excellent contralateral side pain relief in 21 patients; pain relief was maintained up to death and to the moment of last observation in living patients. In one deaf patient it was impossible to carry out the procedure due to incomplete co-operation and pain returned after 48 hours. Ventilatory depression caused death in one patient. Other complications recorded included ataxia, headache, motor deficit, dysesthesia and orthostatic hypotension. CONCLUSIONS: The conclusion is drawn that percutaneous cordotomy should, in carefully selected cases, be considered the only technique to relieve incident pain.     

Knowledge of palliative care which a surgeon should know

The Japanese who are in a hospice or a palliative care ward recently, and pass away are increasing in number. However, the present condition is that most pass away in a general ward. In Japan, since a surgeon is concerned in many cases to terminal care, in addition to the operation method and perioperative management, has to learn the knowledge of palliative care. Terminally ill cancer patients experience the severe pain which takes about 70% or more of patients painkilling by opioid with various pain, such as loss of appetite, general malaise, and insomnia, in many cases. For this reason, in especially terminally ill cancer patient's palliative care, sharp pain medical treatment is important. A surgeon has to learn about how to use the concept of WHO Cancer Pain Relief Program and opioid rotation, and adjuvant analgesics. To spend life whose terminally ill cancer patients seeming is the person, the surgeon should do palliative care.     

Palliativmedizin

Palliative medicine has its origin in the modern hospice movement. It is based upon an integrated-care concept for seriously ill and dying patients. The first consideration of this particular form of treatment is not to prolong life, but to reach the best possible quality of a patient’s remaining lifetime. Therefore, palliative medicine consists of: (1) excellent pain treatment and symptom control; (2) an integrated approach towards the psychic, social, and spiritual needs of the patient, relatives, and attending staff during the periods of illness, dying, and, after the patient’s death; (3) competence in dealing with vital mat- ters of communication and ethics; and (4) acceptance of death as a normal process. Palliative medicine clearly rejects euthanasia. Practical implementation of the idea of hospice services can be realised anywhere when taking care of seriously ill and dying patients, whether at home, in a nursing home, or in hospital. Experience shows that quite a few patients cannot be treated successfully without additional services, such as home-care serivices, day-care centres, in patient hospices, and palliative-care units. Up to now, severely ill tumour patients have benefited most from these services. In palliative care units an interdisciplinary team of doctors and nursing staff assisted by physiotherapists and members of psycho-social professions is taking care of and treating patients. Additional support is given by voluntary services and the integration of the patient’s relatives in the caring process. Palliative medicine is the overall term for this special kind of treatment and care. In Great Britain, Canada, and Scandinavia considerable progress has been achieved in this field, including recognition as an independent clinical discipline and the establishment of lectureships in palliative medicine.     

The history of neurosurgical procedures for the relief of pain

Pain has been a major medical problem from the beginning of recorded history. Since the earliest medical writings, there have been innumerable procedures designed to relieve pain and its suffering. In this study, we have reviewed both the early medical writings of various civilizations and the first modern publications, to compile a history of neurosurgical procedures for the relief of pain.     

Management of acute traumatic pain by peripheral transcutaneous electrical stimulation.

Peripheral transcutaneous electrical stimulation has been used in an attempt to relieve the pain associated with fractured ribs. Sixty-two per cent of the patients considered their pain to be greatly relieved by this electro-analgesic technique and a further 28% gained some relief. Pain was assessed by means of a visual analogue scale. In most of the patients there was a clinical improvement in their condition, the degree of which correlated well with the pain relief. This trial indicated that transcutaneous electro-analgesia is a useful technique for producing analgesia in patients suffering from acute trauma, without some of the side-effects inherent in more conventional forms of therapy.     

Multidisciplinary care of the terminally ill patient

This article discusses sedation, the assessment and management of physical symptoms, and symptom-assessment scales for the terminally ill patient. The evaluation of the ability of the family or community to care for a terminally ill patient in pain also is discussed.     

Pain management

This article provides information regarding treatments for the management of moderate to severe pain in patients who are at the end of life. Discussion focuses on the use of strong opioids and adjuvant analgesics. Special attention also is given to the most frequently used forms of interventional pain management. Although pain in terminally ill patients is not always related to cancer, many of the studies cited in this article were performed in cancer patients, a model that informs much of what is presented.