ArticleLiterature Review

Monolithic Moral Frameworks: How Are the Ethics of Palliative Sedation Discussed in the Clinical Literature?

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Abstract

A variety of moral frameworks can assist clinicians in making ethical decisions. In examining articles on palliative sedation and terminal extubation, we were struck that bioethical discussions uniformly appealed to principlism and especially to the rule of double effect. Other moral frameworks were rarely invoked, an observation consistent with Daniel Callahan's assertion that principlism has a "blocking effect" on broader ethical deliberation. We review here the principle of double effect as it applies to clinical acts that may hasten death, and present one radically different ethical formulation developed by Dan Brock. We then offer brief examples of how clinicians might use other moral frameworks to assess the ethics of preemptive sedation for terminal extubation. We argue for greater moral pluralism in approaching end-of-life decisions.

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... We identified 627 references to the doctrine of double effect, of which the vast majority (432 articles, 68.9%) were related to topics in end-of-life care, including euthanasia (260, 41.5%), palliative sedation/analgesia (104, 16.6%), and other palliative care (68, 10.8%) ( Table 1). Moreover, ethical discussions surrounding palliative sedation nearly always referenced the doctrine of double effect [14][15][16][17][18][19]. ...
... Similarly, historically important moral frameworks from prominent philosophers would not support the use of the doctrine for palliative sedation. Under the philosophy of Immanuel Kant, the relief of suffering would not have proportionately trumped the production of unconsciousness, let alone hastening death [14,21]. The ninth criterion of proportionality requiring the balancing of benefits and harms would not be satisfied. ...
... What are the consequences of invoking the doctrine in palliative scenarios? First, the doctrine is a form of "ethical reductionism" that appeals to physicians' algorithmic intuitions to simplify clinical decision making [14], which might produce a "blocking effect" on the consideration of the ethical complexities surrounding palliative care. Such oversimplification could lead to the impoverishment of the ethical reasoning, and clinical care, that physicians provide to all patients. ...
Article
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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.
... Palliative sedation differs ethically and conceptually from euthanasia and assisted suicide in many ways, including the intention of the act (sedation), the act itself (sedation process), and the intended outcome (Billings and Churchill, 2012;Ten Have and Welie, 2014;National Ethics Committee, 2006). The intent of palliative sedation is to relieve the patient's suffering, not to hasten death. ...
... Continuous deep sedation is the most controversial type of sedation since it involves ethically controversial such as the absence of precise concepts of refractory symptoms and intolerable suffering and the proportional level of sedation required controlling it [4,5,10,[13][14][15]. Evaluation of clinical practices and clinical guidelines from different countries however indicate that there is a considerable variation regarding definitions for sedation practices and terminology [7-9, 13, 16-20]. ...
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Purpose To explore the consistency in international expert opinions about palliative sedation. Methods A modified electronic-Delphi procedure was carried out in two rounds. On hundred nine eligible experts were identified from their publications in MEDLINE related with terminal delirium, dyspnea and palliative sedation in the last 3 years. Delphi study included three vignettes of cancer patients and two non-cancer patients, with an estimated survival of days and severe suffering secondary to refractory complications. Experts were asked about whether they would perform continuous sedation and sedation level (described as Richmond Agitation Sedation Scale or defined as patient/family report of symptom relief). Consensus was considered when 70% or more of the experts agreed on a certain topic. Results Thirty-four and 27 panellists completed the 2 Delphi rounds, respectively. Participants were from the USA, Canada, Europe, Australia and Asia. One hundred per cent, 97% and 88% of the respondent agreed use of sedatives, continuously or temporary, in cases of refractory delirium, dyspnea secondary to lung cancer and GOLD IV-EPOC. There were discrepancies for cases of dementia and psycho-existential suffering. Expert selection of continuous palliative sedation was 93% for delirium, 41% for cancer dyspnea, 66% for EPOC dyspnea, 22% for agitation/pain in dementia and 19% for existential suffering. Responses about types and levels of sedation did not achieve consensus in any cases. Conclusions The Delphi study failed to reach consensus in continuous palliative sedation and sedation levels for patients with refractory symptoms described in hypothetical clinical scenarios.
... Not only can they be highly personal, locked within the mind of the physician or the patient, and difficult to validate externally, but they may also be multi-layered, ambiguous and, in some cases, even contradictory [38,39]. Similarly, the application of the double-effect principle to clinical situations has been criticized on the basis of preconceived ideas of what constitutes 'good' and 'bad' acts and the challenges posed by determining intentions [40]. Several studies examining end-of-life sedation confirm such criticisms by reporting subjectivity, confusion and considerable ambiguity of intentions [41][42][43]. ...
Article
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End-of-life sedation, though increasingly prevalent and widespread internationally, remains one of the most highly debated medical practices in the context of palliative medicine. This qualitative study aims to elicit and record the perspectives of leading international palliative care experts on current debates. Twenty-one professionals from diverse backgrounds, sharing field-specific knowledge/expertise defined by significant scholarly contribution on end-of-life sedation, were recruited. Open-ended, semi-structured interviews, following a topic-oriented structure reflecting on current debates, were conducted. Results were analysed using thematic content analysis. Three main aspects of sedation were identified and discussed as potentially problematic: (a) continuous deep sedation as an extreme facet of end-of-life sedation, (b) psycho-existential suffering as an ambivalent indication for sedation and (c) withdrawal or withholding of artificial nutrition and hydration as potentially life-shortening. On these grounds, concerns were reported over end-of-life sedation being morally equivalent to euthanasia. Considerable emphasis was placed on intentions as the distinguishing factor between end-of-life acts, and protective safeguards were introduced to distance sedation from euthanasia. This study shows that, despite the safeguards introduced, certain aspects of sedation, including the intentions associated with the practice, are still under question, parallels being drawn between end-of-life sedation and euthanasia. This reaffirms the existence of a grey area surrounding the two practices, already evidenced in countries where euthanasia is legalized. More clarity over the issues that generate this grey area, with their causes being uncovered and eliminated, is imperative to resolve current debates and effectively inform research, policy and practice of end-of-life sedation.
Article
Background In the last two decades, nursing authors have published ethical analyses of palliative sedation—an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care. Research aim The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses’ moral identities are portrayed within this literature. Research design We reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher’s Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors’ portrayal of the nursing role. Findings Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses’ proximity to patients and families in end-of-life care. Discussion and conclusion Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples’ moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation.
Article
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Background Palliative sedation for existential suffering (PS-ES) is a controversial clinical intervention. Empirical studies about physicians’ perceptions do not converge in a clear position and current clinical practice guidelines do not agree either regarding this kind of intervention. Aim To gain deeper insight into physicians’ perceptions of PS-ES, the factors influencing it, the conditions for implementing it and the alternatives to it. Design Systematic review of qualitative, quantitative and mixed-methods studies following the Peer Review Electronic Search Strategies and Preferred Reporting Items for Systematic Reviews and Meta-analyses protocols; quality appraisal and thematic synthesis methodology. Data sources Seven electronic databases (PubMed, CINAHL, Embase, Scopus, Web of Science, PsycINFO, PsycARTICLES) were exhaustively searched from inception through March 2019. Two reviewers screened paper titles, abstracts and full texts. We included only peer-reviewed journal articles published in English, French, German, Dutch, Spanish, Italian or Portuguese that focused on physicians’ perceptions of PS-ES. Results The search yielded 17 publications published between 2002 and 2017. Physicians do not hold clear views or agree if and when PS-ES is appropriate. Case-related and individual-related factors that influenced physicians’ perceptions were identified. There is still no consensus regarding criteria to distinguish between necessary and sufficient conditions for invoking PS-ES. Some alternatives to PS-ES were identified. Conclusions To date, there is still no consensus on physicians’ perceptions of PS-ES. Further research is necessary to understand factors that influence physicians’ perceptions and philosophical-ethical presuppositions underlying this perceptions.
Article
Background Palliative care clinicians frequently encounter situations in which there are ethical dilemmas about the right thing to do. Palliative medicine fellowships are required to include education about ethics. Our fellowship increased fellows’ ethics education through monthly didactics, lectures in a professional development series, and a month-long ethics rotation. Methods We sought input from graduates of our palliative medicine fellowship about the content and amount of the ethics education they received. Fellowship graduates were invited via e-mail to complete an online survey about the ethics education they received during fellowship. They were asked questions about their work environment, frequency with which they encounter ethical dilemmas, their perspectives on the ethics content, the amount of ethics education they received during fellowship, and their input on ways to improve the ethics education within the fellowship. Results Twenty-eight (82%) of 34 fellowship graduates completed the survey; 93% noted that they encounter ethical dilemmas in their work, with half encountering these on a daily or weekly basis, and 86% noted that colleagues ask them questions about ethics because of their palliative medicine training. None responded that they had received too much ethics education. Fellowship graduates identified ethics content that has been useful since completing fellowship and suggested ways to improve ethics education for future fellows. Conclusion Graduates of a palliative medicine fellowship encounter ethical dilemmas often and frequently are asked questions about ethics. Palliative medicine fellowships may want to examine their ethics curriculum to ensure that graduating fellows are learning about relevant ethics topics and are comfortable discussing ethical dilemmas with others.
Article
Context: While unanimity exists on using palliative sedation (PS) for controlling refractory physical suffering in end-of-life situations, using it for controlling refractory existential suffering (PS-ES) is controversial. Complicating the debate is that definitions and terminology for existential suffering are unclear, ambiguous, and imprecise, leading to a lack of consensus for clinical practice. Objectives: To systematically identify, describe, analyze, and discuss ethical arguments and concepts underpinning the argument-based bioethics literature on palliative sedation for refractory existential suffering. Methods: We conducted a systematic search of the argument-based bioethics literature in PubMed, CINAHL, Embase®, The Philosopher's Index, PsycINFO®, PsycARTICLES®, Scopus, ScienceDirect, Web of Science, Pascal Francis and Cairn. We included articles published in peer reviewed journals till 31st of December 2016, written in English or French, that focused on ethical arguments related to PS-ES. We used Peer Review of Electronic Search Strategies protocol (PRESS), Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) and The Qualitative Analysis Guide of Leuven (QUAGOL) for data extraction and synthesis of themes. Results: We identified 18 articles that met the inclusion criteria. Our analysis revealed mind-body dualism, existential suffering, refractoriness, terminal condition, and imminent death as relevant concepts in the ethical debate on PS-ES. The ethical principles of double effect, proportionality, and the four principles of biomedical ethics were used in argumentations in the PS-ES debate. Conclusions: There is a clear need to better define the terminology used in discussions of PS-ES and to ground ethical arguments in a more effective way. Anthropological presuppositions such as mind-body dualism underpin the debate and need to be more clearly elucidated using an interdisciplinary approach.
Article
Nurses on the front lines of palliative care are frequently presented with ethically challenging situations involving the use of palliative sedation and increasing opioids at the end of life. The doctrine of double effect is an ethical principle dating back to the 13th century that explains how the bad consequences of an action can be considered ethically justified if the original intent was for good intention. This article examines the doctrine of double effect through case examples and presents supporting and opposing opinions about its relevance to clinical practice. Implications for nursing care are discussed. Copyright © 2017 by The Hospice and Palliative Nurses Association. All rights reserved.
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What is the best way to care for a child with severe neurologic impairment who seems to be dying and is in intractable pain? Can we give sedation as we remove life support? Is it ethically permissible to hasten death? In the United States, 5 states have legalized assisted suicide (although only for competent adults). In Belgium and the Netherlands, euthanasia is legal for children under some circumstances. We present a case in which parents and doctors face difficult decisions about palliative care. Experts from Belgium, the Netherlands, and the United States then discuss how they would respond to such a case.
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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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Despite receiving state-of-the-art palliative care, some patients still experience severe suffering toward the end of life. Palliative sedation is a potential way to respond to such suffering, but access is uneven and unpredictable, in part because of confusion about different kinds of sedation. Proportionate palliative sedation (PPS) uses the minimum amount of sedation necessary to relieve refractory physical symptoms at the very end of life. To relieve suffering may require progressive increases in sedation, sometimes to the point of unconsciousness, but consciousness is maintained if possible. Palliative sedation with the intended end point of unconsciousness (PSU) is a more controversial practice that may be considered for much fewer refractory cases. There is more ethical consensus about PPS than PSU. In this article, the authors explore the clinical, ethical, and legal issues associated with these practices. They recommend that palliative care and hospice programs develop clear policies about PPS and PSU, including mechanisms for training and ensuring competency for clinicians, and approaching situations where individuals or institutions may conscientiously object.
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Intensivists must provide enough analgesia and sedation to ensure dying patients receive good palliative care. However, if it is perceived that too much is given, they risk prosecution for committing euthanasia. The goal of this study is to develop consensus guidelines on analgesia and sedation in dying intensive care unit patients that help distinguish palliative care from euthanasia. Using the Delphi technique, panelists rated levels of agreement with statements describing how analgesics and sedatives should be given to dying ICU patients and how palliative care should be distinguished from euthanasia. Participants were drawn from 3 panels: 1) Canadian Academic Adult Intensive Care Fellowship program directors and Intensive Care division chiefs (N = 9); 2) Deputy chief provincial coroners (N = 5); 3) Validation panel of Intensivists attending the Canadian Critical Care Trials Group meeting (N = 12). After three Delphi rounds, consensus was achieved on 16 statements encompassing the role of palliative care in the intensive care unit, the management of pain and suffering, current areas of controversy, and ways of improving palliative care in the ICU. Consensus guidelines were developed to guide the administration of analgesics and sedatives to dying ICU patients and to help distinguish palliative care from euthanasia.
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The decline in the interest in ethical theory is first outlined, as a background to the author's discussion of principlism. The author's own stance, that of a communitarian philosopher, is then described, before the subject of principlism itself is addressed. Two problems stand in the way of the author's embracing principlism: its individualistic bias and its capacity to block substantive ethical inquiry. The more serious problem the author finds to be its blocking function. Discussing the four scenarios the author finds that the utility of principlism is shown in the two scenarios about Jehovah's Witnesses but that when it comes to selling kidneys for transplantation and germline enhancement, principlism is of little help.
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Although palliative sedation therapy is often required in terminally ill cancer patients to achieve acceptable symptom relief, empirical data supporting the ethical validity of this approach are lacking. The primary aim of this study was to systematically investigate whether empirical evidence supports the ethical validity of sedation. This was a multicenter, prospective, observational study, which was conducted by 21 specialized palliative care units in Japan. One-hundred two consecutive adult cancer patients who received continuous deep sedation were enrolled. Continuous deep sedation was defined as the continuous use of sedative medications to relieve intolerable and refractory distress by achieving almost or complete unconsciousness until death. Prior to the study, we conceptualized the ethical validity of sedation from the viewpoints of physicians' intent, proportionality, and autonomy. Sedation was performed mainly with midazolam and phenobarbital. The initial doses of midazolam and phenobarbital were 1.5 mg/hour and 20 mg/hour, respectively. Main administration routes were continuous subcutaneous infusion and continuous intravenous infusion, and no rapid intravenous injection was reported. Of 59 patients who received artificial hydration or could intake adequate fluids/foods orally before sedation, 63% received artificial hydration therapy after sedation, and in the remaining patients, artificial hydration was withheld or withdrawn due to fluid retention symptoms and/or patient wishes. Of 66 patients who were able to verbally express themselves, 95% explicitly stated that symptoms were intolerable. The etiologies of the symptoms requiring sedation were primarily related to the progression of the underlying malignancy, such as cancer cachexia and organ failure, and standard palliative treatments had failed: steroids in 68% of patients with fatigue, opioids in 95% of patients with dyspnea, antisecretion medications in 75% of patients with bronchial secretion, antipsychotic medications in 74% of patients with delirium, and opioids in all patients with pain. On the basis of the Palliative Prognostic Index, 94% of the patients were predicted to die within 3 weeks. Before sedation, 67% of the patients expressed explicit wishes for sedation. In the remaining 34 patients, previous wishes for sedation were noted in 4 patients, and in the other 30 patients, the families were involved in the decision-making process. The chief reason for patient non-involvement in the decision making was cognitive impairment. These data indicate that palliative sedation therapy performed in specialized palliative care units in Japan generally followed the principles of double effect, proportionality, and autonomy.
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How should modern medicine's dramatic new powers to sustain life be employed? How should limited resources be used to extend and improve the quality of life? In this collection, Dan Brock, a distinguished philosopher and bioethicist and co-author of Deciding for Others (Cambridge, 1989), explores the moral issues raised by new ideals of shared decision making between physicians and patients. The book develops an ethical framework for decisions about life-sustaining treatment and euthanasia, and examines how these life and death decisions are transformed in health policy when the focus shifts from what is best for a patient to what is just for all patients. Professor Brock combines acute philosophical analysis with a deep understanding of the realities of clinical health policy. This is a volume for philosophers concerned with medical ethics, health policy professionals, physicians interested in bioethics, and undergraduate courses in biomedical ethics.
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A novel contribution to the age-old debate about free will versus determinism. Do we consciously cause our actions, or do they happen to us? Philosophers, psychologists, neuroscientists, theologians, and lawyers have long debated the existence of free will versus determinism. In this book Daniel Wegner offers a novel understanding of the issue. Like actions, he argues, the feeling of conscious will is created by the mind and brain. Yet if psychological and neural mechanisms are responsible for all human behavior, how could we have conscious will? The feeling of conscious will, Wegner shows, helps us to appreciate and remember our authorship of the things our minds and bodies do. Yes, we feel that we consciously will our actions, Wegner says, but at the same time, our actions happen to us. Although conscious will is an illusion, it serves as a guide to understanding ourselves and to developing a sense of responsibility and morality. Approaching conscious will as a topic of psychological study, Wegner examines the issue from a variety of angles. He looks at illusions of the will—those cases where people feel that they are willing an act that they are not doing or, conversely, are not willing an act that they in fact are doing. He explores conscious will in hypnosis, Ouija board spelling, automatic writing, and facilitated communication, as well as in such phenomena as spirit possession, dissociative identity disorder, and trance channeling. The result is a book that sidesteps endless debates to focus, more fruitfully, on the impact on our lives of the illusion of conscious will.
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RECENTLY, the rule of double effect, which has a long history in ethics, especially medical ethics, has come under serious criticism in the medical literature.1,2 Because of its immense practical importance in the care of dying patients, any attack on this rule must be taken seriously. In this article, therefore, we present a systematic rejoinder to what we take to be serious misunderstandings of the nature and use of this rule.
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Death, previously a private, usually spiritual or religious event involving family and friends is today by contrast, often public and technological. The severity of illness of hospitalised patients has progressively increased over recent decades, whilst sophisticated technological support has allowed such patients to survive longer. At the same time it is increasingly accepted that continued aggressive care might not always be beneficial. Death in the ICU, therefore, now frequently follows limitation of life-supporting therapies. As a result, the mission of intensive care has expanded to encompass the provision of the best possible care to dying patients and their families. The International Consensus Conference was convened to discuss some of the challenges posed by these social and medical changes. On 24–25 April 2003, in Brussels, Belgium, a jury of 10 persons, including an anthropologist and nine intensivists, attended the presentations of 30 experts in the field of end-of-life care, and the subsequent discussions, with the objective to answer five specific questions. (1) Is there a problem with end-of-life care in the ICU? (2) What is the epidemiology of death in the ICU? (3) How does one explain the differences between and within countries and cultures regarding end-of-life care? (4) Who decides to limit life-sustaining treatments in the ICU? (5) What is the optimal care for patients dying in the ICU? The following document is a synthesis of the experts’ opinion, the available literature and 2 days of deliberation by the jury.
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One of the most important questions in the debate over the morality of euthanasia and assisted suicide is whether an important distinction between killing patients and allowing them to die exists. The U.S. Supreme Court, in rejecting challenges to the constitutionality of laws prohibiting physician-assisted suicide (PAS), explicitly invoked this distinction, but did not explicate or defend it. The Second Circuit of the U.S. Court of Appeals had previously asserted, also without argument, that no meaningful distinction exists between killing and allowing to die. That court had reasoned that if this were so, it would be discriminatory to allow persons on life support to end their lives by removing such treatment, while those who are not connected to life support would be denied similar access to death.
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American bioethicists lack the theoretical resources to work in cross-cultural settings. All we have are two approaches to ethics--principles vs. narratives--that are mostly at odds, and neither of which is up to the job. If moral principles are too abstract to be useful, and if stories cannot provide moral authority, then where do we find our moral norms?
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This article introduces a structure for standardization in the ongoing debate about the application of palliative sedation for psychological and existential suffering at the end of life. We differentiate the phenomenon of existential distress from the more general one of existential suffering, defining existential distress as a special case of existential suffering that applies to persons with terminal illness. We introduce both a clinical classification system of existential distress based on proximity to expected death and a decision-making process for considering palliative sedation (represented by the mnemonic, TIRED). Neuropsychiatric clinical cases will be used to demonstrate some of the concepts and ethical arguments.
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This article has no abstract; the first 100 words appear below. Medical ethicists place great weight on the intentions of clinical actions. The religious principle of “double effect,” based on a distinction between intentions and consequences, is an ethical cornerstone in the medical treatment of the terminally ill¹,². Giving high doses of narcotic analgesics to a dying patient to relieve pain and suffering is considered ethical even if it inadvertently hastens death, provided the clinician did not intend to help the patient die. Death may even be foreseen as a side effect of the intervention as long as it is not intended. On the other hand, should a clinician . . . Timothy E. Quill, M.D. University of Rochester School of Medicine and Dentistry, Rochester, NY 14607 The views expressed in this article are those of the author and do not necessarily represent those of the University of Rochester.
Article
According to the ethical principle known as the “rule of double effect,” effects that would be morally wrong if caused intentionally are permissible if foreseen but unintended. This principle is often cited to explain why certain forms of care at the end of life that result in death are morally permissible and others are not.1–9 According to the rule, administering high-dose opioids to treat a terminally ill patient's pain may be acceptable even if the medication causes the patient's death. In contrast, the rule does not authorize practices such as physician-assisted suicide, voluntary euthanasia, and certain instances of forgoing . . .
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RECENTLY, the rule of double effect, which has a long history in ethics, especially medical ethics, has come under serious criticism in the medical literature.1- 2 Because of its immense practical importance in the care of dying patients, any attack on this rule must be taken seriously. In this article, therefore, we present a systematic rejoinder to what we take to be serious misunderstandings of the nature and use of this rule.
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Is the profession of medicine ethically neutral? If so, whence shall we derive the moral norms or principles to govern its practices? If not, how are the norms of professional conduct related to the rest of what makes medicine a profession?
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While the author believes that Nuccetelli and Seay have not succeeded in replacing the Rule of Double Effect with a more workable and practical moral principle, he believes they have emphasized a frequently overlooked element: that certain clear conditions must first be met before the Rule can be applied.
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Author offers an analytic defense of the coherence of the distinction between "killing" and "allowing to die," based on contemporary philosophy of action and intention.
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The purpose of the conference was to provide clinical practice guidance in end-of-life care in the ICU via answers to previously identified questions relating to variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of healthcare providers, the use of imprecise and insensitive terminology and incomplete documentation in the medical record. Presenters and jury were selected by the sponsoring organizations (American Thoracic Society, European Respiratory Society, European Society of Intensive Care Medicine, Society of Critical Care Medicine, Société de Réanimation de Langue Française). Presenters were experts on the question they addressed. Jury members were general intensivists without special expertise in the areas considered. Experts presented in an open session to jurors and other healthcare professionals. Experts prepared review papers on their specific topics in advance of the conference for the jury's reference in developing the consensus statement. Jurors heard experts' presentations over 2 days and asked questions of the experts during the open sessions. Jury deliberation with access to the review papers occurred for 2 days following the conference. A writing committee drafted the consensus statement for review by the entire jury. The 5 sponsoring organizations reviewed the document and suggested revisions to be incorporated into the final statement. Strong recommendations for research to improve end-of-life care were made. The jury advocates a shared approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honor decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the team, to decide on the reasonableness of the planned action. If a conflict cannot be resolved, an ethics consultation may be helpful. The patient must be assured of a pain-free death. The jury subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double-effect" should not detract from the primary aim to ensure comfort.
Article
Despite skilled palliative care, some dying patients experience distressing symptoms that cannot be adequately relieved. A patient with metastatic breast cancer, receiving high doses of opioids administered to relieve pain, developed myoclonus. After other approaches proved ineffective, palliative sedation was an option of last resort. The doctrine of double effect, the traditional justification for palliative sedation, permits physicians to provide high doses of opioids and sedatives to relieve suffering, provided that the intention is not to cause the patient's death and that certain other conditions are met. Such high doses are permissible even if the risk of hastening death is foreseen. Because intention plays a key role in this doctrine, clinicians must understand and document which actions are consistent with an intention to relieve symptoms rather than to hasten death. The patient or family should agree with plans for palliative sedation. The attending physician needs to explain to them, as well as to the medical and nursing staff, the details of care and the justification 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.
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