Is it palliative sedation or just good symptom management?

Transcription

1 Is it palliative sedation or just good symptom management? Cautions, Concerns, Indications Geoff Davis M.D. Nov 2010

2 Objectives Explain the Principle of Double Effect and list its conditions for an appropriate application Consider differing terminology for sedation at the end of life and ethical importance Describe what is appropriate end of life sedation

3 Conflict Disclosure Information: Presenter: Dr. Geoff Davis I have no financial or personal relationships to disclose

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5 What s Double Effect? Allowing an unintended bad event to happen in the course of trying to do a good thing The intention of those who do the action is critical Often a highly emotional and difficult decision double effect does not mean everything is crystal clear

6 Ethical Issues in Care of Dying Ethical responsibility to treat pain and physical symptoms Recognition that on occasion efforts to treat pain and physical symptoms may cause death even though the desire is not to hasten death Principle of Double Effect provides rule of thumb for ethical behavior in complex situation

7 Principle of Double Effect Pain or other medication may be used in a terminal illness even if it may hasten an otherwise inevitable death Four conditions must be fulfilled before the Principle of Double Effect can be invoked

8 Principle of Double Effect The action itself must be good or indifferent The physician/clinician intends the good effect (i.e., pain control NOT death) The good effect must not occur via the bad effect Proportionate reason for tolerating evil

9 Pain should be treated vigorously The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed, as either an end or a means, but only foreseen and tolerated as inevitable. Catechism of the Catholic Church,

10 The potential for confusion Morally appropriate responses to suffering can be confused with assisted suicide and euthanasia

11 example Elderly man with end stage malignancy at home with moderate pain controlled with oral oxycodone, irritable, angry, lonely wants medication increased so I can fall asleep and die.

12 Terminology Jansen LA, Sulmasy D. Sedation, Alimentation, Hydration, and Equivocation: Careful Conversation about Care at the End of Life. Ann Intern Med. 2002;136: Terminal Sedation may be better described as SEDATION OF THE IMMINENTLY DYING 1) Patient is close to death (hours to days) 2) Patient has one or more severe symptoms that are refractory to the standard techniques of palliative care 3) Care team has vigorously treated these symptoms with therapy that is appropriate 4) Therapy has a dose dependent effect of sedation that is a foreseen but unintended consequence of attempt at symptom relief 5) May withdraw or withhold life-sustaining treatments that are not working or are burdensome

13 13 Defining Palliative Sedation Palliative sedation is also referred to as terminal sedation The intention is to deliberately induce and maintain deep sleep, But NOT deliberately causing death the intention is to relieve intractable symptoms when all other possible interventions have failed and the patient is perceived to be close to death Chater, S. et al. A survey of experts. Palliative Medicine 12: , LEAP Version 1.1

14 14 Indications for Palliative Sedation Common indications Intractable agitated delirium Intractable dyspnea Massive hemorrhaging Refractory seizuring Less common indications Intractable pain Controversial indications Psychological or spiritual distress Cowan and Walsh, Supportive Care in Cancer, 2001 Leap Version

15 Terminology continued Lo B, Rubenfeld G. Palliative sedation in dying patients. JAMA 2005; 294: Palliative sedation, used to avoid the connotation of intent to cause death sometimes conveyed by the term terminal sedation. 1) Alternative means of relieving symptoms are ineffective or intolerable adverse effects 2) Goal is relieving symptoms, not hastening death 3) Patient is imminently dying

16 16 Dignity Conserving Care The basic tenets of palliative care may be summarized as the goal of helping patients to die with dignity. The term "dignity" provides an overarching framework that may guide the physician, patient, and family in defining the objectives and therapeutic considerations fundamental to end-of-life care. Dignity-conserving care is care that may conserve or bolster the dignity of dying patients. Dignity-conserving care offers an approach that clinicians can use to explicitly target the maintenance of dignity as a therapeutic objective and as a principle of bedside care for patients nearing death Chochinov,JAMA Jul 10;288(2):162

17 Physician-assisted suicide/euthanasia Definitions Physician-assisted suicide--- Physician provides the means, the patient acts Euthanasia--- Physician performs the intervention [EPEC]

18 Euthanasia For a correct moral judgment on euthanasia, in the first place a clear definition is required. Euthanasia in the strict sense is understood to be an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering. John Paul II, Evangelium Vitae,

19 Understanding the need to respond to suffering Requests for physician assisted suicide represent deep concerns on the part of patients and their families There is a need to assess the causes of suffering Request for physician assisted suicide does not minimize the anguish of those who request it.

20 Clarifying conversations When a patient is intractably suffering how should you proceed? Assessment Consultation Resources

21 When the subject comes up (from EPEC) Clarify the request and find out why now Assess the underlying causes Affirm commitment to care for the patient Address root causes Address social suffering, practical concerns Address spiritual suffering

22 Assessment Why now? Underlying causes Types of suffering

23 Assess underlying causes The 4 dimensions of suffering physical psychological social spiritual [EPEC]

24 Spiritual suffering Existential concerns Meaning, value, purpose in life Abandoned, punished by God questions faith, religious beliefs, anger [EPEC]

25 Common fears Future Pain, other symptoms Loss of control, independence Abandonment, loneliness Indignity, loss of self-image Being a burden on others [EPEC]

26 Consult with colleagues Seek support from trusted colleagues about how best to help the patient without killing Obtain skilled consultation, ethical included, especially in the face of intractable symptoms Look to one s own spiritual needs in accompanying patients in difficult situations

27 Summary Palliative sedation has a variety of different names and meanings It is allowed if the Principle of Double Effect is strictly followed for the control of intractable physical and bodily symptoms in the imminently dying This requires very careful assessment and conversation as well as a willingness to consult and obtain ethical advice

28 Summary cont Assessing psychological, social, spiritual domains of suffering can be critical in determining the best course of action Sedation for spiritual, psychological, and social reasons is. Caring for persons who are suffering in these ways can be extremely difficult

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