Hospice eNews 
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What the Media Said about End-of-Life Care This Week
Week of
October 17, 2005
…a
service of
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JAMA EXAMINES PALLIATIVE
SEDATION IN DYING PATIENTS
The story of Mrs. B, a 49-year-old woman
dying of metastatic breast cancer, is used in the
current JAMA to illustrate the issues
involved in the use of palliative sedation.
The term palliative sedation
is used rather than terminal sedation
for the administration of sedatives to induce unconsciousness “to avoid any
implication that the intention of such treatment is to cause the patient’s
death.”
Traditionally, the article says, the justification for palliative sedation is the “doctrine of double effect, which draws a moral distinction between what a person intends and what is accepted as a foreseen but unintended side effect.” The double effect doctrine holds that intentionally causing death is not acceptable but prescribing high doses of sedatives and opioids to relieve pain is, even if the resulting death is foreseen.
There are three characteristics of cases in
which palliative sedation may be justified, say the authors.
* “Alternative means of relieving symptoms either are ineffective or have intolerable adverse effects.”
* “The goal or intention of sedation is to relieve symptoms, not to shorten life.”
* “The patient is ‘at the point of death, in a dying state, or close to death.’”
Additionally, other double effect doctrine
conditions must be met.
* “The action itself [such as the administration of opioids and/or sedatives] must not be morally wrong, independent of its consequences.”
* The resulting
secondary effect, such as respiratory depression or death, “must not be the means to accomplish the
pri
* “There must be
proportionality between the intended pri
* “There must be no less harmful option for achieving the goal of relieving suffering.”
The authors make it clear that palliative sedation should be used only as a last resort for intractable pain that can’t be controlled by any other means. Patients whose pain is not controlled by opioids should be switched to another opioid, offered other modalities such as palliative chemotherapy or radiation and offered interventions that address other issues that might exacerbate pain. A palliative care specialist or pain specialist, or both, should be consulted.
“Broader uses of palliative sedation … are ethically controversial,” the authors write. They give examples of such broader uses as when a patient is terminally ill but not “moribund,” when palliative sedation is combined with the withdrawal of other life-sustaining measures (especially artificial nutrition or hydration), or when “the refractory symptom is existential or spiritual suffering rather than physical symptoms.”
The article suggests several key points,
which should be made when physicians discuss palliative sedation with other
members of the healthcare team and family.
* The patient’s unbearable suffering cannot be controlled in any other way.
* “Be explicit about goals and outcomes.” The patient probably will not regain consciousness, and will die.
* Many people “are ambivalent or uncertain about palliative sedation.” Discuss concerns and possible misunderstandings.
* Anticipate questions about the process of dying.
* Explain that palliative sedation is not the same as euthanasia, and is “ethically and legally acceptable.”
* Ask about things, which can be done for the patient to provide closure and comfort, such as allowing people to say goodbye, or conducting specific religious rituals.
The authors list several points for
consideration when a decision for palliative sedation is being made:
* If a palliative or pain specialist is readily available, arrange for a consultation.
* Discuss the decision with all caregivers.
* Clearly distinguish between euthanasia and palliative sedation.
* Get informed consent from the patient or surrogate.
* Document an explicit plan that includes drugs, dosages and criteria for increasing the dosages.
* The site of care should provide an appropriate level of monitoring and nursing care.
* Document the procedure carefully in the patient’s chart.
* Elicit, and respond to, questions, suggestions and concerns.
* After death, hold follow-up discussions with both the family and the healthcare team.
* Review, and if necessary, revise hospital policies concerned with palliative sedation.
The authors conclude by saying, “Because palliative sedation should be considered a last resort, it usually occurs in complicated cases, under stressful conditions, and with time constraints. Although palliative sedation should never be easy for caregivers, it is immensely rewarding to relieve a dying patient’s suffering, without crossing the line into ethically controversial ground.”
The full text of the patient page on this topic is online at
jama.ama-assn.org/cgi/collection/patient_page. Other recent pages on related topics, available at the same URL, include a page on palliative care (3/15/2005), one on hospice care (2/21/2001) and a page on end-of-life care (11/1/2000). (JAMA, 2005;294:1810-1816)
PAIN STUDIES REVEAL MORE
ABOUT PLACEBO EFFECT IN BRAIN
JAMA includes an article titled, “Pain
Studies Illuminate the Placebo Effect.” Magnetic resonance imaging (MRI) and
positron emission tomography (PET) scans show that activity at the brain’s opioid receptors “mediates the placebo effect.” These findings, and others that identify
brain areas that are active when a placebo is given, “demonstrate a mechanism
through which the patient’s expectation of pain relief can alter their
experience of pain and their emotional state.”
The University of Michigan Medical School study injected a saltwater solution into the jaws of health volunteers. While undergoing PET scans, the men received a placebo described to them as something “that might relieve their pain.” At 15-second intervals, the men described their pain and the descriptions were correlated with the brain images. The results show that endogenous opioids, which were released in several areas of the brain and in the dorsal lateral prefrontal cortex, correlated with how effective the patient expected the placebo to be.
Tor Wager,
PhD, assistant professor of psychology at
Dr. Jon-Kar Zubieta, the professor who led the study, thinks that a
strong placebo response in individuals may provide an adaptive advantage to
individuals who have it. “You can
interpret this as a resiliency mechanism that you want to preserve and
enhance,” he said.
In the future, medications may target these areas of the brain to enhance the placebo effect. Psychosocial interventions, in conjunction with medication, may reduce pain. Researchers say that much more study is needed, because the placebo effect can “confound the results of clinical trials.” Wager says that too many researchers “fail to take into account the consequences of a patient’s psychological state” on the patient’s health. “Clinical trials as they are conducted now don’t do a good job of separating drug effects from the effects of expectations and belief.” Researchers are beginning to study the effects of drugs “when patients know they are receiving it vs when the pain is administered covertly.” (JAMA, 2005;294:1750-1751)
RESEARCH AND RESOURCE NOTES
* Narrative, Pain, and Suffering, volume 34 of Progress in Pain Research and Management, is reviewed in the current NEJM. The physician’s understanding of the patients’ narrative of pain experience is seen as essential to good diagnosis and therapy, communication and empathy with the patient. Reviewer Philip R. Appel says, “The editors have created a work that addresses several topics stemming from the challenge of understanding what is happening in the patient’s brain as he or she relates the experience of pain.” (NEJM, 2005;353:1637)
* A recently released
report summarizes the results of last fall’s
* Currents: Pain Management News and Research is the
new monthly online magazine of the
PAIN NOTES
* The results of a new
study by researchers from the
* “Use of Acupuncture for Chronic Pain: Optimizing Clinical Practice” examines acupuncture principles, discusses clinical evidence, and “identifies acupuncture resources to optimize practice for chronic pain management.” A NIH consensus conference held in 1997 “concluded that acupuncture needling releases endorphins and other neurotransmitters in the brain and should be considered as an appropriate pain treatment option.” (Holistic Nursing Practice, 2005;19(5):217-221)
* “Children are less likely than adults to receive appropriate pain medication” in an emergency room, according to an article in the current Newsweek. Parents should ask at check-in if the child should receive an analgesic so it can begin to work, stay with children to comfort and distract them and tell them the truth. (Newsweek, 10/17)
.
OTHER NOTES
* On October 12, former HHS Secretary Tommy G. Thompson
received the Mattie Stepanek Award from Children’s
Hospice International for his “outstanding work on behalf of
* Bill Burke, volunteer
at a hospice unit in Oregon and Washington VA Medical Centers, has written a
reflection on life in the unit. Saying
that he is reminded often of “a concept that once prevailed in
*
* Following the Supreme
Court’s hearing of Gonzales vs.
* Mitch Albom, author of Tuesdays
with Morrie, says that even when plans for death
are carefully made, the plans may be cast aside in the light of terminal
illness, when decisions may be made that were “previously unimaginable.” Albom, a supporter
of