 |
 |
|
Home |
Current Issue |
Past Issues |
In the Clinic |
ACP Journal Club |
CME |
Collections |
Audio/Video |
Mobile |
Subscribe |
Tools |
Help |
ACP Online
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7 March 2000 | Volume 132 Issue 5 | Pages 408-414
When provided by a skilled, multidisciplinary team, palliative care is highly effective at addressing the physical, psychological, social, and spiritual needs of dying patients and their families. However, some patients who have witnessed harsh death want reassurance that they can escape if their suffering becomes intolerable. In addition, a small percentage of terminally ill patients receiving comprehensive care reach a point at which their suffering becomes severe and unacceptable despite unrestrained palliative efforts; some of these patients request that death be hastened. This paper presents terminal sedation and voluntary refusal of hydration and nutrition as potential last resorts that can be used to address the needs of such patients. These two practices allow clinicians to address a much wider range of intractable end-of-life suffering than physician-assisted suicide (even if it were legal) and can also provide alternatives for patients, families, and clinicians who are morally opposed to physician-assisted suicide. This paper will define the two practices, distinguish them from more standard palliative care interventions and from physician-assisted suicide, illustrate them with a real clinical scenario, provide potential guidelines and practicalities, and explore their moral and legal status. Although medicine cannot sanitize dying or provide perfect answers for all challenging end-of-life clinical problems, terminal sedation and voluntary refusal of hydration and nutrition substantially increase patients' choices at this inherently challenging time.
Author and Article Information
This paper was written by Timothy E. Quill, MD, and Ira R. Byock, MD, for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel. Members of the ACP-ASIM End-of-Life Care Consensus Panel were Bernard Lo, MD (Chair); Janet Abrahm, MD; Susan Block, MD; William Breitbart, MD; Ira R. Byock, MD; Kathy Faber-Langendoen, MD; Lloyd W. Kitchens Jr., MD; Paul Lanken, MD; Joanne Lynn, MD; Diane Meier, MD; Timothy E. Quill, MD; George Thibault, MD; and James Tulsky, MD. Primary staff to the Panel were Lois Snyder, JD (Project Director), and Jason Karlawish, MD. This paper was reviewed and approved by the Ethics and Human Rights Committee, although it does not represent official ACP-ASIM policy. Members of the Ethics and Human Rights Committee were Risa Lavizzo-Mourey, MD (Chair); Joanne Lynn, MD; Richard J. Carroll, MD; David A. Fleming, MD; Steven H. Miles, MD; Gail J. Povar, MD; James A. Tulsky, MD; Alan L. Gordon, MD; S.Y. Tan, MD, JD; Vincent Herrin, MD; and Lee J. Dunn Jr., JD, LLM.
Grant Support: The Greenwall Foundation provided support to the End-of-Life Care panel.
Requests for Single Reprints: Lois Snyder, JD, Center for Ethics and Professionalism, American College of Physicians-American Society of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, mailto:lsnyder{at}mail.acponline.org.
Requests To Purchase Bulk Reprints (minimum, 100 copies): Reprints Coordinator; phone, 215-351-2657; e-mail, reprints{at}mail.acponline.org.
Current Author Addresses: Dr. Quill: Department of Medicine, The Genesee Hospital, 224 Alexander Street, Rochester, NY 14607.
Dr. Byock: The Palliative Care Service, 341 University Avenue, Missoula, MT 59801. POSITION PAPER
Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids
Related articles in Annals:
This article has been cited by other articles:
|
|
 |
|
  P. N. Lanken, P. B. Terry, H. M. DeLisser, B. F. Fahy, J. Hansen-Flaschen, J. E. Heffner, M. Levy, R. A. Mularski, M. L. Osborne, T. J. Prendergast, et al. An Official American Thoracic Society Clinical Policy Statement: Palliative Care for Patients with Respiratory Diseases and Critical Illnesses Am. J. Respir. Crit. Care Med., April 15, 2008; 177(8): 912 - 927. [Full Text] [PDF]
|
|
|
|
 |
|
 S. A Murray, K. Boyd, and I. Byock Continuous deep sedation in patients nearing death BMJ, April 12, 2008; 336(7648): 781 - 782. [Full Text] [PDF]
|
|
|
|
 |
|
 V Cellarius Terminal sedation and the "imminence condition" J. Med. Ethics, February 1, 2008; 34(2): 69 - 72. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. A. C. Rietjens, J. Hauser, A. van der Heide, and L. Emanuel Having a difficult time leaving: experiences and attitudes of nurses with palliative sedation Palliative Medicine, October 1, 2007; 21(7): 643 - 649. [Abstract] [PDF]
|
|
|
|
 |
|
 J. M. Lyness End-of-Life Care: Issues Relevant to the Geriatric Psychiatrist Focus, January 1, 2007; 5(4): 459 - 471. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 National Ethics Committee, Veterans Health Adminis The Ethics of Palliative Sedation as a Therapy of Last Resort American Journal of Hospice and Palliative Medicine, January 1, 2007; 23(6): 483 - 491. [Abstract] [PDF]
|
|
|
|
 |
|
 L. Snyder, C. Leffler, and for the Ethics and Human Rights Committee, America Ethics Manual: Fifth Edition Ann Intern Med, April 5, 2005; 142(7): 560 - 582. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. M. Lyness End-of-Life Care: Issues Relevant to the Geriatric Psychiatrist Focus, April 1, 2005; 3(2): 341 - 353. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. M. Lyness End-of-Life Care: Issues Relevant to the Geriatric Psychiatrist Am J Geriatr Psychiatry, October 1, 2004; 12(5): 457 - 472. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L C Kaldjian, J F Jekel, J L Bernene, G E Rosenthal, M Vaughan-Sarrazin, and T P Duffy Internists' attitudes towards terminal sedation in end of life care J. Med. Ethics, October 1, 2004; 30(5): 499 - 503. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. A.C. Rietjens, A. van der Heide, A. M. Vrakking, B. D. Onwuteaka-Philipsen, P. J. van der Maas, and G. van der Wal Physician Reports of Terminal Sedation without Hydration or Nutrition for Patients Nearing Death in the Netherlands Ann Intern Med, August 3, 2004; 141(3): 178 - 185. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. R. Gillick Terminal Sedation: An Acceptable Exit Strategy? Ann Intern Med, August 3, 2004; 141(3): 236 - 237. [Full Text] [PDF]
|
|
|
|
|
|
K R. Yabroff, J. S Mandelblatt, and J. Ingham The quality of medical care at the end-of-life in the USA: existing barriers and examples of process and outcome measures Palliative Medicine, April 1, 2004; 18(3): 202 - 216. [Abstract] [PDF]
|
|
|
|
|
|
P. Rutsohn and N. Ibrahim An analysis of provider attitudes toward end-of-life decision-making American Journal of Hospice and Palliative Medicine, September 1, 2003; 20(5): 371 - 381. [Abstract] [PDF]
|
|
|
|
 |
|
 M. J. Kahn, C. J. Lazarus, and D. P. Owens Allowing Patients to Die: Practical, Ethical, and Religious Concerns J. Clin. Oncol., August 1, 2003; 21(15): 3000 - 3002. [Full Text] [PDF]
|
|
|
|
 |
|
 L. Ganzini, E. R. Goy, L. L. Miller, T. A. Harvath, A. Jackson, and M. A. Delorit Nurses' Experiences with Hospice Patients Who Refuse Food and Fluids to Hasten Death N. Engl. J. Med., July 24, 2003; 349(4): 359 - 365. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. E. Meier, C.-A. Emmons, A. Litke, S. Wallenstein, and R. S. Morrison Characteristics of Patients Requesting and Receiving Physician-Assisted Death Arch Intern Med, July 14, 2003; 163(13): 1537 - 1542. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Lorenz and J. Lynn Moral and Practical Challenges of Physician-Assisted Suicide JAMA, May 7, 2003; 289(17): 2282 - 2282. [Full Text] [PDF]
|
|
|
|
|
|
T. E. Quill Careful Conversation about Care at the End of Life Ann Intern Med, December 17, 2002; 137(12): 1009 - 1009. [Full Text] [PDF]
|
|
|
|
|
|
P. C. Rousseau Palliative sedation American Journal of Hospice and Palliative Medicine, September 1, 2002; 19(5): 295 - 297. [PDF]
|
|
|
|
|
|
S. J. Baumrucker Sedation, dehydration, and ethical uncertainty American Journal of Hospice and Palliative Medicine, September 1, 2002; 19(5): 299 - 300. [PDF]
|
|
|
|
|
|
P. B. Bascom and S. W. Tolle Responding to Requests for Physician-Assisted Suicide: "These Are Uncharted Waters for Both of Us. . . ." JAMA, July 3, 2002; 288(1): 91 - 98. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. L. Back, H. Starks, C. Hsu, J. R. Gordon, A. Bharucha, and R. A. Pearlman Clinician-Patient Interactions About Requests for Physician-Assisted Suicide: A Patient and Family View Arch Intern Med, June 10, 2002; 162(11): 1257 - 1265. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. A. Jansen and D. P. Sulmasy Sedation, Alimentation, Hydration, and Equivocation: Careful Conversation about Care at the End of Life Ann Intern Med, June 4, 2002; 136(11): 845 - 849. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R M Perkin and D B Resnik The agony of agonal respiration: is the last gasp necessary? J. Med. Ethics, June 1, 2002; 28(3): 164 - 169. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. C. Jackson Palliative sedation vs. terminal sedation: What's in a name? American Journal of Hospice and Palliative Medicine, March 1, 2002; 19(2): 81 - 82. [PDF]
|
|
|
|
|
|
D. J. Casarett, S. K. Inouye, and for the American College of Physicians-American So Diagnosis and Management of Delirium near the End of Life Ann Intern Med, July 3, 2001; 135(1): 32 - 40. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Meisel, L. Snyder, T. Quill, and for the American College of Physicians-American So Seven Legal Barriers to End-of-Life Care: Myths, Realities, and Grains of Truth JAMA, November 15, 2000; 284(19): 2495 - 2501. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. E. Quill Initiating End-of-Life Discussions With Seriously Ill Patients: Addressing the "Elephant in the Room" JAMA, November 15, 2000; 284(19): 2502 - 2507. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Syme Intractable Terminal Suffering Ann Intern Med, November 7, 2000; 133(9): 749 - 750. [Full Text] [PDF]
|
|
|
|
|
|
M. L. Yanow Responding to Intractable Terminal Suffering Ann Intern Med, October 3, 2000; 133(7): 560 - 560. [Full Text] [PDF]
|
|
|
|
|
|
D. P. Sulmasy, W. A. Ury, J. C. Ahronheim, M. Siegler, L. Kass, J. Lantos, R. A. Burt, K. Foley, R. Payne, C. Gomez, et al. Palliative Treatment of Last Resort and Assisted Suicide Ann Intern Med, October 3, 2000; 133(7): 562 - 563. [Full Text] [PDF]
|
|
|
|
|
|
T. E. Quill, B. Coombs Lee, and S. Nunn Palliative Treatment of Last Resort and Assisted Suicide Ann Intern Med, October 3, 2000; 133(7): 563 - 563. [Full Text] [PDF]
|
|
|
|
|
|
F. Davidoff Publication of Papers on Assisted Suicide and Terminal Sedation Ann Intern Med, October 3, 2000; 133(7): 566 - 566. [Full Text] [PDF]
|
|
|
|
|
|
E. L. Krakauer Responding to Intractable Terminal Suffering Ann Intern Med, October 3, 2000; 133(7): 560 - 560. [Full Text] [PDF]
|
|
|
|
|
|
D. P. Sulmasy, W. A. Ury, J. C. Ahronheim, M. Siegler, L. Kass, J. Lantos, R. A. Burt, K. Foley, R. Payne, C. Gomez, et al. Responding to Intractable Terminal Suffering Ann Intern Med, October 3, 2000; 133(7): 560 - 561. [Full Text] [PDF]
|
|
|
|
|
|
D. P. Sulmasy, W. A. Ury, J. C. Ahronheim, M. Siegler, L. Kass, J. Lantos, R. A. Burt, K. Foley, R. Payne, C. Gomez, et al. Publication of Papers on Assisted Suicide and Terminal Sedation Ann Intern Med, October 3, 2000; 133(7): 564 - 565. [Full Text] [PDF]
|
|
|
|
|
|
J A. Billings Recent advances: Palliative care BMJ, September 2, 2000; 321(7260): 555 - 558. [Full Text]
|
|
|
|
|
|
R. E. Enck Terminal sedation American Journal of Hospice and Palliative Medicine, May 1, 2000; 17(3): 148 - 149. [PDF]
|
|
|
|
|
|
J. A. Tulsky, R. Ciampa, E. J. Rosen, and for the University of Pennsylvania Center for Bioe Responding to Legal Requests for Physician-Assisted Suicide Ann Intern Med, March 21, 2000; 132(6): 494 - 499. [Abstract] [Full Text] [PDF]
|
|
Article
