Biomedical subjects
Publications and source records attributed to J L Hallenbeck.
Cross-cultural encounters at the end of life are common and can result in misunderstandings and conflicts. The primary care physician is ideally suited to facilitate communication that can promote understanding and conflict resolution.
Terminal sedation (TS) is a recently coined term that may apply to a variety of practices with differing ethical implications. Two hypothetical cases are presented and contrasted. The first presents the more common scenario in which sedation is used for severe distress in a patient very close to death, who has stopped eating and drinking. The second case is more problematic: a nonterminally ill spinal cord injury patient requests sedation because of psychic distress. Sedation is supported in the former, but not the latter case. Suggested principles guiding the ethical use of sedation are: (1) While respect for autonomy is important, we are not obliged under all circumstances to provide sedation. (2) Physician intent matters. In providing sedation the physician's primary intent should be to alleviate suffering. (3) Reasonable inferences of intent can be made from physician actions, providing safeguards to ensure proper care. Sedatives should be titrated to observable signs of distress. (4) Proximity to death is a more useful concept than terminality in weighing benefits and burdens of sedation. (5) The nature of physician action should depend upon the nature of the suffering. Not all suffering is appropriately treated with sedation. (6) In patients close to death who have already stopped eating and drinking, sedation cannot be said to hasten death through dehydration or starvation. (7) Where TS is otherwise appropriate and where dehydration may in fact hasten death, ethical concerns may be addressed through informed consent. If hydration is refused, TS cannot be considered synonymous with euthanasia.
PURPOSE: To evaluate intern experience in end-of-life care and self-assessed changes in attitude and knowledge, following a mandatory rotation on an inpatient hospice and in a nursing home. SUBJECTS AND METHODS: Twenty-seven interns enrolled in an internal medicine residency program completed a questionnaire examining experiences with dying patients, prior training in end-of-life care, and self-ratings of pertinent attitudes and knowledge. The questionnaire used a retrospective before and after design. Comparisons were evaluated using dependent two-tailed r-tests. RESULTS: Prior training was largely limited to undergraduate didactic courses. Few interns had received formal training in symptom management. Most felt poorly prepared to care for terminally ill patients. Eighty-two percent of interns had previously cared for a dying patient only in acute care. Fifty-nine percent had never cared for a dying patient without intravenous fluids. Prior modeling of end-of-life care communication by attending physicians was uncommon. On a 5-point scale (strongly disagree-strongly agree) mean responses increased from 2.1 before-rotation to 3.0 after-rotation (p < 0.001) for the statement, "I feel as comfortable with a dying patient as I do with any other patient." Pain management knowledge increased from 2.0 before-rotation to 3.8 after-rotation (p < 0.001). Seventy-seven percent strongly agreed with the statement, "some training in care of terminally ill patients should be mandatory for all internists." CONCLUSIONS: Prior experiences did not adequately prepare interns to deliver competent care. Significant improvements in attitude and knowledge were noted following the intervention. More hands-on clinical experiences in end-of-life care for residents are needed. Occasional didactic sessions will be inadequate.