Abstract
Emmerich N, Gordijn B: Ethics of crisis sedation: Questions of performance and consent. J Med Ethics 2019. [Epub ahead of print]; doi.org/10.1136/medethics-2018-105285
This article focuses on the practice of injecting patients who are dying with a relatively high dose of sedatives in response to a catastrophic event that will shortly precipitate death, something that we term “crisis sedation.” The authors first present a confabulated case before offering a more detailed account of the practice. They then comment on some of the ethical issues that crisis sedation might raise. They identify the primary value of crisis sedation as allowing health care professionals to provide some degree of reassurance to patients, their families, and the professionals who are caring for them. Next, they focus on the issue of informed consent. Finally, we ask whether continuous deep sedation might be preferable to crisis sedation in scenarios where potential catastrophic events can be anticipated.
Ingersoll LT, Alexander SC, Ladwig S, et al. The contagion of optimism: The relationship between patient optimism and palliative care clinician overestimation of survival among hospitalized patients with advanced cancer. Psychooncology 2019. [Epub ahead of print]; doi.org/10.1002/pon.5080
Clinicians frequently overestimate survival time among seriously ill patients, and this can result in medical treatment at end of life that does not reflect the patient's preferences. Little is known, however, about the sources of clinicians' optimistic bias in survival estimation. Related study in social networks and experimental psychology demonstrates that psychological states—such as optimism—can transfer from one person to another. In this study, the authors directly observed and audio recorded 189 initial inpatient palliative care consultations among hospitalized patients with advanced cancer. Patients self-reported their level of trait optimism and expectations for survival prognosis before the palliative care consultation, and the palliative care clinicians rated their expectations for the patient's survival time after the initial conversation with the patient. The authors followed patient mortality for six months. Results demonstrated that patient optimism was associated with clinician overestimation of their survival in a dose–response relationship. Clinicians were approximately three times as likely to overestimate the survival of patients endorsing both high trait optimism and optimistic ratings of their survival time compared with neither. This association was not attenuated by adjustment for age, gender, race, ethnicity, education, income, cancer type, functional status, quality of life, or white blood cell count. The authors conclude that patients' optimism may have some influence over their clinicians' prognostic judgments.
Khera R, Pandey A, Link MS, Sulistio M. Managing implantable cardioverter-defibrillators at end-of-life: Practical challenges and care considerations. Am J Med Sciences 2019;357:143–150.
Implantable cardioverter-defibrillators (ICDs) monitor for and terminate malignant arrhythmias. Given their potential as a life-saving therapy, an increasing number of people receive an ICD every year, and a growing number are currently living with ICDs. However, cardiopulmonary arrest serves as the final common pathway of natural death, and the appropriate management of an ICD near the end of life is crucial to ensure that a patient's death is not marked by further suffering due to ICD shocks. The tenets of palliative care at the end of life include addressing any medical intervention that may preclude dying with dignity; thus, management of ICDs during this phase is necessary. Internists are at the forefront of discussions about end-of-life care, and are likely to find discussions about ICD care at the end of life particularly challenging. This review addresses issues pertaining to ICDs near the end of a patient's life and their potential impact on dying patients and their families. The authors suggest that a multidisciplinary patient-centered approach can ensure that patients receive the maximum benefit from ICDs, without any unintended pain or suffering.
Kass JS, Lewis A, Rubin MA. Ethical considerations in end-of-life care in the face of clinical futility. Continuum 2018;24:1789–1793.
Management of patients with terminal brain disorders can be medically, socially, and ethically complex. Although a growing number of feasible treatment options may exist, there are times when further treatment can no longer meaningfully improve either quality or length of life. Clinicians and patients should discuss goals of care although patients are capable of making their own decisions. However, because such discussions can be challenging, they are often postponed. These discussions are then conducted with patients' health care proxies after patients lose the capacity to make their own decisions. Disagreements may arise when a patient's surrogate desires continued aggressive interventions that are either biologically futile (incapable of producing the intended physiological result) or potentially inappropriate (potentially capable of producing the patient's intended effect but in conflict with the medical team's ethical principles). This article explores best practices in addressing these types of conflicts in the critical care unit, but these concepts also broadly apply to other sites of care.
Lim CY, Park JY, Kim DY, et al. Terminal lucidity in the teaching hospital setting. Death Stud 2018. [Epub ahead of print]; https://doi.org/10.1080/07481187.2018.1541943
Terminal lucidity is an unpredictable end-of-life experience that has invaluable implications in preparation for death. We retrospectively evaluated terminal lucidity at a university teaching hospital. Of 338 deaths that occurred during the study period (187 in the ICU and 151 in general wards), terminal lucidity was identified in 6 cases in general wards. Periods of lucidity ranged from several hours to four days. After experiencing terminal lucidity, half of the patients died within a week, and the remainder died within nine days. The authors suggest that more attention should be directed toward understanding terminal lucidity to improve end-of-life care in a meaningful way.
Brizzi K, Creutzfeld CJ. Neuropalliative care: A practical guide for the neurologist. Semin Neurol 2018;38:569–575.
Neuropalliative care is a new and growing field within neurology that focuses on improving the quality of life of patients with serious neurological illnesses. Although specialty-level palliative care training is available to interested neurologists, all neurologists can strive to provide primary palliative care for their patients. In this review, the authors describe the scope of neuropalliative care, define patient populations who may benefit from palliative care, and explore the communication and symptom management skills essential to palliative care delivery.
Shen MJ, Wellman JD. Evidence of palliative care stigma: The role of negative stereotypes in preventing willingness to use palliative care. Palliat Support Care 2018. [Epub ahead of print]; doi.org/10.1017/S1478951518000834
Although palliative care is critical to managing symptoms, pain, and transitions to end-of-life care among those facing serious or chronic illness, it is often underused, which may be due to stigma associated with palliative care representing giving up fighting one's illness. The goal of these studies was to test the theoretical framework of stigma within the context of palliative care to inform future study on intervention development that addresses potential barriers to palliative care utilization. In study 1, participants (n = 152) had an oncologist describing two treatment options to a terminally ill cancer patient: (1) palliative care and (2) chemotherapy. Participants were then randomly assigned to read that the patient chose palliative care or chemotherapy. In study 2, these stereotypes about those receiving palliative care were examined as a potential mediator between perceived palliative care stigma and prospective palliative care use. Participants (n = 199) completed self-report measures of palliative care stigma, negative stereotypes about palliative care users, and prospective use of palliative care. Mediation analysis tested the mediational effects of stereotypes on the relationship between palliative care stigma and prospective usage of palliative care. Results demonstrated that in study 1, those in the palliative care condition endorsed significantly higher levels of negative stereotypes about the patient, viewed the decision more negatively, and saw the patient as less afraid of death. In study 2, palliative care stigma was associated with less prospective usage of palliative care for self and for one's family member. This relationship was mediated by negative stereotypes about individuals receiving palliative care. The authors noted that the studies suggest that palliative care stigma exists (study 1) and that this stigma may be a barrier to the utilization of palliative care (study 2). Future research should examine stigma reduction as a potential intervention target to improve palliative care utilization.