Background Intensivists must provide enough analgesia and sedation to ensure dying patients receive good palliative care. However, if it is perceived that too much is given, they risk prosecution for committing euthanasia. The goal of this study is to develop consensus guidelines on analgesia and sedation in dying intensive care unit patients that help distinguish palliative care from euthanasia. Methods Using the Delphi technique, panelists rated levels of agreement with statements describing how analgesics and sedatives should be given (...) to dying ICU patients and how palliative care should be distinguished from euthanasia. Participants were drawn from 3 panels: 1) Canadian Academic Adult Intensive Care Fellowship program directors and Intensive Care division chiefs (N = 9); 2) Deputy chief provincial coroners (N = 5); 3) Validation panel of Intensivists attending the Canadian Critical Care Trials Group meeting (N = 12). Results After three Delphi rounds, consensus was achieved on 16 statements encompassing the role of palliative care in the intensive care unit, the management of pain and suffering, current areas of controversy, and ways of improving palliative care in the ICU. Conclusion Consensus guidelines were developed to guide the administration of analgesics and sedatives to dying ICU patients and to help distinguish palliative care from euthanasia. (shrink)

Riassunto : L’ effetto nocebo è l’effetto psicobiologico dovuto al contesto psicosociale negativo che accompagna una terapia. Dal momento che lo studio dell’ anticipazione dolorifica prende in considerazione la fase temporale della “attesa dell’iperalgesia”, e considerando che – proprio come il nocebo – è possibile elicitarla con il solo uso di verbalizzazioni negative, questo modello può permettere di studiare la risposta nocebo. Ad oggi infatti non si dispone di dati univoci circa le aree coinvolte in questi processi e circa il (...) ruolo cognitivo da queste ricoperto. Abbiamo condotto una meta-analisi su studi fMRI di anticipazione dolorifica su cui applicare un modello di connettività meta-analitica su due regioni di interesse: la corteccia cingolata e l’insula anteriori, le cui attivazioni sembrerebbero correlano ai domini comportamentali dell’azione, dell’emozione e della percezione. I risultati avvalorano l’ipotesi dell’esistenza di un sistema supramodale altamente distribuito, attivato dall’anticipazione del dolore, e, infine, volto all’elaborazione delle informazioni e all’auto-regolazione delle risposte adattive all’ambiente. Parole chiave : Placebo; Nocebo; Dolore; Correlati neurali; Comportamento umano Placebo Analgesia, Pain Anticipation, and the Possible Neural Correlates of Nocebo Effect: The nocebo effect is a psychobiological effect that occurs when a negative psychosocial context that accompanies a therapy. Since the study of pain anticipation takes into account the temporal phase of the “expectation of hyperalgesia”, and considering that it is possible to stimulate such anticipatory processes merely through the use of negative verbalizations, this model is appropriate for studying the nocebo response. To date, there are no univocal data about the brain areas involved in these processes or their cognitive roles. We conducted a meta-analysis on pain anticipation fMRI studies. We then applied a meta-analytic connectivity model to activations in the anterior cingulate cortex and the anterior insula, which correlate with the behavioral domains of action, emotion and perception. Our results support the hypothesis that there is a highly-distributed supramodal system, activated by pain anticipation, for processing information that enhances the self-regulation of adaptive responses to the environment. Keywords : Placebo; Nocebo; Pain; Neural Correlates; Human Behaviour. (shrink)

Although religious belief is often claimed to help with physical ailments including pain, it is unclear what psychological and neural mechanisms underlie the influence of religious belief on pain. By analogy to other top-down processes of pain modulation we hypothesized that religious belief helps believers reinterpret the emotional significance of pain, leading to emotional detachment from it. Recent findings on emotion regulation support a role for the right ventrolateral prefrontal cortex, a region also important for driving top-down pain inhibitory circuits. (...) Using functional magnetic resonance imaging in practicing Catholics and avowed atheists and agnostics during painful stimulation, here we show the existence of a context-dependent form of analgesia that was triggered by the presentation of an image with a religious content but not by the presentation of a non-religious image. As confirmed by behavioral data, contemplation of the religious image eneabled the religious group to detach themselves from the experience of pain. Critically, this context-dependent modulation of pain specifically engaged the right VLPFC, whereas group-specific preferential liking of one of the pictures was associated with activation in the ventral midbrain. We suggest that religious belief might provide a framework that allows individuals to engage known pain-regulatory brain processes. (shrink)

This paper examines research on three hypnotic phenomena: suggested amnesia, suggested analgesia, and “trance logic.” For each case a social-psychological interpretation of hypnotic behavior as a voluntary response strategy is compared with the traditional special-process view that “good” hypnotic subjects have lost conscious control over suggestion-induced behavior. I conclude that it is inaccurate to describe hypnotically amnesic subjects as unable to recall the material they have been instructed to forget. Although amnesics present themselves as unable to remember, they in (...) fact retain control over retrieval processes and accommodate their recall (or lack of it) to the social demands of the test situation. Hypnotic suggestions of analgesia do not produce a dissociation of pain from phenomenal awareness. Nonhypnotic suggestions of analgesia and distractor tasks that deflect attention from the'noxious stimuli are as effective as hypnotic suggestions in producing reductions in reported pain. Moreover, when appropriately motivated, subjects low in hypnotic suggestibility report pain reductions as large as those reported by highly suggestible hypnotically analgesic subjects. Finally, the data fail to support the view that a tolerance for logical incongruity (i.e., trance logic) uniquely characterizes hypnotic responding. So-called trance-logic-governed responding appears to reflect the attempts of “good” subjects to meet implicit demands to report accurately what they experience. (shrink)

There are reasons to believe that decision‐making capacity (mental competence) of women in labor may be compromised in relation to giving informed consent to epidural analgesia. Not only severe labor pain, but also stress, anxiety, and premedication of analgesics such as opioids, may influence women’s decisional capacity. Decision‐making capacity is a complex construct involving cognitive and emotional components which cannot be reduced to ‘understanding’ alone. A systematic literature search identified a total of 20 empirical studies focused on women’s decision‐making (...) about epidural analgesia for labor pain. Our review of these studies suggests that empirical evidence to date is insufficient to determine whether women undergoing labor are capable of consenting to epidural analgesia. Given such uncertainties, sufficient information about pain management should be provided as part of prenatal education and the consent process must be carefully conducted to enhance women’s autonomy. To fill in the significant gap in clinical knowledge about laboring women’s decision‐making capacity, well‐designed prospective and retrospective studies may be required. (shrink)

In this commentary we discuss the possibility of subcortical consciousness and its implications for fetal anesthesia and analgesia. We review the neural development of structural and functional elements that may participate in conscious representation, with a particular focus on the experience of pain. (Published Online May 1 2007).

This work focuses on the application of machine learning techniques to assist the clinicians in the administration of analgesic drug during general anaesthesia. Specifically, the main objective is to propose the basis of an intelligent system capable of making decisions to guide the opioid dose changes based on a new nociception monitor, the analgesia nociception index. Clinical data were obtained from 15 patients undergoing cholecystectomy surgery. By means of an off-line study, machine learning techniques were applied to analyse the (...) possible relationship between the analgesic dose changes performed by the physician due to the hemodynamic activity of the patients and the evolution of the ANI. After training different classifiers and testing the results under cross validation, a preliminary relationship between the evolution of ANI and the dosage of remifentanil was found. These results evidence the potential of the ANI as a promising index to guide the infusion of analgesia. (shrink)

Negative feedback is an important mechanism whereby the organism maintains its balance in a complicated system. It may beregarded as a modern version of the ancient Eastern wisdom of Yin and Yang balance. Control of pain and analgesia, is no exception: CCK seems to serve as a built-in mechanism for the modulation of opioid analgesia system [dickenson].

dickenson briefly mentions that peripheral opioid receptors somehow become active following inflammation and that the appearance of endogenous opioid peptides at the injury site may be related to immune cell proliferation. Recent findings elucidate the underlying mechanisms in more detail and provide an incentive for the development of a novel generation of analgesics devoid of typical central opioid side effects.

Background and aimsExcessive pain during medical procedures is a worldwide medical problem. Most scald burns occur in children under 6, who are often undermedicated. Adjunctive Virtual Reality distraction has been shown to reduce pain in children aged 6–17, but little is known about VR analgesia in young children. This study tests whether desktop VR can reduce the just noticeable pressure pain of children aged 2–10.MethodsA within-subject repeated measures design was used. With treatment order randomized, each healthy volunteer pediatric participant (...) underwent brief cutaneous pressure stimuli under three conditions: no distraction, a verbal color naming task, and a large TV-based desktop VR distraction. A hand-held Wagner pressure pain stimulation device was used to generate just noticeable pain sensations. Participants indicated when a steadily increasing non-painful pressure stimulus first turned into a painful pressure sensation.ResultsA total of 40 healthy children participated. Compared to the no distraction condition, the 40 children showed significant VR analgesia, t = 9.83, p < 0.001, SD = 6.24. VR was also significantly more effective at reducing pain sensitivity vs. an auditory color naming task, t = 5.42, p < 0.001, SD = 5.94. The subset of children aged 2–5 showed significant reductions in pain during VR. Children under 6 showed greater sensitivity to pain during no distraction than children aged 6–10.ConclusionDuring no distraction, children under 6 years old were significantly more sensitive to pain than children aged 6–10. Virtual reality significantly reduced the “just noticeable” pressure pain sensitivity of children in both age groups. (shrink)

Analgesia and amnesia represent two complimentary pillars of anesthesia directed, respectively, at mitigating the experience of pain and the processes of encoding that experience into memory. These elements are typically combined in modern anesthetic techniques, but some circumstances exist – such as conscious sedation – in which the conditions of amnesia are satisfied while analgesia plays an auxiliary and often incomplete role. These activities reflect a widely held yet underrecognized belief in clinical practice that although pain experiences may (...) be short-lived, their representation in memory and its subsequent effects on thought and emotion can have enduring consequences for patients. In this exploratory article, we delineate phenomenal and abstract ontological categories of pain experience; advance a claim that they are treated by analgesic and amnestic agents, respectively; and describe how each class of experience is uniquely able to bring about individual harm. Beginning with the question of how it can be permissible to allow any preventable experiences or memories of pain, we identify that both phenomenal and abstract pain manifest on a spectrum of severity, each with an enigmatic threshold – unique to circumstance and individual – that determines whether or not pain will translate into harm, and what permissions therefore surround its treatment. Ultimately, we find that there are compelling physiological reasons for the concurrent use of analgesics and amnestics when pain experience exceeds these thresholds, while the treatment of “sub-threshold” experience in either class is a purely ethical imperative to be balanced with considerations of the potential harms posed by the treatments themselves. (shrink)

Music reduces pain in fibromyalgia (FM), a chronic pain disease, but the functional neural correlates of music-induced analgesia (MIA) are still largely unknown. We recruited FM patients ( n = 22) who listened to their preferred relaxing music and an auditory control (pink noise) for 5 min without external noise from fMRI image acquisition. Resting state fMRI was then acquired before and after the music and control conditions. A significant increase in the amplitude of low frequency fluctuations of the (...) BOLD signal was evident in the left angular gyrus (lAnG) after listening to music, which in turn, correlated to the analgesia reports. The post-hoc seed-based functional connectivity analysis of the lAnG showed found higher connectivity after listening to music with right dorsolateral prefrontal cortex (rdlPFC), the left caudate (lCau), and decreased connectivity with right anterior cingulate cortex (rACC), right supplementary motor area (rSMA), precuneus and right precentral gyrus (rPreG). Pain intensity (PI) analgesia was correlated ( r = 0.61) to the connectivity of the lAnG with the rPreG. Our results show that MIA in FM is related to top-down regulation of the pain modulatory network by the default mode network (DMN). (shrink)

The spinal mechanisms of action of opioids under normal conditions are reasonably well understood. The spinal effects of opioids can be enhanced or reduced depending on pathology and activity in other segmental and nonsegmental pathways. This plasticity will be considered in relation to the control of different pain states using opioids. The complex and contradictory findings on the supraspinal actions of opioids are explicable in terms of heterogeneous descending pathways to different spinal targets using multiple transmitters and receptors – therefore (...) opioids can both increase and decrease activity in descending pathways. These pathways could exhibit considerable plasticity. There is increasing evidence that delta opioid receptor agonists have the potential to replace morphine as major analgesics with reduced side-effect profiles. The concept of preemptive analgesia, based on preventing the induction of some of the negative plastic influences on opioid controls and the detrimental effects of pain, is sound, but experimental verification in the clinical setting is difficult. For example, a delayed compensatory upregulation of inhibitory systems, particularly in inflammation, may counter persistent painful inputs. Combination therapy with opioids may be beneficial in many pain states where either negative influences are blocked or inhibitory controls are enhanced. Finally, developmental aspects of these systems are discussed in connection with the treatment of pain in young children, where inhibitory systems in the spinal cord are immature. (shrink)

There is compelling evidence that pain experience is influenced by cognitive states. We explore one specific form of such influence, namely placebo analgesia, and examine its relevance for the cognitive penetration debate in philosophy of mind. We single out as important a form of influence on experience that we termradical cognitive penetration,and argue that some cases of placebo analgesia constitute compelling instances of this phenomenon. Still, we urge caution in extrapolating from this to broader conclusions about cognitive penetration (...) in perceptual experience. Instead, we suggest that the cognitive penetration of pain raises distinctive psychological, epistemological, and ethical issues. (shrink)

Discussions concerning the modularity of the pain system have been focused on questions regarding the cognitive penetrability of pain mechanisms. It has been claimed that phenomena such as placebo analgesia demonstrate that the pain system is cognitively penetrated; therefore, it is not encapsulated from central cognition. However, important arguments have been formulated which aim to show that cognitive penetrability does not in fact entail a lack of modularity of the pain system. This paper offers an alternative way to reject (...) the modularity of the pain system, which is independent from, but consistent with, the presence of cognitive penetration. It is proposed that, given the current knowledge regarding the functioning and the structure of the pain system, there are good reasons to accept that certain central cognitive mechanisms are part of the pain system. It is argued that such a ‘cognitive constitution’ of the pain system entails that the pain system is not modular. (shrink)

Interest in hypnotic treatment for pain conditions seems to be on the rise. Recent evidence shows that hypnotic analgesia interventions result in substantial cost savings following medical procedures. Experimental studies suggest that hypnosis can differentially modulate the sensory or affective dimension of pain, depending on the nature of the suggestions. However, there have been few systematic approaches to quantifying this effect across literature and less attention has been given to the specific procedures and suggestions used in hypnotic treatment in (...) research. The present paper evaluates the magnitude of the effect of hypnosis on the affective component of pain. A scientific background presents the usefulness of a hypnotic approach that uses emotion-specific wording that would elicit prior positive experience to intervene at both the sensory and affective dimensions of pain. Such an approach would enable patients who cannot effectively dissociate from the sensation of pain to diminish their affective response. The paper concludes with a discussion of the implications of the findings for future hypnosis research and for the clinical applications of hypnotic analgesia. (shrink)

BackgroundPalliative sedation and analgesia are employed in patients with refractory and intractable symptoms at the end of life to reduce their suffering by lowering their level of consciousness. The doctrine of double effect, a philosophical principle that justifies doing a “good action” with a potentially “bad effect,” is frequently employed to provide an ethical justification for this practice. Main textWe argue that palliative sedation and analgesia do not fulfill the conditions required to apply the doctrine of double effect, (...) and therefore its use in this domain is inappropriate. Furthermore, we argue that the frequent application of the doctrine of double effect to palliative sedation and analgesia reflects physicians’ discomfort with the complex moral, intentional, and causal aspects of end-of-life care. ConclusionsWe are concerned that this misapplication of the doctrine of double effect can consequently impair physicians’ ethical reasoning and relationships with patients at the end of life. (shrink)

Health care providers are expected both to relieve pain and to provide anticipatory guidance regarding how much a procedure is going to hurt. Fulfilling those expectations is complicated by the cognitive modulation of pain perception. Warning people to expect pain or setting expectations for pain relief not only influences their subjective experience, but it also alters how nociceptive stimuli are processed throughout the sensory and discriminative pathways in the brain. In light of this, I reconsider the characterization of placebo (...) class='Hi'>analgesia as pharmacologically inert and the use of it as deceptive. I show that placebo analgesia exploits the same physical mechanisms as proven analgesics and argue that it should be utilized to relieve pain. Additionally, I describe factors to help identify situations in which clinicians have the obligation to disclose the potential for pain coupled with ways of mitigating the risk of high-intensity pain by setting positive expectations. (shrink)

Converging data from different disciplines are showing the role of classical conditioning processes in the elaboration of human and animal behavior to be larger than previously supposed. Restricted views of classically conditioned responses as merely secretory, reflexive, or emotional are giving way to a broader conception that includes problem-solving, and other rule-governed behavior thought to be the exclusive province of either operant conditiońing or cognitive psychology. These new views have been accompanied by changes in the way conditioning is conducted and (...) evaluated. Data from a number of seemingly unrelated phenomena such as relapse to drug abuse by postaddicts, the placebo effect, and the immune response appear to involve classical conditioning processes. Classical conditioning, moreover, has been found to occur in simpler and simpler organisms and recently even demonstrated in brain slices and in utero. This target article will integrate the several research areas that have used the classical conditioning process as an explanatory model; it will challenge teleological interpretations of the classically conditioned CR and offer some basic principles for testing conditioning in diverse areas. (shrink)

Pains are unpleasant, universally unpleasant. What seems trivially true has been rejected by various pain scientists because of several phenomena which allegedly show that there can be pain which is not unpleasant. This rejection is partly based on the ambiguity of ‘pain unpleasantness’ which can be avoided by distinguishing between primary and secondary pain affect. As for the alleged counterexamples to the above, I will argue that experiences of episodic analgesia as well as the ‘pain’ experiences of some lobotomized (...) and morphine patients should not be construed as cases in which pain and unpleasantness come apart, but rather as cases in which nociceptive activity and pain dissociate. Regarding the notorious case of pain asymbolia, I will demonstrate that the behaviour of patients with this syndrome suggests that they do feel pain, and that their pain sensations are unpleasant, but much less unpleasant than the pains normal people would have if exposed to the same noxious stimuli. Adopting such an account of these phenomena allows us to retain the widely accepted IASP definition of pain, and thus avoids the issue of integrating non-unpleasant pains into a plausible definition of pain. (shrink)

During the past decade, debate has intensified about the role of long-term opioid therapy in the management of chronic nonmalignant pain. Specialists in pain management have discussed the issues extensively and now generally agree that a selected population of patients with chronic pain can attain sustained analgesia without significant adverse consequences. This perspective, however, is not uniformly accepted by pain specialists and has not been widely disseminated to other disciplines or the public. Rather, the more traditional perspective, which ascribes (...) both transitory benefit and substantial cumulative risk to long-term opioid therapy, continues to predominate. According to this perspective, the inevitability of tolerance limits the possibility of sustained efficacy, and other pharmacological properties increase the likelihood of adverse outcomes, including persistent side-effects, impairment in physical and psychosocial functioning, and addiction. If accurate, these outcomes would indeed justify the withholding of opioid therapy for all but the most extreme cases of chronic nonmalignant pain. (shrink)

Objectives—To assess perceptions of the informed consent process in patients undergoing urgent abdominal surgery.Design—A prospective observational study was carried out using structured questionnaire-based interviews. Patients who had undergone urgent abdominal surgery were interviewed in the postoperative period to ascertain their perceptions of the informed consent process. Replies were compared to responses obtained from a control group undergoing elective surgery, to identify factors common to the surgical process and those specific to urgent surgery. Patients' perceptions of received information were also compared (...) to the information perceived to have been provided by the consent obtainers. Setting—Gastrointestinal surgical service of a university teaching hospital.Patients—Seventy-four consecutive patients undergoing urgent abdominal surgery and 80 control patients undergoing elective surgery. Main measurements—Principal outcome measures were patients' perceptions of factors interfering with the ability to give informed consent, assessment of the quality of informed consent and the degree of discussion of the expected outcomes. Results—Forty-nine of the seventy-four (66%) patients undergoing urgent surgery perceived that pain did not affect their ability to give informed consent. Twenty-seven reported an adverse effect of analgesia on the ability to give informed consent. Only 22% of patients undergoing urgent surgery perceived that there had been any discussion of potential side effects and complications of surgery. Conclusion–The majority of patients in this series with acute intra-abdominal surgical conditions perceive that they retain the ability to give informed consent for surgery. There is a need for improved discussion of therapeutic options and likely outcomes. (shrink)

One of the barriers between ordinarily compassionate animal researchers and pro-animal ethicists is that the ethicists are usually seen as asking for far too much. They are perceived as demanding the complete abandonment of careers. In consequence, the ethicist is often ignored. Ethicists rarely give clear-cut rules to animal researchers as to how they can continue in animal research while at the same time adopting an increasingly moral approach. The purpose of this paper is to provide some rules to help (...) the animals by aiding conscientious researchers who are not in a position to give up their careers entirely. These are ethical rules and not, therefore, in quite the same category as Russell and Burch's or the proposal that experimenters should seek proper training and retraining in animal care, and in the skills of euthanasia, anaesthesia, and analgesia. Nor are ethical rules quite the same as the requirement that all experimenters should acquaint themselves with the latest techniques for improving the animals' quality of life or the need to keep themselves up to date in alternative research techniques that do not use animals. All these steps are of great importance and should be taken in addition to the ethical rules I propose. (shrink)

In late February and early March 2020, Italy became the European epicenter of the COVID-19 pandemic. Despite increasingly stringent containment measures enforced by the government, the health system faced an enormous pressure, and extraordinary efforts were made in order to increase overall hospital beds’ availability and especially ICU capacity. Nevertheless, the hardest-hit hospitals in Northern Italy experienced a shortage of ICU beds and resources that led to hard allocating choices. At the beginning of March 2020, the Italian Society of Anesthesia, (...) Analgesia, Resuscitation, and Intensive Care issued recommendations aimed at supporting physicians in prioritizing patients when the number of critically ill patients overwhelm the capacity of ICUs. One motivating concern for the SIAARTI guidance was that, if no balanced and consistent allocation procedures were applied to prioritize patients, there would be a concrete risk for unfair choices, and that the prevalent “first come, first served” principle would lead to many avoidable deaths. Among the drivers of decision for admission to ICUs, age, comorbidities, and preexisting functional status were included. The recommendations were criticized as ageist and potentially discriminatory against elderly patients. Looking forward to the next steps, the Italian experience can be relevant to other parts of the world that are yet to see a significant surge of COVID-19: the need for transparent triage criteria and commonly shared values give the Italian recommendations even greater legitimacy. (shrink)

One of the main challenges in medicine is to guarantee an appropriate drug supply according to the real needs of patients. Closed-loop strategies have been widely used to develop automatic solutions based on feedback variables. However, when the variable of interest cannot be directly measured or there is a lack of knowledge behind the process, it turns into a difficult issue to solve. In this research, a novel algorithm to approach this problem is presented. The main objective of this study (...) is to provide a new general algorithm capable of determining the influence of a certain clinical variable in the decision making process for drug supply and then defining an automatic system able to guide the process considering this information. Thus, this new technique will provide a way to validate a given physiological signal as a feedback variable for drug titration. In addition, the result of the algorithm in terms of fuzzy rules and membership functions will define a fuzzy-based decision system for the drug delivery process. The method proposed is based on a Fuzzy Inference System whose structure is obtained through a decision tree algorithm. A four-step methodology is then developed: data collection, preprocessing, Fuzzy Inference System generation, and the validation of results. To test this methodology, the analgesia control scenario was analysed. Specifically, the viability of the Analgesia Nociception Index as a guiding variable for the analgesic process during surgical interventions was studied. Real data was obtained from fifteen patients undergoing cholecystectomy surgery. (shrink)

OBJECTIVE: To report and analyse the pattern of end-of-life decision making for terminal Chinese cancer patients. DESIGN: Retrospective descriptive study. SETTING: A cancer clinical trials unit in a large teaching hospital. PATIENTS: From April 1992 to August 1997, 177 consecutive deaths of cancer clinical trial patients were studied. MAIN MEASUREMENT: Basic demographic data, patient status at the time of signing a DNR consent, or at the moment of returning home to die are documented, and circumstances surrounding these events evaluated. RESULTS: (...) DNR orders were written for 64.4% of patients. Patients in pain (odds ratio 0.45, 95% CI 0.22-0.89), especially if requiring opioid analgesia (odds ratio 0.40, 95% CI 0.21-0.77), were factors associated with a higher probability of such an order. Thirty-five patients were taken home to die, a more likely occurrence if the patient was over 75 years (odds ratio 0.12, 95% CI 0.04-0.34), had children (odds ratio 0.14, 95% CI 0.02-0.79), had Taiwanese as a first language (odds ratio 6.74, 95% CI 3.04-14.93), or was unable to intake orally (odds ratio 2.73, 95% CI 1.26-5.92). CPR was performed in 30 patients, none survived to discharge. CONCLUSIONS: DNR orders are instituted in a large proportion of dying Chinese cancer patients in a cancer centre, however, the order is seldom signed by the patient personally. This study also illustrates that as many as 20% of dying patients are taken home to die, in accordance with local custom. (shrink)

As we die, our respiratory pattern is altered and we seem to gasp and struggle for each breath. Such gasping is commonly seen as a clear sign of dyspnoea and suffering by families and loved ones, however, it is unclear whether it is perceived at all by the dying person. Narcotics and sedatives do not seem to affect these gasping respirations. In this issue of the Journal of Medical Ethics, we are asked to consider whether the last gasp of a (...) dying patient could be or, perhaps, even should be avoided by administering neuromuscular blockers to palliate dying patients. For many reasons, such as our current failure to alleviate pain and distress, stories of inadequate analgesia and sedation in critically ill paralysed patients and the inability to know the intent—whether to palliate or to euthanise—it would seem that administering neuromuscular blockers should not be ethically permissible. (shrink)

One of the most commonly referenced ethical principles when it comes to the management of dying patients is the doctrine of double effect (DDE). The DDE affirms that it is acceptable to cause side effects (e.g. respiratory depression) as a consequence of symptom‐focused treatment. Much discussion of the ethics of end of life care focuses on the question of whether actions (or omissions) would hasten (or cause) death, and whether that is permissible. However, there is a separate question about the (...) permissibility of hastening or causing unconsciousness in dying patients. Some authors have argued that the DDE would not permit end of life care that directly aims to render the patient unconscious. The claim is that consciousness is an objective human good and therefore doctors should not intentionally (and permanently) suppress it. Three types of end of life care (EOLC) practices will be explored in this article. The first is symptom‐based management (e.g. analgesia); the second is proportional terminal sedation as a means of relieving suffering (also referred to as palliative sedation or continuous deep sedation); and finally, deliberate and rapid sedation to unconsciousness until death (a practice we call terminal anaesthesia in this paper). After examining the common arguments for the various types of symptom‐based management and sedation, we apply the DDE to the latter two types of EOLC practices. We argue that aiming at unconsciousness, contrary to some claims, can be morally good or at least morally neutral in some dying patients. (shrink)

Despite the fact that the requirement to obtain informed consent for medical procedures is deeply enshrined in both U.S. moral and legal doctrine, empirical studies and anecdotal accounts show that women's rights to informed consent and refusal of treatment are routinely undermined and ignored during childbirth. For example, citing the most recent Listening to Mothers survey, Marianne Nieuwenhuijze and Lisa Kane Low state that "a significant number of women said they felt pressure from a caregiver to agree to having an (...) intervention that they did not want during birth". Specifically, Nieuwenhuijze and Low cite that "19% of women who did not have epidural analgesia felt... (shrink)

Objective: To describe the frequency of support for terminal sedation among internists, determine whether support for terminal sedation is accompanied by support for physician assisted suicide , and explore characteristics of internists who support terminal sedation but not assisted suicide.Design: A statewide, anonymous postal survey.Setting: Connecticut, USA.Participants: 677 Connecticut members of the American College of Physicians.Measurements: Attitudes toward terminal sedation and assisted suicide; experience providing primary care to terminally ill patients; demographic and religious characteristics.Results: 78% of respondents believed that if (...) a terminally ill patient has intractable pain despite aggressive analgesia, it is ethically appropriate to provide terminal sedation . Of those who favoured terminal sedation, 38% also agreed that PAS is ethically appropriate in some circumstances. Along a three point spectrum of aggressiveness in end of life care, the plurality of respondents were in the middle, agreeing with terminal sedation but not with PAS. Compared with respondents who were less aggressive or more aggressive, physicians in this middle group were more likely to report having more experience providing primary care to terminally ill patients and attending religious services more frequently .Conclusions: Support for terminal sedation was widespread in this population of physicians, and most who agreed with terminal sedation did not support PAS. Most internists who support aggressive palliation appear likely to draw an ethical line between terminal sedation and assisted suicide. (shrink)