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E
C
Module 5:
Physician-Assisted Suicide
© EPEC Project, 2003
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E
P
E
C
P
E
C
Physician-Assisted Suicide
Module=
5
![](3D"master08_background.gif")
![](3D"master08_image003.gif")
Objectives . . .
<=
span
style=3D'mso-special-format:bullet;color:#FF3300;position:absolute;left:-4=
.38%'>•Define
physician-assisted suicide (PAS) and euthanasia
<=
span
style=3D'font-weight:normal'>•Describe their current
legal status
•Identify root causes of
suffering that prompt requests
•Understand a 6-step
protocol for responding to requestsPhysician-assisted suicide
/ euthanasia . . .
•A=
ncient
medical issue
•A=
iding
or causing a suffering person’s death
physician-assisted suicide
physician provides the means, patient acts
euthanasia
physician performs the intervention
. .
. Physician-assisted suici=
de /
euthanasia
<=
span
style=3D'font-weight:normal'>•Many physicians receiv=
e a
request
<=
span
style=3D'font-weight:normal'>•Requests are a sign of
patient crisis
Why patients ask for PAS
•A=
sking
for help
•F=
ear
of
psychosocial, mental suffering
future suffering, loss of control, indignity,
being a burden
•D=
epression
•P=
hysical
suffering
The legal and
ethical debate . . .
ethical debate . . .
•P=
rinciples
obligation to relieve pain and suffering
respect decisions to forgo life-sustaining
treatment
•T=
he
ethical debate is ancient
•US
Supreme Court recognized
NO right to PAS
. .
. The legal and
ethical debate
ethical debate
•The
legal status of PAS can differ from state to state
<=
/span>•Oregon is the only sta=
te
where PAS is legal (as of 1999)
<=
span
style=3D'mso-special-format:bullet;color:#FF3300;position:absolute;left:-4=
.21%'>•Supreme
Court Justices supported right to palliative care =
6-step protocol to respond
to requests . . .
l1. Clarify the request
l=
2. Assess the underlying causes of the request
l=
3. Affirm your commitment to care for the
patient
l
. .
. 6-step protocol to respo=
nd to
requests
l=
4. Address the root causes of the request
l=
5. Educate the patient and discuss <=
span
style=3D'position:absolute;top:36.82%;left:7.41%;width:87.71%;height:9.74%=
'>legal
alternatives
l6. Consult with colleagues
Step 1: Clarify the request
•Im=
mediate,
compassionate response
•O=
pen-ended
questions
•S=
uicidal
thoughts, plans?
•Be
aware of
personal biases
potential for counter-transference
Step 2: Assess underlying
causes . . .
•T=
he 4
dimensions of suffering
physical
psychological
social
spiritual
. .
. Step 2: Assess under=
lying
causes
•P=
articular
focus on
fears about the future
depression, anxiety
Assess for clinical <=
span
style=3D'position:absolute;top:51.8%;left:1.09%;width:97.36%;height:49.39%=
'>depression
. . .
•U=
nderdiagnosed,
undertreated
•S=
ource
of suffering
•B=
arrier
to life closure, “good death”
•D=
iagnosis
challenging
no somatic symptoms
helplessness, hopelessness, worthlessness
. .
. Assess for clinical depre=
ssion
•T=
reatment
choices depend on time available
fast-acting psychostimulants
SSRIs
tricyclic antidepressants
Psychosocial
suffering, practical concer=
ns . .
.
•S=
ense
of shame
•N=
ot
feeling wanted
•I=
nability
to cope
•L=
oss
of
function
self-image
control, independence
. . . Psychosocial suffering, practical concerns
•T=
ension
with relationships
•I=
ncreased
isolation, misery
•W=
orries
about practical matters
who caregivers will be
how domestic chores will be tended to
who will care for dependents, pets
Physical suffering
<=
span
style=3D'font-weight:normal'>•Pain
<=
span
style=3D'font-weight:normal'>•Breathlessness
•Anorexia / <=
span
style=3D'font-weight:normal'>•Weakness / fatigue
=
;
<=
span
style=3D'font-weight:normal'>•Nausea / vomiting
<=
/span>
<=
span
style=3D'font-weight:normal'>•Constipation
<=
span
style=3D'font-weight:normal'>•Dehydration
<=
span
style=3D'font-weight:normal'>•Edema
<=
span
style=3D'font-weight:normal'>•Incontinence
Spiritual suffering
•E=
xistential
concerns
•M=
eaning,
value, purpose in life
•A=
bandoned,
punished by God
questions faith, religious beliefs
anger
Common fears
Step 3: Affirm your <=
span
style=3D'position:absolute;top:51.8%;left:1.09%;width:97.36%;height:49.39%=
'>commitment
<=
span
style=3D'font-weight:normal'>•Listen, acknowledge
feelings, fears
Step 4: Address root =
causes
•P=
rofessional
competence in:
withholding, withdrawal
aggressive comfort measures
palliative care principles
local palliative care programs
•A=
ddress
suffering, fears
Address psychological suffering
•T=
reat
depression
anxiety
delirium
•I=
ndividual,
group counseling
•S=
pecialty
referral as appropriate
Address
social suffering, pract=
ical
concerns . . .
. . . Address social suffering, practical concerns
<=
span
style=3D'font-weight:normal'>•Who will care for
dependents, pets
Address
physical suffering
physical suffering
•A=
ggressive
symptom management
•E=
ngage
physical, occupational therapy
exercises
aids to optimize function
Address
spiritual suffering
spiritual suffering
•E=
xplore
prayer
transcendental dimension
meaning, purpose in life
life closure
gift giving, legacies
•C=
onsult
chaplain, psychiatrist, psychologist
Address fear of
loss of control . . .
loss of control . . .
•E=
xplore
areas of control, independence
•R=
ight
to determine one’s own medical care
accept or refuse any medical intervention
=
life-sustaining therapies
. .
. Address fear of
loss of control
loss of control
•S=
elect
personal advocate(s)
proxy for decision-making
•P=
repare
advance directives
•P=
lan
for death
•M=
ake
a commitment to help patient maintain as much control as possible=
Address fear of
pain, other symptoms
pain, other symptoms
•E=
xplain
about
control of pain, other symptoms
sedation for intractable symptoms
•C=
ommitment
to manage symptoms
Address fear of
being a burden
being a burden
•E=
stablish
specifics
worry about caregiving
family willing
alternate settings
worry about finances
resources, services available
•R=
efer
to a social worker
Address fear of indignity
•D=
iscuss
what indignity means to the individual
dependence, burden, embarrassment
•I=
mportance
of control
•E=
xplore
resources to maintain dignity
•R=
eassure
patient
Address fear of abandonment
•Assurance
that physician will continue to be involved in care
=
•Resources provided by
hospice and palliative care
Step 5: Educate, discuss legal
alternatives
Decline oral intake . . .
<=
span
style=3D'font-weight:normal'>•Any person can decline
oral intake
. . .
Decline oral intake
•A=
ccept
/ decline artificial hydration, nutrition
•E=
ducate,
support family members, caregivers
refocus their need to give care
End-of-life sedation . . .
•When
symptoms are intractable at the end of life
• Continuous,
intermittent
•Death attributed to
illness, not sedation
. . .
End-of-life sedation
Step 6: Consult with =
colleagues
•Seek
support from trusted colleagues
<=
span
style=3D'font-weight:normal'>•Reasons for reluctance=
to
consult
End of Module 5:
Physician Assisted Suicide
Review Fast Facts
Complete Module 5 Post Assessment
‹header›
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‹#›
Some physicians have received on=
e or
more requests to help a patient end his or her life prematurely. This modu=
le
focuses on the skills that the physician can use to respond both
compassionately and with confidence to a request, not on the merits of arg=
uments
for oragainst legalizing physician-assisted suicide (PAS) or euthanasia, b=
ut using
solid clinical skills. To respond effectively, physicians must know the
reasons why patients ask for
assistance. Depression, psychosocial fact=
ors,
and anticipated distress are common reasons, but current physical suffering
can also be a factor. Physicians need to be able to assess the root causes=
of
the specific request, make a commitment to the patient’s care, addre=
ss
each of the patient’s sources of suffering, educate the patient about
legal alternatives, and seek counsel from colleagues. The vast majority of
requests for PAS or euthanasia should abate when approached in this way.&#=
13;
Key words
abandonment, burden, consultation, control, deliberation, depression, dign=
ity,
euthanasia,
fears, listening, pain, physician-assisted suicide,
psychological, social, spiritual, suffering
Suffering has always been a part=
of
human existence. Requests to end suffering by means of death through both
physician-assisted suicide and euthanasia have occurred since the beginnin=
g of
medicine. Based on a recent study, 57% of physicians practicing today have
received a request for physician-assisted suicide in some form or
another.
While unrelieved physical suffering may have been greater in =
the
past, modern medicine now has more knowledge and skills to relieve sufferi=
ng
than ever before. Today, specialists in palliative care believe that if all
patients had access to careful assessment and optimal symptom control and
supportive care, the suffering of most patients with life-threatening
illnesses could be reduced sufficiently to eliminate their desire for
hastened
death. Even when the desire persists, avenues other than
physician-assisted suicide or euthanasia are available to remedy suffering=
and
avoid prolonging life against the patient’s wish.
This module presents an approach=
for
responding to such requests, both compassionately and competently. The focus is not on the debate to legalize PAS or euthanasia, but rather on the practical=
steps
that a physician can take to =
assess
the patient’s request, address the root causes of the request, and ensure that the best quality of
end-of-life care is practiced=
.
=
Patients ask physicians about
physician-assisted suicide (PAS) for a variety of reasons. It is a rare
patient with a life-threatening illness who doesn’t think about suic=
ide,
if only in passing. Some patients may approach the physician about PAS wit=
h the
intent of “thinking out loud” about their response to their
present and anticipated future. Others may raise the question based on
lifelong values. For some, a request for PAS is sign of patient crisis whe=
re
unmet needs have built up and result in this plea for help. For all patien=
ts,
the request for PAS should prompt the physician to assess the reasons for =
the
request. Patients make requests for many different reasons that usually ar=
ise
from physical, psychological, social, or spiritual suffering, or practical=
concerns.
For some patients, the request is the first expression of unrelieved
suffering.
Each person will have a unique set of needs and reasons why he or she would
like to hasten death. While more research is needed, available data suppor=
t a
few generalizations. In all surveys, unrelieved psychosocial and mental
suffering is the most common stimulus for requests. In one study patients =
who
were depressed were 4 to 5 times more likely to have made serious inquiries
about PAS or euthanasia. Fear of future suffering, loss of control, indign=
ity,
or being a burden are also prominent reasons for requests.
Physical
suffering, including pain, is a less frequent motivator than many think. In
one study, pain alone was a motivator in 3% of requests, pain was one of
several motivators in 46% of requests, and in the remaining 51% of requests
pain was not cited as a factor at all. Nonetheless, the contribution of
physical suffering is important. Its
As the current debate unfolds, there are 2 principles on which virtually a=
ll
agree. First, physicians have an obligation to relieve pain and suffering =
and
to promote the dignity of dying patients in their care. Second, the princi=
ple
of patient bodily integrity requires that physicians respect patients̵=
7;
competent decisions to forgo life-sustaining treatment.
An
important event in the present debate occurred in 1997, when the US Suprem=
e Court
recognized no federal constitutional right to physician-assisted suicide b=
ut
did affirm that state legislatures may choose to legalize it. As of early
1999, Oregon is the only state that has voted to legalize PAS.
In contrast to the PAS debate, the right to palliative care is uniformly
acknowledged. The same US Supreme Court Justices’ concurring opinions
supported the right of all Americans to receive quality palliative care.&#=
13;
anticipation is a common motivator and because it is treatable.
<=
/div>
The debate about the legalizatio=
n of
active steps to intentionally end life as a means to end suffering remains
controversial. Modern history suggests that the topic comes up for intense
attention periodically. Because of the added risk of misunderstanding or o=
verriding
the patient’s wishes, there is currently less support for euthanasia
than for physician assisted suicide. Nonetheless, both requests do occur a=
nd
physicians need to know how to
respond to either type of request.
In any discussion of physician-assisted suicide or euthanasia, it is impor=
tant
that the terminology be clear. Euthanasia is defined as “the act of
bringing about the death of a hopelessly ill and suffering person in a
relatively quick and painless way for reasons of mercy”. Although they may have similar goals, physician-assisted suicide and&=
#13;
euthanasia differ in whether or not the physician participates in the acti=
on
that finally ends
life:
Physician-assisted suicide: The physician provides the necessary me=
ans
or information
and the patient performs the act.
Euthanasia: The physician performs the intervention.
Professional competence
As most physicians are likely to receive a request for hastened death, eve=
ry
physician must be capable of dealing with these difficult requests in a way
that responds to the needs and expectations of the patient and offers the =
best
possible care that is both ethical and legal.
The ability to respond to
requests for hastened death with realistic alternatives requires a working
knowledge of all aspects of palliative care. The physician must follow usu=
al
standards for information giving, know how to provide aggressive symptom
control and supportive care, and be skilled at approaches to withdraw or w=
ithhold
life-sustaining interventions.
As effective approaches for responding =
to
suffering may be time consuming, physicians will be more effective if they
work collaboratively with other health care disciplines, ideally in an
interdisciplinary team. As some requests for PAS or euthanasia can be inte=
nse,
even for physicians who are skilled and experienced, access to consultative
palliative care expertise, both physicians and programs, as part of the sp=
ectrum
of contemporary health
care is essential.
When a request for hastened deat=
h is
first received, listen carefully to the nature of the request. Ask open-en=
ded
questions in a calm and nonjudgmental manner to elicit specific information
about the type of request that is being made and the underlying causes for=
it.
While some physicians fear that talking about suicide or hastened death wi=
ll
increase the likelihood that the patient will act, this fear has not been =
substantiated.
An open discussion is more likely to reduce the intensity of the request.&=
#13;Once
the underlying reasons are known, more directed questions can be asked. Se=
veral
examples, and the common areas to which answers may point, follow:
MD: “What makes you ask that?”
- desire for a
pain-free death
- control over the dying process
MD: “What do you expect will happen without PAS?”
As this dimension often lies outside of the areas most physicians feel
confident in addressing, consider requesting assistance from other members=
of
the health care team (eg,social work, nursing, chaplains, occupational
therapy, etc). Additional resources for help and support may be available =
in
the community, through a health care institution, or from a local hospice =
or
palliative care program.
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var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram=
es", gIsEndShow=3D0, NUM_VIS_SLDS=3D39, SCRIPT_HREF=3D"script.js", FULLSCR_=
HREF=3D"fullscreen.htm";
var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO=
tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true
window.gPPTHTML=3DSupportsPPTHTML()
var gMainDoc=3Dnew Array(new hrefList("slide0029.htm",1,-1,1),new hrefList(=
"slide0002.htm",1,-1,1),new hrefList("slide0003.htm",1,-1,1),new hrefList("=
slide0032.htm",1,-1,1),new hrefList("slide0005.htm",1,-1,1),new hrefList("s=
lide0004.htm",1,-1,1),new hrefList("slide0033.htm",1,-1,1),new hrefList("sl=
ide0006.htm",1,-1,1),new hrefList("slide0034.htm",1,-1,1),new hrefList("sli=
de0007.htm",1,-1,1),new hrefList("slide0008.htm",1,-1,1),new hrefList("slid=
e0036.htm",1,-1,1),new hrefList("slide0035.htm",1,-1,1),new hrefList("slide=
0037.htm",1,-1,1),new hrefList("slide0010.htm",1,-1,1),new hrefList("slide0=
038.htm",1,-1,1),new hrefList("slide0039.htm",1,-1,1),new hrefList("slide00=
13.htm",1,-1,1),new hrefList("slide0011.htm",1,-1,1),new hrefList("slide001=
4.htm",1,-1,1),new hrefList("slide0015.htm",1,-1,1),new hrefList("slide0016=
.htm",1,-1,1),new hrefList("slide0017.htm",1,-1,1),new hrefList("slide0040.=
htm",1,-1,1),new hrefList("slide0023.htm",1,-1,1),new hrefList("slide0024.h=
tm",1,-1,1),new hrefList("slide0020.htm",1,-1,1),new hrefList("slide0041.ht=
m",1,-1,1),new hrefList("slide0022.htm",1,-1,1),new hrefList("slide0018.htm=
",1,-1,1),new hrefList("slide0021.htm",1,-1,1),new hrefList("slide0019.htm"=
,1,-1,1),new hrefList("slide0025.htm",1,-1,1),new hrefList("slide0026.htm",=
1,-1,1),new hrefList("slide0042.htm",1,-1,1),new hrefList("slide0027.htm",1=
,-1,1),new hrefList("slide0043.htm",1,-1,1),new hrefList("slide0028.htm",1,=
-1,1),new hrefList("slide0044.htm",1,-1,1));
/*********************************************
Frameset functions
These functions control slide navigation
and state of the frameset.
**********************************************/
function FullScrInit()
{
g_allowAdvOnClick =3D GetCurSld().mAdvOnClk
document.body.style.backgroundColor=3D"black"
document.oncontextmenu=3Dparent._CM;
document.onkeydown =3D _KDH;
document.ondragstart=3DCancel
document.onselectstart=3DCancel
self.focus()
}
function Redirect( frmId )
{=09
var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId()
if(idx>=3D0) str=3Dstr.substr(1);
if( window.name !=3D frmId && ( sId !=3D str) ) {
obj =3D GetObj("Main-File")
window.location.href=3Dobj.href+"#"+sId
return 1
}
return 0
}
var MHTMLPrefix =3D CalculateMHTMLPrefix();=20
function CalculateMHTMLPrefix()
{
if ( document.location.protocol =3D=3D 'mhtml:') {=20
href=3Dnew String(document.location.href)=20
Start=3Dhref.indexOf('!')+1=20
End=3Dhref.lastIndexOf('/')+1=20
if (End < Start)=20
return href.substring(0, Start)=20
else=20
return href.substring(0, End)=20
}
return '';
}
function GetTags(base,tag)
{
if(g_supportsPPTHTML) return base.all.tags(tag);
else return base.getElementsByTagName(tag);
}
function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP=
refix+GetHrefObj( gCurSld ).mNtsHref ) }
function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() }
function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() }
function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() }
function SetHasNts( fVal )
{
if( gHasNts !=3D fVal ) {
gHasNts=3DfVal
UpdNavPane()
}
}
function ToggleOtlText()
{
gOtlTxtExp=3D!gOtlTxtExp
UpdOtlPane()
}
function ClearMedia()
{
// Clear any sounds playing before launching another browser window. Other=
wise,
// in fullscreen mode, you'll continue to hear the sound in the frames mod=
e.
if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0;
}
function FullScreen()
{=20
if ( PPTSld.g_animUseRuntime )
PPTSld.document.body.pause();
ClearMedia();
var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF =
: FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref;
if(PPTNav.event.ctrlKey) {
var w =3D (window.screen.availWidth * 1.0) / 2.0
var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW
win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top=
=3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
else
{
win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
}
function ToggleVNarration()
{
rObj=3DPPTSld.document.all("NSPlay")
if( rObj && !PPTSld.g_animUseRuntime ) {
if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) )
rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{ =20
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else =20
return gCurSld
}
function GetNumSlds()
{ =20
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
=09
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln(' 0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
/*********************************************
Navigation button implementation
There are 2 types of buttons: ImgBtn, TxtBtn
implemented as function objects. They share
a similiar interface so the event handlers
can call SetActive, for example, on a button=20
object without needing to know exactly=20
what type of button it is.
**********************************************/
//----------------------------------
function ImgBtn( oId,bId,w,action )
//----------------------------------
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0=20
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{ =20
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0=20
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
//-----------------------------------------
function TxtBtn( oId,oeId,action,chkState )
//-----------------------------------------
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{ =20
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {=20
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
} =20
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1=20
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etPressed() }
function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval"
function ShowMenu()
{
BuildMenu();
var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=
=3DPPTSld.event.clientY+doc.scrollTop
m =3D PPTSld.document.all.item("ctxtmenu")
m.style.pixelLeft=3Dx
if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
m.style.pixelLeft=3Dx-m.scrollWidth
m.style.pixelTop=3Dy
if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
m.style.pixelTop=3Dy-m.scrollHeight
m.style.display=3D""
}
function _CM()
{
if( !parent.IsFullScrMode() ) return;
if(!PPTSld.event.ctrlKey) {
ShowMenu()
return false
} else
HideMenu()
}
function BuildMenu()
{
if( PPTSld.document.all.item("ctxtmenu") ) return
var mObj=3DCreateItem( PPTSld.document.body )
mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
var s=3DmObj.style
s.position=3D"absolute"
s.cursor=3D"default"
s.width=3D"120px"
SetCMBorder(mObj,"menu","black")
var iObj=3DCreateItem( mObj )
SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
=09
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
mObj.style.visibility=3D"visible"
}
function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa=
lue=3Dfalse }
function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() )
e.Action()
else
PPTSld.event.cancelBubble=3Dtrue
}
function ChangeClr( bg,clr )
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() ) {
e.style.backgroundColor=3Dbg
e.style.color=3Dclr
}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();=
PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
{
var e=3DCreateItem( node )
e.type=3D"menuitem"
e.Action=3Daction
e.IsActive=3Deval
e.innerHTML=3Dtext
if( !e.IsActive() )
e.style.color=3D"threedshadow"
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------=_NextPart_01C7D4F3.672E0880
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Module 5
------=_NextPart_01C7D4F3.672E0880--
- understanding and expectations of the illness
As you listen to the answers, use the therapeutic effect of empathic
listening. Avoid endorsing the request for PAS in a way that confirms the
patient’s perception that his or her life is worthless. Remember that
empathizing is not the same thing as agreeing. Premature affirmation of any
perspective can propel both parties to stark choices.
Be open to the possibility that your personal reactions to the patientR=
17;s
suffering may give insight into his or her experience. If the physician fe=
els
weighed down by meeting with the patient, perhaps the patient is
depressed.
Only when the patient’s point of view has been characterized will it=
be
possible to talk about what suffering means to the patient and what assura=
nces
can or cannot be given.
- expectation of what dying will be like
MD: “What type of assistance do you want?”
- pills, injection
MD: “Who do you want to be involved? Why?”
- self, family member, physician
MD: “When do you think you want to die?”
- now
- at some later point
MD: “What do you hope to accomplish?”
- freedom from pain, disability, bankruptcy, dependency,
indignity
- removing burden on others
The answer to the question, “When do you think you want to die?̶=
1;
will provide some indication of acuity. “What do you hope to
accomplish?” will provide some understanding of the patient’s
reasoning and what he or she is hoping for. During the course of the
questioning, it is particularly important to learn whether the patient is =
imagining
a future that is either unlikely or easily preventable.
Personal biases
To respond effectively to the needs of the patient, the physician must be
aware of his or her own biases and the potential for countertransference. =
If
the idea of suicide is offensive to the physician, the patient may feel hi=
s or
her disapprobation and worry about abandonment.
Conversely, if the
physician feels it would be best for everyone if the patient were to die s=
oon
then the patient may sense this and become more concerned about being an u=
nwelcome
burden.
A request for PAS may indicate a failure to address the full scope of=
a
patient’s needs.
Focus on all 4 dimensions of physical, psychological, social, and spiritual
suffering as well as practical concerns (see Module Whole Patient Assessment; Pain Management; Depression, Anxiety, Delirium; Go=
als of
Care; and
Common Physical Symptoms).
Among all the psychological and physical possibilities, give particular
consideration to the possibility of clinical depression or anxiety, as
research indicates correlation between requests and their presence. When
evaluating psychological and social issues, explore the patient’s fe=
ars
about his or her future.
Clinical depression occurs frequ=
ently
and is both underdiagnosed and undertreated. It can be a source of intense
mental suffering and a barrier to completing life closure and achieving a
“good death.”
Diagnosis of depression is more challenging in patients with advanced illn=
ess,
since the physical symptoms typically associated with depression (eg, chan=
ges
in appetite, weight, energy level, libido, or sleeping) frequently occur in
these patients as a result of their illness.
Studies have shown that t=
he
screening question, “Do you feel depressed most of the time?” =
is
highly sensitive and specific in the medically ill.
Feelings of pervas=
ive
helplessness, hopelessness, and worthlessness are not normal. Do not assume
they are situational and leave them unattended.
Emotional and coping responses to
life-threatening illness may include a strong sense of shame, feelings of =
not
being wanted, and/or inability to cope. Adjustment to the loss of previous
function, independence, control, and/or self-image may be difficult. Each
change may lead to tensions within relationships that further increase
isolation and misery.
Worries about practical matters (eg, who the
caregivers will be, how domestic chores will be done, who will care for
dependents and pets, etc) can create considerable distress. If support is =
not
forthcoming or is insufficient, suffering may ensue or increase.
A host of physical issues may ac=
company
advanced illness. These may include pain, breathlessness, anorexia/cachexi=
a,
weakness/fatigue, nausea/vomiting, constipation, dehydration, edema,
incontinence, loss of function, sleep deprivation, etc. Their presence,
particularly if they are unmanaged for long periods, may markedly increase=
suffering.
The prospect of dying may evoke
seemingly unresolvable existential concerns that are then experienced as
suffering. As illness advances and disability increases, the patient’=
;s
sense of his or her meaning, value, and purpose in life may all come into =
question.
If there is a sense of abandonment or punishment by God, faith and religio=
us beliefs
may be eroded and anger may ensue. Approaches to the assessment of spiritu=
al issues
are covered in Module: Whole Patient Assessment.
In addition to current concerns,=
many
patients are fearful about what the future will be like. They worry about =
pain
and other symptoms, loss of control or independence, abandonment, loneline=
ss,
indignity, loss of self-image, and being a burden to others. While their
thoughts may be unrealistic in the setting of quality care, many have witn=
essed
suboptimal care in others that fuels their fears and fantasies.
Direct
questions may be adequate to assess a patient’s fears. If not,
discussing a series of scenarios and preferences, as is done during advance
care planning, may be helpful. When personal values and goals of care are
being discussed, clarify the things the person most wants to avoid. This m=
ay
help to preempt unrealistic fears
Patients facing the end of life =
often
have fears of abandonment. Listen to and acknowledge expressed feelings and
fears. Make a commitment to help find solutions to the issues of concern, =
both
current and anticipated. Reinforce that you want to continue to be the
patient’s physician until the last possible moment. Explore options =
to
allay immediate concerns and fears.
This section provides a general
framework for addressing some of the potential root causes for a request f=
or
hastened death in each dimension of suffering. Start by discussing the
patient’s health care goals and preferences, explaining palliative c=
are approaches
and services, and describing the legal alternatives to PAS. Remember that =
some
patients may not trust either individual health caregivers or the health c=
are system
to meet their needs.
This may relate either to culture or to past
experiences. It helps to discuss this lack of trust with the patient at the
outset, so that the issues can be understood, if not dealt with, early.=
3;
As psychosocial suffering leads =
to many
of the requests for physician-assisted suicide or euthanasia, its manageme=
nt
warrants considerable attention. Start by assessing and managing any
depression, anxiety, or delirium aggressively
As each patient’s emotional
response to illness can be profound and coping responses varied, they will
require careful exploration in a positive and understanding way. Supportive
counseling, which involves active listening and acknowledgment of the pati=
ent’s
feelings, may be woven into general care, or it may be provided more inten=
sively
through dedicated individual or group counseling. Social workers and chapl=
ains
trained in supportive
counseling can provide considerable assistance.
Referral to trained counselors, psychotherapists may be required if the is=
sues
are complex and/or the risks high.
Stresses and conflicts in the so=
cial
dimension or practical aspects of a person’s life can have profound
effects on his or her will to live. Express interest and inquire in detail=
about
this aspect of the patient’s life:
· What is the patient’s family situation? Does he or she
live with someone? Are family
members supportive? Are there unresolved issues?
· How is the patient’s financial situation? Is health
insurance available and sufficient?
· Are legal affairs in order? Does the patient have a living w=
ill,
power of attorney for
health care, power of attorney for business affairs, last will and
testament?
· Where would the patient like to receive care? Who is there to
help? Who will the
caregivers be? Is there tension over the caregiving role for either
party?
· Who attends to domestic chores such as cooking, cleaning,
shopping, banking, bill
payments?
· Are there any dependents the patient cares for, or pets? Who
will care for them if the
patient is not able to?
The spiritual dimension of human
experience is universally challenged in the face of a lifethreatening
=
illness.
Each person has a sense of meaning and purpose to his or her life, and a s=
ense
of where he or she fits into the grand scheme of things. This may have a
frankly religious orientation or they may be expressed through faith or a
personal sense of spirituality. Nevertheless, the transcendental dimension=
is
present in each one of us, and it is critical that this dimension be explo=
red
when a patient requests PAS or euthanasia.
Helping patients to establi=
sh
or reestablish a sense of meaning and purpose is often fundamental to the
relief of spiritual suffering. Encouraging them to reminisce with family a=
nd
friends; assisting with life closure, gift giving, and creation of legacie=
s may
also be helpful.
Some physicians feel comfortable dealing with spiritu=
al
suffering. Others feel inexperienced and out of their depth. As these issu=
es
are critical and may be very time consuming, a skilled hospice chaplain who
works with a psychiatrist or psychologist skilled in end-of-life care may
bring considerable skill and support to both the patient and the
physician.
While it would be ideal if the needed skills came from the
patient’s own pastor, do not assume that all members of the clergy a=
re
equally comfortable with the care of patients with advanced life-threateni=
ng
illness. Like physicians, many have not received adequate training in
chaplaincy issues and are ill equipped to deal with the profound conflicts
surrounding requests for physician-assisted suicide or euthanasia.
The autonomy and control that ea=
ch one
of us has over our lives and affairs is central to our personhood. While t=
his
need for control varies in some cultures, it is a central feature of Weste=
rn
society. For many, independence is profoundly challenged by illness that is
debilitating and deprives them of mastery or control over their day-to-day
activities and their sense of future.
This fear of loss of control may=
be
further heightened by fears that their expectations and needs won’t =
be
addressed, or fears that people will do things to them that they don’=
;t
want (eg, forced feeding, invasive procedures, life-sustaining therapies,
etc).
The specific issues that are most
important for each person to control are unique to that individual. They m=
ay
include a whole range of issues, including the ability to choose day-to-day
activities and experiences that are meaningful, choices for therapies,
settings of care, caregivers, etc.
The physician can be instrumental in
helping the patient to continue to realize as much control as possible, gi=
ven
the changes in function that are likely to occur. This may take unusual
flexibility on the part of the physician and the health care team. Educate=
and
help the patient plan for aspects of medical care that are rightfully unde=
r his
or her control (eg, the ability to accept or refuse any medical interventi=
on,
life-sustaining therapies, etc).
Encourage the patient to select perso=
nal
advocates and proxy decision makers, prepare advance directives, and plan =
for
death. This planning can include funeral plans, wills, and disposing of
personal belongings after death. Teach family members and caregivers alter=
nate
approaches to caregiving that optimize patient participation in decision
making, ie,instead of “doing without asking,” encourage family=
and
caregivers to “ask before doing.”
While patients may find current =
symptoms
acceptable, they frequently fear a future where symptoms will be out of
control and unbearable, particularly when they are dying. Reassure the pat=
ient
that almost all symptoms can be well controlled. As appropriate, discuss
alternate approaches to symptom management, including anesthesia. Ensure t=
hat
patients and families know that pain does not get suddenly worse as death
approaches. Help them
to understand the difference between pain and
terminal delirium, particularly if they have known someone else who had a
difficult death. As many patients fear adverse effects of medications,
particularly drowsiness and confusion, discuss their management should they
occur.
The possibility of end-of-life sedation, should pain or other
symptoms be unbearable for the patient and unmanageable by experts, may be
explored with the patient and family during advance care planning discussi=
ons.
Some patients and families will find the possibility reassuring; others wi=
ll
not want to consider it.
Most importantly, during all of these
discussions, make a commitment to keep working to manage the symptoms until
they are satisfactorily controlled. Patients fear being told, “IR=
17;m
sorry, there’s nothing more I can do.”
In several studies, one of the t=
hings
patients fear most about a life-threatening illness is the prospect of bei=
ng a
burden to others. This is, in some ways, a corollary of the fear of losing
control, particularly as our culture generally does not value being depend=
ent
on others.
Try to establish why the patient does not want to be a burd=
en.
If there are caregiving issues, facilitate a discussion between the patient
and family. In many cases, families are willing and eager to care for the
patient, and their desires simply remain unspoken. If patients and families
are worried that family members will not have enough skill to provide adeq=
uate
care, suggest home hospice care. This is the fundamental goal of the home
hospice team, to help educate, train, and supplement the family in the car=
e of
the patient.
Alternate care settings can be arranged as a backup if ca=
re
at home does not go as planned. Home hospice agencies must make provisions=
for
brief periods of respite care if it is needed. If there are financial issu=
es,
help the patient find information and resources that will be
acceptable—many people are unaware of the services available. Social
workers and nurses, who can help find solutions to issues and provide trai=
ning
and backup to unskilled family members, can be a significant resource to t=
he physician
to help lessen the patient’s fear of being a burden.
Patients may fear the loss of th=
eir
dignity. As this is a complex concept that may include elements of being
dependent, loss of control, being a burden, being embarrassed, etc, explore
what it means to the particular patient.
Once the issues are clear,
explore approaches to caring and resources that can help to maintain digni=
ty.
Ensure that the patient, where possible, participates in decision making.
Ensure that family members and caregivers know how to approach and address
these issues. Ensure that everyone has permission for their roles and each
task that they will do. Reassure the patient that he or she has dignity in
your eyes.
For some patients, their worst p=
ossible
fear is abandonment—by families, their friends, their physicians, or
other health care professionals. This fear can be heightened by the
realization that others cannot cope with the illness and the changes it
brings, or the role of being a caregiver.
Explore this fear in detail =
with
the patient and family in a family conference. Try to establish how realis=
tic
the patient’s concerns may be. If tensions seem high or there are
indications that family and friends are not coping, a meeting with everyone
may be helpful to assess the situation. If caregiving is becoming onerous,
offer a respite break or an alternate setting for care. As appropriate, tr=
y to
connect families to available supports in
the community, particularly
those provided by the interdisciplinary teams available through hospice and
palliative care programs.
Above all, when addressing fear of abandonme=
nt,
the physician must be able to honestly reassure the patient about his or h=
er
plans for being involved in ongoing care.
Deal with misconceptions
When making a request for PAS, patients may have misconceptions about the
benefits of their requested course of action. Some may be unaware of what
emotional effort goes into planning for physician-assisted suicide or
euthanasia; others may be unaware of the risk of emotional consequences to
family and friends, and to the personal legacy they hope to protect.
Legal alternatives
Patients may also not be aware of the legal alternatives available to them.
This may be particularly true if they have not participated in discussions=
to
clearly define their goals of care and treatment priorities. As part of the
process of discussion, planning, and decision making, the physician may wi=
sh
to discuss the 4 following legal alternatives to PAS
Refusal of intervention
Patients should be clear that they have the right to consent to, or declin=
e,
any intervention (eg, surgery, chemotherapy, pacemakers, ventilators,
medications including antibiotics, IV fluids) or settings of care (eg,
hospitalization) if any of them seem too burdensome. They should also be a=
ware
that their choices to decline particular therapies will not affect their
ability to receive high-quality end-of-life care (see Module : Sudden
Illness).
Withdrawal of treatment
Patients should be clear that they have the right to stop any treatment at=
any
time. This includes the cessation of fluid and nutrition, either enterally=
or
parenterally. Again, they should know that their choices to withdraw
particular therapies will not affect their ability to receive high-quality
end-of-life care.Patients with advanced disease o=
ften
lose appetite and/or thirst. Just like any other medical decision, a compe=
tent
individual can determine what goes into his or her mouth. Based on the
principle of bodily integrity, force-feeding is not acceptable.
To ass=
ist
with decision making, patients will usually benefit from knowledge that th=
ey will
not suffer from dehydration or starvation. A detailed discussion of their =
potentially
protective properties and the appropriate management of symptoms should th=
ey
occur will usually allay fears and reduce anxiety considerably.
As fluids and food are synonymou=
s with
life, and culturally ingrained, family and caregivers will likely need
considerable education and support if the patient decides to cease oral
intake. Encourage them to always have food and water accessible so that the
patient can change his or her mind at any time. Discuss the potential for
anger and resentment if they persist in badgering or attempting to force
things on the patient. Above all, recognize their desire and need to give =
care
and refocus them on activities that will be beneficial to everyone.
For the rare patient with unbear=
able and
unmanageable pain, or other intractable symptoms, who is approaching the l=
ast
hours or days of his or her life, the induction and maintenance of a state=
of
sedation may be the only remaining option. Sedation in the imminently dyin=
g is
intended to produce a level of obtundation sufficient to relieve suffering
without hastening death. This approach has an ethical basis that derives f=
rom
the importance of intended effect over possible secondary and unintended
consequences. (See Common Physical Symptoms for a discussion of intended
effects and unintended consequences.)
Before end-of-life sedation is
considered, it should be clear to the attending physician, members of the
health care team, and consultants with expertise in palliative care that a=
ll
available therapies have been tried to their limits without benefit.
Individual physicians should not consider this issue without consulting
others. This is not an alternative to high-quality palliative care or
limitations in available resources imposed by institutions or health
care funders.
If no other options are apparent,
consider how the patient and family might react to this option. Advance ca=
re
planning discussions and recent statements they have made may provide
guidance. If the team feels that the patient and family will not perceive =
the
discussion as a sign of abandonment, discuss the option with them and soli=
cit
their opinion.
Before making a decision, it should be clear to everyone
that the intent in offering sedation is to make the patient comfortable du=
ring
the last days of his or her life when all other alternatives have not been
successful. If anyone perceives that the intent of sedation is to kill the
patient and not simply relieve suffering, the approach should not be pursu=
ed.
If the patient and family find the option acceptable and the patient
chooses to receive sedation, intermittent or continuous intravenous or
subcutaneous infusions of midazolam, lorazepam, propofol, or barbiturates =
have
been used successfully to induce sedation and reduce awareness.
Opioids
are not recommended if the primary goal is to induce sedation. However, if=
the
patient has been in pain, opioids will need to be continued so that the
sedated patient will not experience pain. Follow standard opioid dosing
guidelines and alter doses if renal clearance decreases.
If the patient
dies while receiving sedation and appropriate doses of medication were use=
d,
the death is attributable to the underlying illnesses, not the sedation.&#=
13;
A request for physician-assisted=
suicide
may be one of the most challenging situations a physician will face in his=
or
her practice of medicine.
Unfortunately, it is in precisely these
situations that physicians may hesitate to involve someone else. There may=
be
several reasons for such reluctance. For some the subject raises personal
issues. Others may have the conviction that it is not appropriate to talk =
about
death. A few may be reluctant to discuss requests for physician-assisted
suicide or euthanasia because of the legal implications of the situation.&=
#13;As
requests for hastened death can have considerable personal, ethical, and l=
egal
ramifications, they should not be dealt with in isolation, but rather with=
the
support and input of at least one trusted colleague or advisor. This person
may be a mentor, a peer, a religious advisor, or an ethics consultant.
Physicians may also find considerable support from nurses, social workers,
chaplains, and other members of the interdisciplinary team who are involve=
d in
the patient’s care.
' + ENDSHOW_MESG + '
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