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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 5: Physician-Assisted Suicide Debate
    A Six Step Protocol

    Step 5: Educate the Patient About Legal Alternatives for Control and Comfort Step 6: Seek Counseling From Trusted Colleagues and Advisors

    Step 5: Educate the Patient About Legal Alternatives for Control and Comfort

    Dealing 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
      • The personal legacy they hope to protect

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    Legal Alternatives to PAS

    • 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 wish to discuss the 4 following legal alternatives to PAS:

    Refusal of Treatment

    • Patients should be clear that they have the right to consent to, or decline, any:
      • Treatment (e.g., surgery, chemotherapy, pacemakers, ventilators, medications including antibiotics, IV fluids)

      • Settings of care (e.g., hospitalization)
    • They should also be aware that their choices to decline particular therapies will not affect their ability to receive high quality end-of-life care

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    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

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    Declining Oral Intake

    • Patients should be clear that they may choose to decline regular oral intake of food and/or fluids. Just like any other medical decision, a competent individual can determine what goes into his or her mouth
    • Based on the principle of bodily integrity, force-feeding is not acceptable
    • To assist with decision-making, patients will usually benefit from knowledge that he or she will not suffer from dehydration or starvation
      • A detailed discussion of their potentially protective properties and the appropriate management of symptoms should they occur will usually allay fears and reduce anxiety considerably

    • As fluids and food are synonymous 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

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    End-of-Life Sedation

    • For the rare patient with unbearable and unmanageable pain, or other intractable symptoms, who is approaching the last 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 dying is intended to produce a level of obtundation sufficient to relieve suffering without hastening death

      • This approach has a firm ethical basis that derives from the importance of intended effect over possible secondary and unintended consequences. (See Module 10: 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 all 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. As a guide, use evidence from:
      • Advance care planning discussions
      • Recent statements they have made
    • If the team feels that the patient and family will not perceive the discussion as a sign of abandonment
      • Discuss the option with them
      • Solicit their opinion
    • Before making a decision:
      • It should be clear to everyone that the intent in offering sedation is to make the patient comfortable during 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 pursued
    • 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

    • If the patient dies while receiving sedation and appropriate doses of medication were used, the death should be attributed to the underlying illnesses, not the sedation
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