The moral importance of the ‘intention-foresight’ distinction has long been a matter of philosophical controversy, particularly in the context of end-of-life care. Previous empirical research in Australia has suggested that general physicians and surgeons may use analgesic or sedative infusions with ambiguous intentions, their actions sometimes approximating ‘slow euthanasia’. In this paper, we report findings from a qualitative study of 18 Australian palliative care medical specialists, using in-depth interviews to address the use of sedation at the end of life. The majority of subjects were agnostic or atheistic. In contrast to their colleagues in acute medical practice, these Australian palliative care specialists were almost unanimously committed to distinguishing their actions from euthanasia. This commitment appeared to arise principally from the need to maintain a clear professional role, and not obviously from an ideological opposition to euthanasia. While some respondents acknowledged that there are difficult cases that require considered reflection upon one’s intention, and where there may be some ‘mental gymnastics,’ the nearly unanimous view was that it is important, even in these difficult cases, to cultivate an intention that focuses exclusively on the relief of symptoms. We present four narratives of ‘terminal’ sedation - cases where sedation was administered in significant doses just before death, and may well have hastened death. Considerable ambiguities of intention were evident in some instances, but the discussion around these clearly exceptional cases illustrates the importance of intention to palliative care specialists in maintaining their professional roles.
Legal in some European countries and US states, physician-assisted suicide and voluntary active euthanasia remain under debate in these and other countries.
CONTEXT: The terms “palliative sedation” and “terminal sedation” have been used to refer to both proportionate palliative sedation, in which unconsciousness is a foreseen but an unintended side effect, and palliative sedation to unconsciousness, in which physicians aim to make their patients unconscious until death. It has not been clear to what extent palliative sedation to unconsciousness is accepted and practiced by U.S. physicians. OBJECTIVES: To investigate U.S. physician acceptance and practice of palliative sedation to unconsciousness and to identify predictors of that practice. METHODS: In 2010, a survey was mailed to 2016 practicing U.S. physicians. Criterion measures included self-reported practice of palliative sedation to unconsciousness until death and physician endorsement of such sedation for a hypothetical patient with existential suffering at the end of life. RESULTS: Of the 1880 eligible physicians, 1156 responded to the survey (62%). One in ten (141/1156) physicians had sedated a patient in the previous 12 months with the specific intention of making the patient unconscious until death, and two of three physicians opposed sedation to unconsciousness for existential suffering, both in principle (68%, n = 773) and in the case of a hypothetical dying patient (72%, n = 831). Eighty-five percent (n = 973) of physicians agreed that unconsciousness is an acceptable side effect of palliative sedation but should not be directly intended. CONCLUSION: Although there is a widespread support among U.S. physicians for proportionate palliative sedation, intentionally sedating dying patients to unconsciousness until death is neither the norm in clinical practice nor broadly supported for the treatment of primarily existential suffering.
The majority of Death with Dignity participants in Washington State and Oregon have received a diagnosis of terminal cancer. As more states consider legislation regarding physician-assisted death, the experience of a comprehensive cancer center may be informative.
Over 200,000 stray and surrendered dogs are admitted to shelters and municipal facilities in Australia each year, and approximately 20% are euthanized. Contemporary, comprehensive data on the characteristics and outcomes of dogs entering shelters are required to reduce shelter admissions and euthanasia. However, there are currently limited up-to-date data published on dog admission into shelters. A retrospective single cohort study was conducted to describe the characteristics and outcomes of the dog population entering Royal Society for Prevention of Cruelty to Animals, Queensland (RSPCA-QLD) shelters in 2014 (n = 11,967). The majority of dog admissions were strays from the public (24%) or from municipal councils (34%). Just over a quarter of admissions were puppies, 18% of adults (>6 months) were desexed, and the majority of admissions were crossbred dogs (92%). The majority of owner surrenders (86%) were due to human-related reasons. Most dogs were reclaimed (32%) or adopted (43%) and aggression was the most common reason for euthanasia of adult dogs (45%). Low-cost or free desexing and identification programs targeted to areas and breeds contributing to high intake, and increased support services for owners at risk of surrendering their dog, should be trialed to determine their cost effectiveness in reducing shelter admissions and euthanasia.
Available evidence indicates that overall levels of feline intake and euthanasia at U.S. shelters have significantly declined in recent decades. Nevertheless, millions of cats, many of them free-roaming, continue to be admitted to shelters each year. In some locations, as many as 70% of cats, perhaps up to one million or more per year nationally, are euthanized. New approaches, including return-to-field (RTF) and targeted trap-neuter-return (TNR) appear to have transformative potential. The purpose of the present study was to examine changes in feline intake and euthanasia, as well as additional associated metrics, at a municipal animal shelter in Albuquerque, New Mexico, after institutionalized RTF and targeted TNR protocols, together referred to as a community cat program (CCP), were added to ongoing community-based TNR efforts and a pilot RTF initiative. Over the course of the CCP, which ran from April 2012 to March 2015, 11,746 cats were trapped, sterilized, vaccinated, and returned or adopted. Feline euthanasia at the Albuquerque Animal Welfare Department (AAWD) declined by 84.1% and feline intake dropped by 37.6% over three years; the live release rate (LRR) increased by 47.7% due primarily to these reductions in both intake and euthanasia. Modest increases in the percentage of cats returned to owner (RTO) and the adoption rate were also observed, although both metrics decreased on an absolute basis, while the number of calls to the city about dead cats declined.
Reports about regulations and laws on Euthanasia and Physician Assisted Suicide (PAS) are becoming increasingly common in the media. Many groups have expressed opposition to euthanasia and PAS while those in favor argue that severely chronically ill and debilitated patients have a right to control the timing and manner of their death. Others argue that both PAS and euthanasia are ethically legitimate in rare and exceptional cases. Given that these discussions as well as the new and proposed laws and regulations may have a powerful impact on patients, caregivers, and health care providers, the International Association for Hospice and Palliative Care (IAHPC) has prepared this statement.
A friend of ours, Dr. Sam Brisbane, died recently. He was a Liberian doctor, and he died from Ebola, a horrible, nightmarish disease. Information coming out of Liberia has been scarce. Since Dr. Brisbane’s death, we’ve learned that other doctors and nurses with whom we’ve worked have also contracted Ebola and have died or are being treated in the types of rudimentary facilities we see on the news. As we live in dread of each phone call, questions about how we die and what we’re willing to die for have been weighing on us. The ancients had a concept of . . .
It is not uncommon for patients to have an expected death in an ICU. This review covers issues related to the end of life in the absence of discordance between the patient’s family and caregivers.
Right to Die NL, an organization in the Netherlands that advocates for the option of euthanasia, founded the End-of-Life Clinic in 2012 to provide euthanasia or physician-assisted suicide for patients who meet all legal requirements but whose regular physicians rejected their request. Many patients whose requests are rejected have less common situations, such as a psychiatric or psychological condition, dementia, or being tired of living.