Wednesday, May 19, 2010

National hospice org advocates for palliative sedation

NHPCO ( Releases Statement and Commentary on Palliative Sedation Therapy to Promote Greater Understanding

Complete document found at:

(Alexandria, Va) – For the very limited number of imminently dying patients whose pain is intolerable and unresponsive to other palliative interventions, the National Hospice and Palliative Care Organization believes that palliative sedation can be a treatment option that should be considered by healthcare providers, patients, and families.

Palliative sedation refers to the lowing of patient consciousness using medications for the purpose of limiting patient awareness of suffering that is intractable and intolerable.

In releasing its position statement and commentary on the "Use of Palliative Sedation in Imminently Dying Terminally Ill Patients," NHPCO seeks to:

1. clarify the position of NHPCO on the use of palliative sedation for patients at the end of life,

2. recommend questions and issues to be addressed when palliative sedation is being considered, and

3. assist health care organizations in the development of policies for the use of palliative sedation.

Approved by the NHPCO board of directors in December 2009, the statement and commentary appears in the May 2010 issue of The Journal of Pain and Symptom Management, and is now publicly available.

The position statement consists of six core tenets:
For the small number of imminently dying patients whose suffering is intolerable and refractory, NHPCO supports making the option of palliative sedation, delivered by highly trained healthcare professionals acting as an interdisciplinary team, available to patients.

Since the goal is symptom relief (and not unconsciousness per se), sedation should be titrated to reduce consciousness to the minimum level necessary to render symptoms tolerable. For most patients this will mean less than total unconsciousness, allowing the patient to rest comfortably, but to be aroused.

Interdisciplinary Evaluation
There must be a physician with expertise in palliative care leading the intervention. Patients suffering at the end of life will receive optimal benefit from the involvement of a highly-skilled interdisciplinary team. NHPCO recommends convening an interdisciplinary conference specifically about the use of palliative sedation for each patient with whom it is being considered. In all cases, care must be patient- and family-centered. If the needs of the patient and family differ, the primary focus is on the needs of the patient.

Professionals involved in the process of providing palliative sedation must have training and competence in this particular intervention. Providers should be engaged in ongoing education that addresses symptom assessment and management. Further, facility with integration of the ethical considerations related to use of palliative sedation is essential.

Concerning Existential Suffering
Suffering can occur even when physical symptoms are well controlled. As with any other type of suffering, NHPCO believes that hospice and palliative care professionals have an ethical obligation to respond to existential suffering using the knowledge, tools, and expertise of the interdisciplinary team. It should be noted that the lack of concurrence by the NHPCO ethics committee on the definition and assessment of existential suffering precludes a recommendation regarding the use of palliative sedation for existential suffering. NHPCO strongly urges providers to carefully consider this question and supports further ethical discussion.

Relationship to Euthanasia and Assisted Suicide
Properly administered, palliative sedation of patients who are imminently dying is not the proximate cause of patient death, nor is death a means to achieve symptom relief in palliative sedation. As such, palliative sedation is categorically distinct from euthanasia and assisted suicide.

This statement addresses the use of palliative sedation only for patients who are terminally ill and whose death is imminent.

"This document provides valuable guidance about a complex issue that—while not frequently used—is often misunderstood," said J. Donald Schumacher, NHPCO president and CEO. "Our intention is to address the ethical issues surrounding palliative sedation and help hospice and palliative care providers create policies and guidelines to ensure they are well-prepared concerning this treatment option."

"We are not calling for an increase in the practice of palliative sedation but want to take a major step forward to redress some of the common misconceptions," added Schumacher.

Developed by the Palliative Sedation Task Force of the NHPCO Ethics Committee, members of the task force wanted to indentify and analyze the most robust evidence and arguments about palliative sedation and summarize that material in a way that would be helpful to the NHPCO membership.

Timothy W. Kirk, who led the task force commented, "We want to stress in this document that palliative sedation, like all interventions in palliative care, needs to be part of evidence-based practice. There are evidence-based clinical protocols based on a growing body of research that many clinicians are not aware of, but should be. Simply turning up current pain medications is not evidence-based sedation. We have a moral obligation to give our patients the best care possible, and this document is intended to help providers reflect on the nature of that obligation when it comes to the practice of palliative sedation."

The complete statement and commentary, as it appears in JPSM, is available at the NHPCO website (go to and click on the link for NHPCO Ethical Statements and Position Statements).

The cover story of NewsLine, May 2010, is about the development of this document.

Jon Radulovic, NHPCO, Vice President of Communications
1731 King Street
Suite 100
Alexandria, VA 22314

Should new laws make organ donation the presumed choice?

Should Laws Push for Organ Donation?
The New York Times

May 2, 2010, 7:00 pm

"A New York assemblyman has introduced a bill aimed at making the state the first to presume people want to donate their organs unless they specifically say otherwise. Under current law, people give permission to donate their organs by checking a box on their driver’s licenses or filling out a donor card.
The legislation, introduced by Assemblyman Richard Brodsky, a Westchester Democrat, is in two parts: the first step would end the right of the next of kin to challenge the decisions of their dead or dying relatives to donate their organs.
In a second measure, which is far more contentious, people would have to indicate in official documents — their driver’s licenses, most commonly — that they specifically don’t want to donate organs. If the box is not checked, it is presumed the person wants to donate.

What are the ethical and practical issues involved in changing the law? Is a “presumed consent” system an effective way to increase the number of organs available, and thus save lives, or will it deter public support for donation? "
Full article here:  

Monday, May 17, 2010

Informed Consent

Some facilities are giving surgical patients individualized risk estimates. Will cost and quality data be the next elements included in informed consent documents?
By Kevin B. O'Reilly, amednews staff .

Informed consent has long been a bedrock principle of medical ethics, but the form intended to document a patient's understanding of a proposed intervention is too often written at a college reading level and is ambiguous about risks. Some doctors are out to change that, bringing a personalized medical approach to informed consent. Nine medical centers around the country -- including the Mayo Clinic in Rochester, Minn., and the Henry Ford Hospital in Detroit -- are testing an informed-consent process for patients undergoing nonemergent cardiac catheterization and potential angioplasty. The Web-based program draws on a national cardiovascular database to predict individualized risks of death, bleeding or restenosis. Proponents of the effort say informed consent should include even more data, telling patients about cost, alternative treatments, and doctors' and hospitals' quality performance. [...]

Read the entire article in American Medical News:


Thought you might be interested - this new approach to informed consent speaks directly to personalized risk levels and apparently tries to do away with all the small-font, complex wording that no one reads or comprehends. Should be a hopeful sign that more changes may be around the corner!