Terminal sedation (TS) is a recently coined term that may apply to a variety of practices with differing ethical implications. Two hypothetical cases are presented and contrasted. The first presents the more common scenario in which sedation is used for severe distress in a patient very close to death, who has stopped eating and drinking. The second case is more problematic: a nonterminally ill spinal cord injury patient requests sedation because of psychic distress. Sedation is supported in the former, but not the latter case. Suggested principles guiding the ethical use of sedation are: (1) While respect for autonomy is important, we are not obliged under all circumstances to provide sedation. (2) Physician intent matters. In providing sedation the physician's primary intent should be to alleviate suffering. (3) Reasonable inferences of intent can be made from physician actions, providing safeguards to ensure proper care. Sedatives should be titrated to observable signs of distress. (4) Proximity to death is a more useful concept than terminality in weighing benefits and burdens of sedation. (5) The nature of physician action should depend upon the nature of the suffering. Not all suffering is appropriately treated with sedation. (6) In patients close to death who have already stopped eating and drinking, sedation cannot be said to hasten death through dehydration or starvation. (7) Where TS is otherwise appropriate and where dehydration may in fact hasten death, ethical concerns may be addressed through informed consent. If hydration is refused, TS cannot be considered synonymous with euthanasia.
To address serious deficiencies in physician training in end-of-life care, the authors developed and disseminated a faculty development curriculum. The overall goals of this curriculum were to enhance physician competence in end-of-life care, foster a commitment to improving care for the dying, and improve teaching related to end-of-life care. The authors provide descriptions of the curriculum and the train-the-trainer programs (2000-2002) that successfully prepared 17 medical faculty as in-house end-of-life care faculty developers at institutions nationwide. They also report on a study of the effects of the 16-hour, end-of-life care curriculum delivered by trained facilitators to 62 faculty and residents at their home sites. Program evaluation showed that the home-site seminars enhanced the knowledge, skills, and attitudes of participating faculty and residents. When project evaluation concluded in 2003, trained facilitators had disseminated the 16-hour curriculum as well as modified versions of the curriculum to approximately 3,400 medical teachers. An adapted version of the curriculum is available on the Internet for use in health professions education. The importance of this type of faculty development effort was confirmed by the positive impact of the 16-hour curriculum on participants' knowledge, skills, and attitudes related to end-of-life care, the high ratings of the program's educational and clinical relevance, and the finding that, on average, more than 50% of the material was new to them.
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