Bert Broeckaert

Palliative Sedation: A Review of the Research Literature

The overall aim of this paper is to systematically review the following important aspects of palliative sedation: prevalence, indications, survival, medication, food and fluid intake, decision making, attitudes of physicians, family experiences, and efficacy and safety. A thorough search of different databases was conducted for pertinent research articles published from 1966 to June 2007. The following keywords were used: end of life, sedation, terminal sedation, palliative sedation, refractory symptoms, and palliative care. Language of the articles was limited to English, French, German, and Dutch. Papers reporting solely on the sedatives used in palliative care, without explicitly reporting the prevalence or intensity of sedation, and papers not reporting on primary research (such as reviews or theoretical articles) were excluded. Methodological quality was assessed according to the criteria of Hawker et al. (2002). The search yielded 130 articles, 33.8% of which were peer-reviewed empirical research studies. Thirty-three research papers and one thesis were included in this systematic review. This review reveals that there still are many inconsistencies with regard to the prevalence, the effect of sedation, food and fluid intake, the possible life-shortening effect, and the decision-making process. Further research to clarify all of this should be based on multicenter, prospective, longitudinal, and international studies that use a uniform definition of palliative sedation, and valid and reliable instruments. Only through such research will it be possible to resolve some of the important ethical issues related to palliative sedation.

Spirituality and Palliative Care

This paper shows how palliative care developed as a reaction to the compartimentalized technical approach of modern medicine. But what does it mean if we say palliative care wants to treat patients as whole persons? A few pitfalls need to avoided. All disciplines involved in palliative care should act within the limits of their own specific professional role. Physicians and nurses should certainly not force patients into spiritual or religious discussions or practices. They should understand that religion and spirituality also influence the ethical (and thus medical) choices people make, respect their own conscience and worldview too and cultivate conscious compassion.

Level of Consciousness in Dying Patients. The Role of Palliative Sedation: A Longitudinal Prospective Study:

Background: Patients suffering from a terminal illness often are confronted with severe symptoms during the last phase of their lives. Palliative sedation, although one of the options of last resort, remains a much debated and controversial issue and is often referred to as a form of slow euthanasia or euthanasia in disguise. Methods: A prospective longitudinal and descriptive design was used. Each patient admitted in one of the 8 participating units was included if they met the inclusion criteria and gave written informed consent. Results: 266 patients were included. The incidence of palliative sedation was 7;5%. For the group of sedated patients results show that 90% entered the palliative care unit being fully conscious. Two patients were comatose upon arrival. 90% of the patients remained fully conscious up to the day palliative sedation was started. When looking at the effect of palliative sedation on the level of consciousness the analysis strongly suggest that the palliative sedation - as expected- has an impact on the GCS score. Irrespective of the dichotomization of the score the probability of having a lower GCS increases substantially once sedation is initiated. Additionally, results show that once palliative sedation is administered, the level of consciousness gradually goes down up until the day of death. Conclusion: Palliative sedation is nor slow euthanasia nor an ambivalent practice. It is an intentional medical treatment which is administered in a proportional way when refractory suffering occurs. It occurs in extraordinary situations and at the very end of the dying process.

The Ongoing Charity of Organ Donation. Contemporary English Sunni Fatwas on Organ Donation and Blood Transfusion

BACKGROUND Empirical studies in Muslim communities on organ donation and blood transfusion show that Muslim counsellors play an important role in the decision process. Despite the emerging importance of online English Sunni fatwas, these fatwas on organ donation and blood transfusion have hardly been studied, thus creating a gap in our knowledge of contemporary Islamic views on the subject. METHOD We analysed 70 English Sunni e-fatwas and subjected them to an in-depth text analysis in order to reveal the key concepts in the Islamic ethical framework regarding organ donation and blood transfusion. RESULTS All 70 fatwas allow for organ donation and blood transfusion. Autotransplantation is no problem at all if done for medical reasons. Allotransplantation, both from a living and a dead donor, appears to be possible though only in quite restricted ways. Xenotransplantation is less often mentioned but can be allowed in case of necessity. Transplantation in general is seen as an ongoing form of charity. Nearly half of the fatwas allowing blood transfusion do so without mentioning any restriction or problem whatsoever. The other half of the fatwas on transfusion contain the same conditional approval as found in the arguments pro organ transplantation. CONCLUSION Our findings are very much in line with the international literature on the subject. We found two new elements: debates on the definition of the moment of death are hardly mentioned in the English Sunni fatwas and organ donation and blood transfusion are presented as an ongoing form of charity.

The Attitudes of Indian Palliative-care Nurses and Physicians to Pain Control and Palliative Sedation

Aim: We wanted to assess Indian palliative-care nurses and physicians’ attitudes toward pain control and palliative sedation. Materials and Methods: From May to September 2008, we interviewed 14 physicians and 13 nurses working in different palliative-care programs in New Delhi, using a semi-structured questionnaire, and following grounded-theory methodology (Glaser and Strauss). Results: The interviewees did not consider administration of painkillers in large doses an ethical problem, provided the pain killers are properly titrated. Mild palliative sedation was considered acceptable. The interviewees disagreed whether palliative sedation can also be deep and continuous. Arguments mentioned against deep continuous palliative sedation were the conviction that it may cause unacceptable side effects, and impedes basic daily activities and social contacts. A few interviewees said that palliative sedation may hasten death. Conclusion: Due to fears and doubts regarding deep continuous palliative sedation, it may sometimes be too easily discarded as a treatment option for refractory symptoms.

‘We are (not) the master of our body’: elderly Jewish women's attitudes towards euthanasia and assisted suicide

Objectives. In Belgium, dominant ideological traditions – Christianity and non-religious humanism – have the floor in debates on euthanasia and hardly any attention is paid to the practices and attitudes of ethnic and religious minorities, for instance, Jews. This article aims to meet this lacuna. Design. Qualitative empirical research was performed in the Orthodox Jewish community of Antwerp (Belgium) with a purposive sample of elderly Jewish (non-)Hasidic and secularised Orthodox women. In-depth interviews were conducted to elicit their attitudes towards (non-)voluntary euthanasia and assisted suicide. Results. The research reveals diverse views among women in the community on intentionally terminating a patients life. Absolute rejection of every act which deliberately terminates life is found among the overwhelming majority of (religiously observant) Orthodox (Hasidic and non-Hasidic) women, as they have an unconditional faith and trust in Gods sovereign power over the domain of life and death. On the other hand, the views of secularised Orthodox women – mostly irreligious women, who do not consider themselves Orthodox, thus not following Jewish law, yet say they belong to the Orthodox Jewish community –show an acceptance of voluntary euthanasia and assisted suicide but non-voluntary euthanasia is approached more negatively. As they perceive illness and death as merely profane facts, they stress a patients absolute right towards self-determination, in particular with regard to ones end of life. Among non-Hasidic Orthodox respondents, more openness is found for cultivating a personal opinion which deviates from Jewish law and for the right of self-determination with regard to questions concerning life and death. In this study, these participants occupy an intermediate position. Conclusion. Our study reveals an interplay between ethical attitudes on euthanasia and religious convictions. The image one has of a transcendental reality, or of God, has a stronger effect on ones (dis)approval of euthanasia than being (ir)religious.

Living in the hands of God. English Sunni e-fatwas on (non-)voluntary euthanasia and assisted suicide

Ever since the start of the twentieth century, a growing interest and importance of studying fatwas can be noted, with a focus on Arabic printed fatwas (Wokoeck 2009). The scholarly study of end-of-life ethics in these fatwas is a very recent feature, taking a first start in the 1980s (Anees 1984; Rispler-Chaim 1993). Since the past two decades, we have witnessed the emergence of a multitude of English fatwas that can easily be consulted through the Internet (‘e-fatwas’), providing Muslims worldwide with a form of Islamic normative guidance on a huge variety of topics. Although English online fatwas do provide guidance for Muslims and Muslim minorities worldwide on a myriad of topics including end-of-life issues, they have hardly been studied. This study analyses Islamic views on (non-)voluntary euthanasia and assisted suicide as expressed in English Sunni fatwas published on independent—i.e. not created by established organisations—Islamic websites. We use Tyan’s definition of a fatwa to distinguish between fatwas and other types of texts offering Islamic guidance through the Internet. The study of e-fatwas is framed in the context of Bunt’s typology of Cyber Islamic Environments (Bunt 2009) and in the framework of Roy’s view on the virtual umma (Roy 2002). ‘(Non-)voluntary euthanasia and assisted suicide’ are defined using Broeckaert’s conceptual framework on treatment decisions at the end of life (Broeckaert 2008). We analysed 32 English Sunni e-fatwas. All of the e-fatwas discussed here firmly speak out against every form of active termination of life. They often bear the same structure, basing themselves solely on Quranic verses and prophetic traditions, leaving aside classical jurisprudential discussions on the subject. In this respect they share the characteristics central in Roy’s typology of the fatwa in the virtual umma. On the level of content, they are in line with the international literature on Islamic end-of-life ethics. English Sunni e-fatwas make up an influential and therefore important developing body of Islamic orthodox normative authority on end-of-life ethics that is still open for further research.

Palliative care physicians' religious / world view and attitude towards euthanasia: A quantitative study among flemish palliative care physicians

Aims: To Study the religious and ideological views and practice of Palliative Care physician towards Euthanasia. Materials and Methods: An anonymous self administered questionnaire approved by Flemish Palliative Care Federation and its ethics steering group was sent to all physicians(n-147) working in Flemish Palliative Care. Questionnaire consisted of three parts. In first part responded were requested to provide demographic information. In second part the respondents were asked to provide information concerning their religion or world view through several questions enquiring after religious or ideological affiliation, religious or ideological self-definition, view on life after death, image of God, spirituality, importance of rituals in their life, religious practice, and importance of religion in life. The third part consisted of a list of attitudinal statements regarding different treatment decisions in advanced disease on which the respondents had to give their opinion using a five-point Likert scale.99 physician responded. Results: We were able to distinguish four clusters: Church-going physicians, infrequently church-going physicians, atheists and doubters. We found that like the Belgian general public, many Flemish palliative care physicians concoct their own religious or ideological identity and feel free to drift away from traditional religious and ideological authorities. Conclusions: In our research we noted that physicians who have a strong belief in God and express their faith through participation in prayer and rituals, tend to be more critical toward euthanasia. Physicians who deny the existence of a transcendent power and hardly attend religious services are more likely to approve of euthanasia even in the case of minors or demented patients. In this way this study confirms the influence of religion and world view on attitudes toward euthanasia.

Flemish palliative-care nurses’ attitudes to palliative sedation A quantitative study

Palliative sedation is an option of last resort to control refractory suffering. In order to better understand palliative-care nurses’ attitudes to palliative sedation, an anonymous questionnaire was sent to all nurses (589) employed in palliative care in Flanders (Belgium). In all, 70.5% of the nurses (n = 415) responded. A large majority did not agree that euthanasia is preferable to palliative sedation, were against non-voluntary euthanasia in the case of a deeply and continuously sedated patient and considered it generally better not to administer artificial floods or fluids to such a patient. Two clusters were found: 58.5% belonged to the cluster of advocates of deep and continuous sedation and 41.5% belonged to the cluster of nurses restricting the application of deep and continuous sedation. These differences notwithstanding, overall the attitudes of the nurses are in accordance with the practice and policy of palliative sedation in Flemish palliative-care units.

Can curative or life-sustaining treatment be withheld or withdrawn? The opinions and views of Indian palliative-care nurses and physicians

Introduction: Decisions to withdraw or withhold curative or life-sustaining treatment can have a huge impact on the symptoms which the palliative-care team has to control. Palliative-care patients and their relatives may also turn to palliative-care physicians and nurses for advice regarding these treatments. We wanted to assess Indian palliative-care nurses and physicians’ attitudes towards withholding and withdrawal of curative or life-sustaining treatment. Method: From May to September 2008, we interviewed 14 physicians and 13 nurses working in different palliative-care programmes in New Delhi, using a semi-structured questionnaire. For the interviews and analysis of the data we followed Grounded-Theory methodology. Results: Withholding a curative or life-sustaining treatment which may prolong a terminal cancer patient’s life with a few weeks but also has severe side-effects was generally considered acceptable by the interviewees. The majority of the interviewees agreed that life-sustaining treatments can be withdrawn in a patient who is in an irreversible coma. The palliative-care physicians and nurses were of the opinion that a patient has the right to refuse life-saving curative treatment. While reflecting upon the ethical acceptability of withholding or withdrawal of curative or life-sustaining treatment, the physicians and nurses were concerned about the whole patient and other people who may be affected by the decision. They were convinced they can play an important advisory role in the decision-making process. Conclusion: While deciding about the ethical issues, the physicians and nurses do not restrict their considerations to the physical aspects of the disease, but also reflect upon the complex wider consequences of the treatment decisions.