Michael A. Ashby

Renal dialysis abatement : Lessons from a social study.

Aim: This study aimed to examine the reasons why some people chose to abate (i.e., stop or not start) renal dialysis, together with the personal and social impact of this decision on the person concerned, and/or their families. Method: A qualitative design based on the principles of Grounded Theory was employed. Semi-structured interviews were conducted with sixteen patients and/or carers (depending on whether the patient was able to be interviewed) where the issue of dialysis abatement was being considered, or had recently been decided. Results: Of 52 participants considered for entry into the study 41 were ineligible, with impaired cognition, rapid medical deterioration, and inability to speak sufficient English being the main reasons for exclusion. The desire not to burden others and the personal experience of a deteriorating quality of life were crucial elements in the decision to stop or decline dialysis. The problem of prognostic uncertainty and a sense of abandonment were also prominently expressed. Conclusions: From this small Australian sample, it appears that there would be considerable potential benefit from a more proactive and open approach to end-of-life issues, with incorporation of the clinical and health promoting principles of palliative care into renal dialysis practice. The high number of exclusions shows how sick and unstable this population of patients is, but the issue of data gathering from people whose main language is not English requires attention.

Description of a mechanistic approach to pain management in advanced cancer. Preliminary report

&NA; A mechanistic approach to advanced cancer pain management is proposed, based on the clinically perceived anatomical and pathophysiological mechanisms of pain generation. It is an extension of the World Health Organisation (WHO) analgesic ladder in which severity of pain is the principal determinant of analgesic choice. The mechanistic categories are: superficial somatic, deep somatic, visceral and neurogenic (mixed or pure i.e., nociceptive component present or absent). Allocation of pain to the different categories is based on clinical history, physical findings and investigations to establish the site and extent of active primary or metastatic tumour deposits, and evidence of previous response to medication. Drug choice sequence is determined by the dominant pain mechanism judged to be present and not the severity of the pain. In order to describe this approach, mechanisms of pain, disease distribution and drug treatment have been analysed in the first 20 consecutive patients who consented to enter a longitudinal pain description and evaluation study on admission to an inpatient hospice unit. Despite a high exclusion rate from research standard monitoring due to severity of illness and related factors, the majority of eligible patients approached to enter the study did so, and the pain scoring was well tolerated. The implications of this for future research and clinical practice are discussed. In 6 patients only 1 pain mechanism was identified (visceral 4, deep somatic 2). Two mechanisms were present in 8 patients and 3 mechanisms in 6 patients. The deep somatic mechanism was identified in 15 patients, visceral mechanism in 13, neurogenic in 10 and superficial somatic in 2. The most common combination of mechanisms was neurogenic/visceral/deep somatic (5 patients) and neurogenic/deep somatic (4 patients). No patient had neurogenic pain alone or superficial pain alone. To achieve optimal analgesia, a mean of 2.8 drug classes per patient was required (range: 1–5). All 20 patients required an opioid, and in 2 patients with visceral pain only, morphine was the initial and sole analgesic used. None of the 15 patients with deep somatic pain achieved acceptable pain relief with an anti‐inflammatory drug alone at conventional dose levels. It is concluded that the approach is feasible, and prospective assessment and validation of the response of these proposed mechanism categories to specific drug classes is now underway. Assessment of the anti‐inflammatory responsive component of nociceptive cancer pain has emerged as a priority for further investigation.

THERAPEUTIC RATIO AND DEFINED PHASES : PROPOSAL OF ETHICAL FRAMEWORK FOR PALLIATIVE CARE

radiation and surgical intervention and, in addition, resources are wasted. Large studies of children who have swallowed foreign bodies do not show that ingested coins that have passed beyond the cardia cause complications in children with a normal gastro? intestinal tract13; only one such case seems to have been described.4 Furthermore, the potential hazard of prolonged asymptomatic gastric retention of swallowed coins (more than two weeks) may have been exag? gerated. In our experience such coins eventually pass spontaneously and, under experimental conditions of gastric acidity, the dissolution of toxicologically significant quantities of metal is unlikely to occur (I M House, National Poisons Unit, Guys Hospital, London, personal communication). The management of swallowed coins in children in the United Kingdom could be improved. Adopting the scheme outlined in the figure would reduce the radiation dose received by many children and produce a considerable financial saving. An initial single antero posterior radiograph of the neck and chest is advisable even in asymptomatic patients because of the dangers from silent oesophageal impaction.5 A lateral radio? graph may then be necessary to localise coins in the neck and upper chest. When the coin is below the cardia only symptomatic patients require further assessment. Searching of stools is both unpleasant and inaccurate.

Questions and Answers on the Belgian Model of Integral End-of-Life Care: Experiment? Prototype?

This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan Bernheim, independent from but together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors.

Intranasal sufentanil for cancer-associated breakthrough pain

The objective of this study was to demonstrate the efficacy, safety and patient acceptability of the use of intranasal sufentanil for cancer-associated breakthrough pain. This was a prospective, open label, observational study of patients in three inpatient palliative care units in Australia. Patients on opioids with cancer-associated breakthrough pain and clinical evidence of opioid responsiveness to their breakthrough pain were given intranasal (IN) Sufentanil via a GO Medical™ patient controlled IN analgesia device. The main outcome measures were pain scores, need to revert to previous breakthrough opioid after 30 min, number of patients who chose to continue using IN sufentanil, and adverse effects. There were 64 episodes of use of IN sufentanil for breakthrough pain in 30 patients. There was a significant reduction in pain scores at 15 (P < 0.0001) and 30 min (P < 0.0001). In only 4/64 (6%) episodes of breakthrough pain did the participants choose to revert to their prestudy breakthrough medication. Twenty-three patients (77%) rated IN sufentanil as better than their prestudy breakthrough medication. The incidence of adverse effects was low and most were mild. Our study showed that IN sufentanil can provide relatively rapid onset, intense but relatively short lasting analgesia and in the palliative care setting it is an effective, practical, and safe option for breakthrough pain.

Prospective audit of short-term concurrent ketamine, opioid and anti-inflammatory ('triple-agent') therapy for episodes of acute on chronic pain.

Aim:  This prospective audit was undertaken in order to document the analgesic response and adverse effects of concurrent short‐term (‘burst’) triple‐agent analgesic (ketamine, an opioid and an anti‐inflammatory agent – either steroidal or non‐steroidal) administration, for episodes of acute on chronic pain. The clinical hypothesis in this study is that better pain control may be obtained by simultaneous multiple target receptor blockade.

Goals of care: a clinical framework for limitation of medical treatment.

A novel clinical framework called “goals of care” (GOC) has been designed as a replacement for not‐for‐resuscitation orders. The aim is to improve decision making and documentation relating to limitations of medical treatment. Clinicians assign a patients situation to one of three phases of care — curative or restorative, palliative, or terminal —according to an assessment of likely treatment outcomes. This applies to all admitted patients, and the default position is the curative or restorative phase. GOC helps identify patients who wish to decline treatments that might otherwise be given, such as treatment with blood products. This includes patients for whom specific limitations apply because of their beliefs. GOC has been introduced at Royal Hobart Hospital, Tasmania, and at Northern Health, Melbourne. So far, audit data and staff feedback have been favourable. There have been no reported major incidents or complaints in which GOC has been causally implicated in an adverse outcome.

Palliative care, double effect and the law in Australia

Care and decision‐making at the end of life that promotes comfort and dignity is widely endorsed by public policy and the law. In ethical analysis of palliative care interventions that are argued potentially to hasten death, these may be deemed to be ethically permissible by the application of the doctrine of double effect, if the doctors intention is to relieve pain and not cause death. In part because of the significance of ethics in the development of law in the medical sphere, this doctrine is also likely to be recognized as part of Australias common law, although hitherto there have been no cases concerning palliative care brought before a court in Australia to test this. Three Australian States have, nonetheless, created legislative defences that are different from the common law with the intent of clarifying the law, promoting palliative care, and distinguishing it from euthanasia. However, these defences have the potential to provide less protection for doctors administering palliative care. In addition to requiring a doctor to have an appropriate intent, the defences insist on adherence to particular medical practice standards and perhaps require patient consent. Doctors providing end‐of‐life care in these States need to be aware of these legislative changes. Acting in accordance with the common law doctrine of double effect may not provide legal protection. Similar changes are likely to occur in other States and Territories as there is a trend towards enacting legislative defences that deal with the provision of palliative care.

Ketamine and Cancer Pain: The Reports of My Death Have Been Greatly Exaggerated

Theauthorsaretobecongratulated on successfully completing a placebo-controlled, ran-domized controlled trial in 185 patients receiving palliative care—nomean feat.However,wequestionwhethertheauthors’sweepingconclusionthat “Ketamine does not have net clinical benefit when used as anadjunct to opioids and standard coanalgesics in cancer pain”

Rethinking the Body and Its Boundaries

Until recently, the idea that the nature of the body is acontested matter may have seemed to many people,whether inside or beyond the ivory tower, as butanother sign of the silliness of the academy. Advancesin biotechnology such as organ transplantation,assisted reproductive techniques (ART), genetics,stem cell research, enhancement, and regenerativemedicine have made use of and manipulated bodies inincreasingly fantastic ways, offering us—academicianand layman alike—new eyes with which to view thebody and unprecedented vantage points from which toconsider what it means to be embodied. The discussionon the nature and limits of human bodies is a specialcaseofamoregeneralproblem:amatterofindividualityand individuation of biological entities. The humanbody is a particular instance of living organisms, andthe frontiers of the body in the case of an animalconstructing its milieu are sometimes no less clearthan in the more familiar cases of organ transplants,and so on. The necessity of understanding the bodyas more than “natural object,” of course, is not new(see, e.g., Wolfe and Gal 2010 for a discussion ofthebodyasbothan“object” and an “instrument” ofresearch, knowledge, and power in the 17th and18th centuries). Western scientific history has paperedits ivy-covered walls with bodies that have beencuriously prodded and oftentimes callously dismissed;we need only look for such horrific evidence to theanthropological collections of indigenous bodies, theanatomical dissection and pathological displays of the19th and early 20th centuries, the medical experimenta-tion on vulnerable people and populations in the name