1. Terminal Sedation Compassion Amidst Ethical Uncertainties

2. Your Instructor Greg Burns, RN, ELNEC Phone: (866) 441-4277 or (207) 773-2947 Fax: (207) 773-3617 Email: gary@jasonprogram.org Web: www.jasonprogram.org

4. General Concept 1992 -- When all else fails: 17 year old girl with relapsed Ewing's sarcoma, multiple bony metastases, pelvic mass compressing her spine and causing bilateral leg paralysis, constant severe bone, abdominal, and pelvic pain. Cannot swallow. Morphine drip at 1000 mg/hour and no pain relief or sedation. Fentanyl and Dilaudid were ineffective. When this happened, ketamine and Precedex were unavailable. The anesthesia team could not place a catheter due to the large tumor burden. What can be done?

7. So Let’s See What The Ethicists Have to Say Since Then

9. Preference for the different terms with medical background without medical background “ Sedation at the end of life” 38% 36% “ Palliative sedation” 53% 41% “ Terminal sedation” 32% 46% Conclusion

10. It’s a close call… and often the answer changes

14. Attitudes: Physical vs. Mental/Emotional Suffering Moral evaluation of different scenarios M=medical professional ØM = Non-medical background Dying patient Acceptable Not acceptable Don't know M øM M øM M øM Physical suffering Only sedation 98 97 1 1 1 1 Sedation + withdrawal of nutrition 86 89 12 8 3 3 Only withdrawal of nutrition 92 95 6 5 3 0 Mental suffering Only sedation 61 52 23 39 16 9 Sedation + withdrawal of nutrition 55 44 29 46 16 10 Only withdrawal of nutrition 68 63 21 22 11 14

15. Attitudes: Physical vs. Mental/Emotional Suffering Moral evaluation of different scenarios M=medical professional ØM = Non-medical background Patient with unfavourable prognosis Acceptable Not acceptable Don't know M øM M øM M øM Physical suffering Only sedation 74 66 17 23 9 11 Sedation + withdrawal of nutrition 63 56 28 30 9 14 Only withdrawal of nutrition 78 71 17 22 5 7 Mental suffering Only sedation 37 36 43 47 20 18 Sedation + withdrawal of nutrition 32 27 48 52 20 21 Only withdrawal of nutrition 52 50 34 39 14 12

18. Careful – People have opinions, and end-of-life issues generate powerful opinions. Could anyone be thinking that you want to euthanize the patient? Communicate well!

24. Sedation in palliative care – a critical analysis of 7 years experience BMC Palliative Care 2003, 2: 2 - No difference was found in the duration of stay in our unit until death between those patients who died with, and those who died without sedation. % patients receiving palliative sedation

28. A Different Approach

35. Now you can do the right thing… Even if it is sad R.M.A

36. Thank you for listening If you even need help, you can easily find us: The Jason Program 65 Washington Avenue Portland, ME 04101 Phone: (207) 773-2947 or (866) 441-4277 Fax: (207) 773-3617 Email: [email_address] or [email_address] Web: www.jasonprogram.org ************************************************************************