RESUMO
Pediatric procedure-related pain management is often incompletely understood, inadequately addressed, and critical in influencing a child's lifelong relationship with the larger health care community. We highlight the evolution of ethics and expectations around optimizing periprocedural pain management as a fundamental human right. We investigate the state-of-the-art of topical anesthetics, reviewing their mechanisms of action and providing comparisons of their relative safety and efficacy data to help guide clinical selection. In total, this two-part review offers a combination of conventional approaches and innovative techniques that should be used multimodally-in series and in parallel-to help optimize pain management and provide alternatives to sedation medication and general anesthesia.
Assuntos
Anestésicos Locais , Manejo da Dor , Humanos , Anestésicos Locais/uso terapêutico , Manejo da Dor/métodos , Manejo da Dor/ética , Criança , Dor Processual/prevenção & controle , Pediatria/éticaRESUMO
The dramatic increases of opioid use and misuse in the past 15 years have resulted in a focus on the responsible and judicious use of opioids. In this Ethics Rounds, the commentators analyze the case of a 16-year-old girl with lymphoma and opioid misuse whose caregiver may have diverted her opioids. She is now at the end of life and prefers to die at home. The commentators, oncologists, palliative care providers, ethicists, and a medical student agree that supporting the patient's goals and practicing good opioid stewardship are not incompatible. They identify additional information that would be required to analyze the case more fully such as the nature of the evidence for misuse and diversion and whether bias inadvertently contributed to these concerns. They agree that multimodal analgesia, including but not limited to opioids, is important. Safeguards could include a contract, directly observed therapy, and/or urine drug screens. Supervision or removal of a caregiver diverting medication or admission of the patient misusing medications would be alternatives if the initial plan was unsuccessful. Such patient-centered care requires well-developed substance misuse treatment, pain management, and home hospice that are adequately reimbursed.
Assuntos
Analgésicos Opioides/uso terapêutico , Linfoma/terapia , Transtornos Relacionados ao Uso de Opioides/terapia , Manejo da Dor/ética , Cuidados Paliativos/ética , Desvio de Medicamentos sob Prescrição/prevenção & controle , Assistência Terminal/ética , Adolescente , Cuidadores , Feminino , Humanos , Linfoma/complicações , Transtornos Relacionados ao Uso de Opioides/complicações , Manejo da Dor/métodos , Cuidados Paliativos/métodos , Equipe de Assistência ao Paciente/ética , Assistência Centrada no Paciente/ética , Assistência Centrada no Paciente/métodos , Relações Profissional-Família/ética , Assistência Terminal/métodosRESUMO
This study explores how stories told at a United States Food and Drug Administration (FDA) public hearing justify a label change intended to reduce the prescribing of opioids to people with chronic noncancer pain (CNCP). Drawing on a social constructionist framework, which holds that narratives play an essential role in influencing public policy, I employ Loseke's method for the empirical analysis of formula stories to examine the institutional narratives told at the hearing. I find that the stories serve to construct moral boundaries around different groups of patients with pain. Patients with cancer and life-limiting illness are constructed as unquestionably deserving of treatment with opioids, while patients with CNCP are constructed as potential "addicts" needing protection from opioid-related harm. I argue that the stories serve as moral justification for the outcome of the hearing while simultaneously marginalizing the voices of CNCP patients who rely on opioids for pain relief.
Assuntos
Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Rotulagem de Medicamentos , Narração , Manejo da Dor/ética , Medicamentos sob Prescrição , Política Pública , Feminino , Humanos , Masculino , Estados Unidos , United States Food and Drug Administration/legislação & jurisprudênciaRESUMO
OBJECTIVES: To determine the views of patients hospitalized in the algology clinic about ethical issues related to pain. METHODS: A total of 135 patients admitted to the algology clinic comprised the population of this descriptive study. Data were collected using the visual analogue scale (VAS) and the questionnaire on ethical issues related to pain. To evaluate the data, percentage distribution and the Tukey test of variance were used. RESULTS: Of the patients, 92.6% believed that they had the right to pain relief, and 94.8% believed that they should be consulted when decisions about them were made. It was determined that 43.0% of the patients disagreed with Proposition 1, 'When a terminal-stage cancer patient with unrelievable pain requests an overdose of pain medication, possibly to cause death, the physician must prescribe it,' while 51.9% of the participants disagreed with Proposition 2, 'When a terminal-stage cancer patient with unrelievable pain and his or her family request an overdose of pain medication, possibly to cause death, the physician must prescribe it,' and 44.4% of them disagreed with Proposition 3, 'When a terminal-stage cancer patient with unrelievable pain requests an overdose of pain medication, possibly to cause death even though his or her family refuses, the physician must prescribe it.' A statistically significant relationship (p<0.05) was found between the mean VAS scores and Propositions 1 and 3. CONCLUSION: The patients were willing to be informed and to be asked about their views regarding the issue, but they did not want to be prescribed a high dose of pain medication, possibly to cause overdose and death.
Assuntos
Pacientes Internados/psicologia , Manejo da Dor/ética , Dor Intratável/psicologia , Padrões de Prática Médica/ética , Adulto , Idoso , Idoso de 80 Anos ou mais , Ética Médica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Intratável/tratamento farmacológico , Inquéritos e Questionários , Turquia , Escala Visual Analógica , Adulto JovemRESUMO
Importance: An increase in opioid prescription has been observed in the Netherlands. It is vital to understand this increase and to identify risk factors for opioid prescription to ensure that health interventions remain appropriately targeted. Objectives: To determine the prevalence of opioid prescriptions and adverse events associated with opioids, and to identify risk factors associated with opioid prescription in the Dutch population. Design, Setting, and Participants: This cohort study used national statistics from the Netherlands from January 1, 2013, to December 31, 2017, including the full Dutch population of 16â¯779â¯575 people in 2013 and 17â¯081â¯507 people in 2017. Data from the Dutch Health Monitor surveys of 2012 and 2016 were also included. Databases were anonymized prior to analysis. All analyses were performed between December 2018 and February 2019. Exposure: Opioid prescription. Main Outcomes and Measures: The main outcomes were the dynamics of opioid prescriptions, hospital admissions for opioid overdose, and opioid overdose mortalities. The secondary outcome was risk factors associated with opioid prescription. Results: In 2013, 814â¯211 individuals (4.9% of the total population) received an opioid prescription. In 2017, 1â¯027â¯019 individuals (6.0% of the total population) received at least 1 opioid prescription (mean [SD] age, 59.3 [18.5] years; 613â¯203 [59.7%] women). The rate of hospital admissions for opioid overdose was 9.2 per 100â¯000 inhabitants in 2013 and 13.1 per 100â¯000 inhabitants in 2017 (relative risk, 1.43 [95% CI, 1.34-1.52]). Similarly, an increased risk of opioid overdose death was observed, from 0.83 per 100â¯000 inhabitants in 2013 to 1.2 per 100â¯000 inhabitants in 2017 (relative risk, 1.49 [95% CI, 1.20-1.85]). Based on data from the 2012 Dutch Health Monitor survey, risk factors associated with opioid prescription included being older than 65 years (odds ratio [OR], 4.20 [95% CI, 3.98-4.43]), having only a primary school education (OR, 3.62 [95% CI, 3.46-3.77]), being widowed (OR, 3.30 [95% CI, 3.13-3.49]), reporting always feeling symptoms of depression (OR, 3.77 [95% CI, 3.41-4.18]), and reporting poor or very poor physical health (OR, 10.40 [95% CI, 10.01-10.81]). Self-reported back pain (OR, 4.34 [95% CI, 4.23-4.46]) and rheumatoid arthritis or fibromyalgia (OR, 3.77 [95% CI, 3.65-3.90]) were also associated with opioid prescription. However, unemployment (OR, 1.05 [95% CI, 0.96-1.13]) was not associated with opioid prescription, and alcohol use disorder (OR, 0.76 [95% CI, 0.73-0.80]) was negatively associated with opioid prescription. Conclusions and Relevance: This study found that opioid prescriptions have increased in the Netherlands. Although the risk of adverse events is still relatively low, there is an urgent need to review pain management to prevent a further increase in opioid prescription.
Assuntos
Analgésicos Opioides/efeitos adversos , Overdose de Drogas/epidemiologia , Prescrições de Medicamentos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Adulto , Idoso , Analgésicos Opioides/uso terapêutico , Comorbidade , Overdose de Drogas/mortalidade , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Transtornos Relacionados ao Uso de Opioides/mortalidade , Avaliação de Resultados em Cuidados de Saúde , Manejo da Dor/ética , Manejo da Dor/métodos , Prevalência , Fatores de RiscoAssuntos
Manejo da Dor/efeitos adversos , Medição da Dor/ética , Dor Pós-Operatória/diagnóstico , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Analgésicos não Narcóticos/administração & dosagem , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Humanos , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Manejo da Dor/ética , Manejo da Dor/métodos , Manejo da Dor/normas , Medição da Dor/normas , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/psicologiaRESUMO
A recent administrative law decision in Victoria, Australia, applied double effect reasoning in a novel way. Double effect reasoning has hitherto been used to legitimate treatments which may shorten life but where the intent of treatment is pain relief. The situation reviewed by the Victorian tribunal went further, supporting actions where a doctor agrees to provide pentobarbitone (Nembutal) to a patient at some time in the future if the patient feels at that time that his pain is unbearable and he wants to end his life. The offer to provide the drug was described as a palliative treatment in that it gave reassurance and comfort to the patient. Double effect reasoning was extended in this instance to encompass potentially facilitating a patient's death. This extension further muddies the murky double effect reasoning waters and creates another challenge to this concept.
Assuntos
Tomada de Decisões/ética , Ética Médica , Legislação Médica , Manejo da Dor/ética , Cuidados Paliativos/legislação & jurisprudência , Médicos , Suicídio Assistido/legislação & jurisprudência , Diretivas Antecipadas , Beneficência , Causas de Morte , Acessibilidade aos Serviços de Saúde/ética , Humanos , Aplicação da Lei , Dor/psicologia , Cuidados Paliativos/ética , Direitos do Paciente , Pentobarbital , Estresse Psicológico , Pensamento , VitóriaRESUMO
AIM: We explored the positions of nurses working in hospitals regarding the acceptability of refusing to give a repeat dose of painkiller to a postoperative patient who requested it. These positions were compared with that of lay people, physicians, and other health professionals. DESIGN AND METHODS: Factorial design was used to assess the impact of 6 situational factors: the patient's age, the current level of pain as assessed by the nurse, the number of requests, the level of risk associated with the administration of a repeat dose, the outcome of surgery, and the giving of alternative mild analgesics. We implemented a combination of scenario technique and of cluster analysis. Data were collected from April 2013 to December 2015. PARTICIPANTS: 138 registered nurses, 32 nurse's aides, 33 physicians, 23 psychologists, and 169 lay people participated in the study. RESULTS: We found 4 qualitatively different meaningful positions. A plurality of participants (57% of nurses) considered that refusing was not acceptable, irrespective of circumstances. A substantial minority of participants (but 52% of physicians) considered that refusing was acceptable only if the level of pain was low and the risk was high. Other participants (mostly lay people) considered that refusing was always acceptable each time a risk of side effects, either serious or simply mild, was present.
Assuntos
Atitude do Pessoal de Saúde , Recursos Humanos de Enfermagem Hospitalar/psicologia , Manejo da Dor/ética , Medição da Dor/ética , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise por Conglomerados , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologiaRESUMO
This issue of the Hastings Center Report (January-February 2017) features three articles exploring aspects of decision-making for others. In the first two, the focus is on the limits of surrogate decision-makers' authority when the surrogates' judgments about a patient's treatment conflict with the physicians'. If a physician decides that a patient will not benefit from CPR, for example, but the patient's surrogate insists on it, is the physician obliged to proceed with the procedure? Or can the physician, pointing to a duty to provide good care to the patient and not to cause the patient to suffer, get a do-not-resuscitate order for the patient-even in the face of the surrogate's objections? These are the questions that animate the first article, in which a group of authors report on a policy implemented at Massachusetts General Hospital to help doctors who face this dilemma. The second article, by physician Jeffrey Berger, flips the questions. If a physician decides that a patient's intractable suffering requires palliative sedation, may the surrogate prevent it anyway? Or can the physician, pointing to a duty to alleviate the suffering, administer palliative sedation even in the face of the surrogate's objections? Such circumstances, says Berger, show the need for conceptual work delineating the limits of surrogates' authority and practical work on mechanisms for doing so-protecting patients and giving physicians a clear route to follow.
Assuntos
Tomada de Decisões/ética , Papel do Médico/psicologia , Médicos/psicologia , Procurador/psicologia , Saúde do Adolescente/ética , Humanos , Julgamento , Manejo da Dor/ética , Cuidados Paliativos/ética , Ordens quanto à Conduta (Ética Médica)/éticaRESUMO
In a recent article in this journal, Carl Knight and Andreas Albertsen argue that Rawlsian theories of distributive justice as applied to health and healthcare fail to accommodate both palliative care and the desirability of less painful treatments. The asserted Rawlsian focus on opportunities or capacities, as exemplified in Normal Daniels' developments of John Rawls' theory, results in a normative account of healthcare which is at best only indirectly sensitive to pain and so unable to account for the value of efforts of which the sole purpose is pain reduction. I argue that, far from undermining the Rawlsian project and its application to problems of health, what the authors' argument at most amounts to is a compelling case for the inclusion of freedom from physical pain within its index of primary goods.
Assuntos
Atenção à Saúde , Manejo da Dor/ética , Dor , Cuidados Paliativos/ética , Justiça Social/ética , Liberdade , Humanos , Defesa do Paciente/éticaRESUMO
Pain is a multidimensional, complex experience. There are many challenges in identifying and meeting the needs of patients experiencing pain. Evaluation of pain from a bio-psycho-social-spiritual framework is particularly germane for patients approaching the end of life. This review explores the relation between the psychospiritual dimensions of suffering and the experience of physical pain, and how to assess and treat pain in a multidimensional framework. A review of empirical data on the relation between pain and suffering as well as interdisciplinary evidence-based approaches to alleviate suffering are provided.
Assuntos
Atitude Frente a Morte , Manejo da Dor/métodos , Dor/psicologia , Cuidados Paliativos/métodos , Espiritualidade , Estresse Psicológico/terapia , Assistência Terminal/métodos , Humanos , Dor/diagnóstico , Manejo da Dor/ética , Manejo da Dor/psicologia , Cuidados Paliativos/ética , Cuidados Paliativos/psicologia , Psicologia , Estresse Psicológico/psicologia , Assistência Terminal/ética , Assistência Terminal/psicologiaRESUMO
BACKGROUND: The practical year (PY) during the final year of medical education is intended to deepen and broaden knowledge, skills, and abilities that were acquired during previous years of their studies. Against this background, this study pursues the question of how the knowledge of future physicians and their confidence in terms of cancer pain therapy and other palliative care issues develops during the PY. MATERIALS AND METHODS: At the end of the PY, students from two university hospitals completed a 3-part online questionnaire (self-assessment of the confidence, questions about palliative care knowledge, and assessment of palliative care training during the PY). These results are compared with previously published data from the same collective that had been collected at the beginning of the PY. RESULTS: Overall, 92 of 318 students participated (28.9 %). Less than 10 % of students said that they were more confident regarding palliative care topics at the end of their medical studies. Improvements in the self-assessment could only be observed in the recognition of and screening for cancer pain (increase from 36 % to 65%). With regard to the palliative care knowledge, only the knowledge of how to treat symptoms other than pain improved significantly; however, knowledge in this regard prior to the PY was particularly low (an increase from 25 % to 35 %, p < 0.05). In the only multiple-choice question about ethics, the correct answer rose slightly from 51 % (before) to 55 % (after the PY). Of participating students, 21% (prior to the PY 27 %) stated that not providing fluids to dying patients is a form of euthanasia. In terms of palliative care training, between 36 and 83 % of participants stated having insufficient opportunities to gain knowledge and experience on various topics in the treatment of patients with advanced and incurable diseases during their PY. CONCLUSION: In the present study, considerable deficits in confidence and knowledge regarding palliative care issues were also observed at the end of PY. Integration of palliative care into the medical school curriculums should be given special attention in terms of a longitudinal training of the PY.
Assuntos
Atitude do Pessoal de Saúde , Dor do Câncer/psicologia , Dor do Câncer/terapia , Competência Clínica , Cuidados Paliativos/psicologia , Preceptoria , Estudantes de Medicina/psicologia , Currículo , Ética Médica , Feminino , Alemanha , Humanos , Masculino , Manejo da Dor/ética , Manejo da Dor/psicologia , Cuidados Paliativos/ética , Preceptoria/ética , Inquéritos e Questionários , Adulto JovemRESUMO
At the end of life, pain management is commonly a fundamental part of the treatment plan for patients where curative measures are no longer possible. However, the increased recognition of opioid diversion for secondary gain coupled with efforts to treat patients in the home environment towards the end of life creates the potential for ethical dilemmas in the palliative care management of terminal patients in need of continuous pain management. We present the case of an end-stage patient with rectal cancer who required a continuous residential narcotic infusion of fentanyl for pain control due to metastatic disease. His functional status was such that he had poor oral intake and ability to perform other activities of daily living, but was able to live at home with health agency nursing care. The patient presented to this institution with a highly suspect history of having lost his fentanyl infusion in a residential accident and asking for a refill to continue home therapy. The treating physicians had concerns of diversion of the infusion medication by caregivers and were reluctant to continue the therapeutic relationship with the patient. This case exemplifies the tension that can exist between wanting to continue with palliative care management of an end-stage patient and the fear of providers when confronted by evidence of potential diversion of opioid analgesic medications. We elucidate how an ethical framework based on a combination of virtue and narrative/relationship theories with reference to proportionality can guide physicians to a pragmatic resolution of these difficult situations.
Assuntos
Analgésicos Opioides/uso terapêutico , Comportamento Criminoso , Manejo da Dor/ética , Neoplasias Retais/tratamento farmacológico , Administração Intravenosa , Tratamento Farmacológico , Fentanila/farmacologia , Fentanila/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Cuidados Paliativos/ética , Cuidados Paliativos/métodos , Médicos/ética , Transtornos Relacionados ao Uso de Substâncias/prevenção & controleRESUMO
Susan D. McCammon and Nicole M. Piemonte offer a thoughtful and thorough commentary on our manuscript entitled "Expanding the use of Continuous Sedation Until Death." In this reply we attempt to clarify and further defend our position. We show how continuous sedation until death is not a "first resort" but rather a legitimate option among many that should available to terminally ill patients whose life expectancy is less than six months. We also attempt to show that we do not equivocate the meaning of palliative care as the commentators suggested. We argue that the traditional notion of palliative care should move beyond relief of "experienced suffering" to relief of potential suffering for those whose life expectancy is less than six months. Lastly, we challenge the commentator's position that the realm of ordinary medicine" should be the guide to care, by showing how the notion of ordinary medicine has been successfully challenged in both bioethical scholarship and the courts in a way that shows ordinary medicine to be an evolving concept rather than a static, universal guide.
Assuntos
Tomada de Decisões/ética , Sedação Profunda/ética , Manejo da Dor/ética , Cuidados Paliativos/ética , Assistência Centrada no Paciente/ética , Autonomia Pessoal , Assistência Terminal/ética , Doente Terminal , Recusa do Paciente ao Tratamento , Humanos , MasculinoRESUMO
As currently practiced, the use of continuous sedation until death (CSD) is controlled by clinicians in a way that may deny patients a key choice in controlling their dying process. Ethical guidelines from the American Medical Association and the American Academy of Pain Medicine describe CSD as a "last resort," and a position statement from the American Academy of Hospice and Palliative Medicine describe it as "an intervention reserved for extreme situations." Accordingly, patients must progress to unremitting pain and suffering and reach a last-resort stage before the option to pursue CSD is considered. Alternatively, we present and defend a new guideline in which decisionally capable, terminally ill patients who have a life expectancy of less than six months may request CSD before being subjected to the refractory suffering of a treatment of "last resort."
Assuntos
Tomada de Decisões/ética , Sedação Profunda/ética , Manejo da Dor/ética , Cuidados Paliativos/ética , Assistência Centrada no Paciente/ética , Autonomia Pessoal , Assistência Terminal/ética , Doente Terminal , Recusa do Paciente ao Tratamento , Comportamento de Escolha/ética , Morte , Eutanásia Ativa Voluntária/ética , Eutanásia Ativa Voluntária/legislação & jurisprudência , Eutanásia Ativa Voluntária/tendências , Pessoal de Saúde/ética , Pessoal de Saúde/legislação & jurisprudência , Pessoal de Saúde/psicologia , Cuidados Paliativos na Terminalidade da Vida/ética , Humanos , Consentimento Livre e Esclarecido/ética , Consentimento Livre e Esclarecido/normas , Expectativa de Vida , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Obrigações Morais , Países Baixos , Dor/etiologia , Medição da Dor , Cuidados Paliativos/métodos , Cuidados Paliativos/tendências , Assistência Centrada no Paciente/métodos , Assistência Centrada no Paciente/tendências , Guias de Prática Clínica como Assunto , Opinião Pública , Valores Sociais , Neoplasias da Coluna Vertebral/complicações , Neoplasias da Coluna Vertebral/secundário , Estresse Psicológico/prevenção & controle , Suicídio Assistido/ética , Suicídio Assistido/legislação & jurisprudência , Suicídio Assistido/tendências , Assistência Terminal/métodos , Assistência Terminal/tendências , Fatores de Tempo , Revelação da Verdade/ética , Incerteza , Estados Unidos , Suspensão de Tratamento/éticaRESUMO
Samuel H. LiPuma and Joseph P. DeMarco argue for a positive right to continuous sedation until death (CSD) for any patient with a life expectancy less than six months. They reject any requirement of proportionality. Their proposed guideline makes CSD an option for a decisional adult patient with an appropriate terminal diagnosis regardless of whether suffering (physical or existential) is present. This guideline purports to "empower" the patient with the ability to control the timing and manner of her death. This extends even to the option to "opt out" of the awareness and experience of dying and to avoid suffering altogether, even if one's symptoms and suffering could be effectively treated. We respond first with a critique of their terminology. We then turn to some purely practical considerations of how this guideline might be enacted in the current atmosphere of American hospice and palliative care medicine. We close with a consideration of one philosophical concern that might ground the discussion of risks, benefits, and alternatives necessary for informed consent.
Assuntos
Tomada de Decisões/ética , Sedação Profunda/ética , Manejo da Dor/ética , Cuidados Paliativos/ética , Assistência Centrada no Paciente/ética , Autonomia Pessoal , Assistência Terminal/ética , Doente Terminal , Recusa do Paciente ao Tratamento , Humanos , MasculinoAssuntos
Analgésicos/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/complicações , Sedação Consciente , Neoplasias Pulmonares/complicações , Manejo da Dor/métodos , Dor Intratável/terapia , Cuidados Paliativos , Adulto , Antineoplásicos/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Carcinoma Pulmonar de Células não Pequenas/secundário , Sedação Consciente/ética , Receptores ErbB/antagonistas & inibidores , Cloridrato de Erlotinib , Evolução Fatal , Feminino , Mutação da Fase de Leitura , Genes erbB-1 , Humanos , Pulmão/diagnóstico por imagem , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/patologia , Metástase Linfática , Manejo da Dor/ética , Dor Intratável/etiologia , Cuidados Paliativos/ética , Quinazolinas/uso terapêutico , RadiografiaRESUMO
An estimated 1.2 to 2.3 million Hindus live in the United States. End-of-life care choices for a subset of these patients may be driven by religious beliefs. In this article, we present Hindu beliefs that could strongly influence a devout person's decisions about medical care, including end-of-life care. We provide four case examples (one sacred epic, one historical example, and two cases from current practice) that illustrate Hindu notions surrounding pain and suffering at the end of life. Chief among those is the principle of karma, through which one reaps the benefits and penalties for past deeds. Deference to one's spouse or family is another important Hindu value, especially among Hindu women, which can impact the decision-making process and challenge the Western emphasis on autonomy. In addition, the Hindu embrace of astrology can lead to a desire to control the exact time of death. Confounding any generalizations, a Hindu patient may reject or accept treatments based on the individual patient's or family's interpretation of any given tradition. Through an awareness of some of the fundamental practices in Hinduism and the role of individual interpretation within the tradition, clinicians will be better able to support their Hindu patients and families at the end of life.
Assuntos
Astrologia , Características Culturais , Morte , Tomada de Decisões , Hinduísmo , Manejo da Dor , Dor , Cuidados Paliativos , Religião e Medicina , Estresse Psicológico , Assistência Terminal , Comunicação , Tomada de Decisões/ética , Escolaridade , Feminino , Hinduísmo/psicologia , História do Século XX , História Antiga , Humanos , Índia , Masculino , Mitologia , Dor/psicologia , Manejo da Dor/ética , Manejo da Dor/história , Manejo da Dor/psicologia , Manejo da Dor/normas , Cuidados Paliativos/ética , Cuidados Paliativos/métodos , Cuidados Paliativos/normas , Autonomia Pessoal , Direito a Morrer , Cônjuges , Estresse Psicológico/psicologia , Assistência Terminal/ética , Assistência Terminal/história , Assistência Terminal/psicologia , Assistência Terminal/normas , Fatores de Tempo , Estados UnidosRESUMO
Elderly patients in palliative situations residing in a nursing home present characteristics and specificities that clearly distinguish them from patients with advanced cancer. Besides the difficulty to define a precise prognosis, their many comorbidities, their communication difficulties because of cognitive disorders, their high sensitivity to primary and secondary effects of drugs render their management a real challenge for physician and caregivers. Accompanying these patients at the end of their life also raises many ethical problems, especially when they are no longer able to express their wishes and have not previously expressed advance directives.
Les personnes âgées en situation palliative, résidant en établissements médico-sociaux, présentent des caractéristiques et des spécificités qui les distinguent des patients atteints d'un cancer avancé. Hormis un pronostic difficile à définir, leurs nombreuses comorbidités, leurs difficultés à communiquer en raison de troubles cognitifs, leur grande sensibilité aux effets primaires et secondaires des médicaments font que leur prise en charge représente un véritable défi pour le médecin et l'équipe soignante. Leur accompagnement en fin de vie pose également de nombreux problèmes éthiques, notamment lorsqu'elles ne sont plus en mesure d'exprimer leurs souhaits et que ceux-ci ne sont pas consignés dans des directives anticipées.