Charles G. Sasser, MD
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Sasser C.; Careful Conversation about Care at the End of Life. Ann Intern Med. 2002;137:1008-1009. doi: 10.7326/0003-4819-137-12-200212170-00025
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Published: Ann Intern Med. 2002;137(12):1008-1009.
TO THE EDITOR:
Jansen and Sulmasy (1) are correct in cautioning against blind acceptance of a “double effect” ratiocination for ethically complex issues that normally surround end-of-life decision making. However, the examples offered do not support their premise that double effect can be reduced to a simple distinction between physical and existential suffering. In case one, the patient, who has already required intermittent respiratory support, may say that she fears loss of dignity, but her impending death will most likely be due to slow suffocation. The appropriate moment to begin sedation to avoid such an outcome is when the patient says the struggle to breathe has become intolerable, regardless of how she characterizes that struggle. Case 3 is equally straightforward (although problematic for the authors' purposes). The patient is not choosing death by suicide. He is choosing an alternative death to expanding intracranial pressure. This is a central theme of palliative medicine: to help people with terminal illness understand the various ways they may die of a particular illness and help them choose a plan of care that offers the most effective palliative interventions. (It should be noted, however, that assisted suicide is not a palliative intervention.) The authors present valid concerns about blanket application of interventions that carry grave moral implications without first exercising intense soul searching. (For example, I routinely obtain an ethics consultation before proceeding with palliative sedation.) However, I object to the suggestion that the current state of knowledge and therapy for existential suffering is comparable to that for physical pain when, for the former, there are no agreed-upon definitions, or proven therapeutic methods, or even instruments of measure. To argue that physical pain can be teased out of the multidimensional suffering of terminal illness and then used as sole basis for the application of appropriate palliative options, to the disregard of the whole person, is archaic mind–body dualism.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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