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Medicine and Public Policy |

Palliative Treatments of Last Resort: Choosing the Least Harmful Alternative

Timothy E. Quill, MD; Barbara Coombs Lee, FNP, JD; Sally Nunn, RN, University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel
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From The Genesee Hospital, University of Rochester School of Medicine, Rochester, New York; Compassion in Dying Federation, Portland, Oregon; and University of Pennsylvania Health System, Philadelphia, Pennsylvania.

This paper was developed by the Assisted Suicide Consensus Panel as part of the Finding Common Ground Project of the University of Pennsylvania Center for Bioethics. The paper was authored on behalf of the Panel by Timothy E. Quill, MD; Barbara Coombs Lee, FNP, JD; and Sally J. Nunn, RN. Members of the Assisted Suicide Consensus Panel were: Arthur Caplan, PhD, Chair; David A. Asch, MD, MBA; Rev. Ralph Ciampa; Kathy Faber-Langendoen, MD; Joseph J. Fins, MD; John Hansen-Flaschen, MD; Barbara Coombs Lee, FNP, JD; Franklin G. Miller, PhD; Sally J. Nunn, RN; David Orentlicher, MD, JD; Timothy E. Quill, MD; Elliott Rosen, EdD; James A. Tulsky, MD and Lois Snyder, JD, Project Director. Joseph J. Fins dissented from the paper. Primary clinical staff to the Panel was Jason Karlawish, MD. Additional staffing was provided by Jennifer Klocinski.

Acknowledgments: The authors thank the University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel for their help in refining and focusing the manuscript and Maria Milella for help with manuscript preparation.

Grant Support: The Walter and Elise Haas Fund and the Wallace Alexander Gerbode Foundation supported the development of this paper and the Finding Common Ground Project on Assisted Suicide.

Requests for Single Reprints: Lois Snyder, JD, Center for Bioethics, University of Pennsylvania Health System, 3401 Market Street, Suite 320, Philadelphia, PA 19104-3308; e-mail lsnyder@mail.acponline.org.

Requests To Purchase Bulk Reprints (minimum, 100 copies): the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints@mail.acponline.org.

Current Author Addresses: Dr. Quill: Department of Medicine, The Genesee Hospital, 224 Alexander Street, Rochester, NY 14607.

Ms. Coombs Lee: Compassion in Dying Federation, 6312 SW Capitol Highway, Suite 415, Portland, OR 97201.

Ms. Nunn: Center for Bioethics, University of Pennsylvania Health System, 3401 Market Street, Suite 321, Philadelphia, PA 19104-3308.

Ann Intern Med. 2000;132(6):488-493. doi:10.7326/0003-4819-132-6-200003210-00011
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Comprehensive palliative care, as exemplified by many state-of-the-art hospice programs, is the standard of care for the dying. Although palliative care is very effective, physicians, nurses, patients, families, and loved ones regularly face clinically, ethically, legally, and morally challenging decisions throughout the dying process. This is especially true when terminally ill patients are ready to die in the face of complex, difficult-to-treat suffering and request assistance from their health care providers. Although physician-assisted suicide has received the most attention as a potential last-resort response, this practice remains illegal in the United States except in Oregon, and even there it is relatively infrequent. More commonly, decisions are made about accelerating opioid therapy for pain, forgoing life-sustaining therapy, voluntarily stopping eating and drinking, and administering terminal sedation in response to unacceptable suffering. The moral distinctions between these practices are critical to some but relatively inconsequential to others. This paper illustrates, through summaries of real clinical cases, how each of these practices might be used in response to patients in particular clinical circumstances, keeping in focus the patient's values as well as those of families, other loved ones, and health care providers. The challenge is to find the least harmful solution to the patient's problem without abandoning patients and their loved ones to unacceptable suffering or to acting in a more deleterious way on their own.





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