A continuum for using placebo interventions in regional anesthesia and analgesia studies.

The anesthesiologist Henry K. Beecher is commonly associated with his crusade for informed consent for research. Less recognized is his contribution to the development of principles of randomized controlled trials through his emphasis on surgery as placebo to minimize bias. This article reviews Beecher's contribution and how it should be applied to modern studies of perioperative analgesia.

End-of-life decision-making in the United States.

Decision-making at the end-of-life in the United States has evolved over the last 50 yr, beginning with the development of the concept of brain death as a criterion for permitting patients who are in a state of 'irreversible coma' to be considered as 'dead' for purposes of ventilator withdrawal and organ transplantation. Since then, a firm consensus has emerged in American law and ethics that 'Patients have a virtually unlimited right to refuse any unwanted medical treatment, even if necessary for life itself.' With regard to patients who are unable to make decisions for themselves, both Europe and the United States are converging toward a view that respects a role for surrogates in decision-making while recognizing the need to limit their authority. Beyond decisions to withdraw and withhold treatments, both the United States and Europe are experimenting with active hastening of the dying process through euthanasia and physician-assisted suicide. In the author's opinion, the next big question to be addressed in end-of-life decision-making is 'Just how bad does the neurological condition and prognosis need to be before it is acceptable to allow a decision to withdraw life support'? Although the practices described here have wide acceptance throughout the United States and Europe, the worldwide emergence of religious fundamentalism and the associated vitalistic view about the sanctity of life may result in significant changes over the next few decades.

'Round-table' ethical debate: is a suicide note an authoritative 'living will'?

Living wills are often considered by physicians who are faced with a dying patient. Although popular with the general public, they remain problems of authenticity and authority. It is difficult for the examining physician to know whether the patient understood the terms of the advance directive when they signed it, and whether they still consider it authoritative at the time that it is produced. Also, there is little consensus on what spectrum of instruments constitutes a binding advance directive in real life. Does a 'suicide note' constitute an authentic and authoritative 'living will'? Our panel of authorities considers this problem in a round-table discussion.

End-of-life care in the pediatric intensive care unit: attitudes and practices of pediatric critical care physicians and nurses.

OBJECTIVE: To determine the attitudes and practices of pediatric critical care attending physicians and pediatric critical care nurses on end-of-life care. DESIGN: Cross-sectional survey. SETTING: A random sample of clinicians at 31 pediatric hospitals in the United States. MEASUREMENTS AND MAIN RESULTS: The survey was completed by 110/130 (85%) physicians and 92/130 (71%) nurses. The statement that withholding and withdrawing life support is unethical was not endorsed by any of the physicians or nurses. More physicians (78%) than nurses (57%) agreed or strongly agreed that withholding and withdrawing are ethically the same (p < .001). Physicians were more likely than nurses to report that families are well informed about the advantages and limitations of further therapy (99% vs. 89%; p < .003); that ethical issues are discussed well within the team (92% vs. 59%; p < .0003), and that ethical issues are discussed well with the family (91% vs. 79%; p < .0002). On multivariable analyses, fewer years of practice in pediatric critical care was the only clinician characteristic associated with attitudes on end-of-life care dissimilar to the consensus positions reached by national medical and nursing organizations on these issues. There was no association between clinician characteristics such as their political or religious affiliation, practice-related variables such as the size of their intensive care unit or the presence of residents and fellows, and particular attitudes about end-of-life care. CONCLUSIONS: Nearly two-thirds of pediatric critical care physicians and nurses express views on end-of-life care in strong agreement with consensus positions on these issues adopted by national professional organizations. Clinicians with fewer years of pediatric critical care practice are less likely to agree with this consensus. Compared with physicians, nurses are significantly less likely to agree that families are well informed and ethical issues are well discussed when assessing actual practice in their intensive care unit. More collaborative education and regular case review on bioethical issues are needed as part of standard practice in the intensive care unit.

Debate: what constitutes 'terminality' and how does it relate to a living will?

A moribund and debilitated patient arrives in an emergency department and is placed on life support systems. Subsequently it is determined that she has a 'living will' proscribing aggressive measures should her condition be judged 'terminal' by her physicians. But, as our round table of authorities reveal, the concept of 'terminal' means different things to different people. The patient's surrogates are unable to agree on whether she would desire continuation of mechanical ventilation if there was a real chance of improvement or if she would want to have her living will enforced as soon it's terms were revealed. The problem of the potential ambiguity of a living will is explored.

End-of-life care in the pediatric intensive care unit after the forgoing of life-sustaining treatment.

OBJECTIVE: To describe the attitudes and practice of clinicians in providing sedation and analgesia to dying patients as life-sustaining treatment is withdrawn. STUDY DESIGN: Prospective case series of 53 consecutive patients who died after the withdrawal of life-sustaining treatment in the pediatric intensive care unit at three teaching hospitals in Boston. Data on the reasons why medications were given were obtained from a self-administered anonymous questionnaire completed by the critical care physician and nurse for each case. Data on what medications were given were obtained from a review of the medical record. RESULTS: Sedatives and/or analgesics were administered to 47 (89%) patients who died after the withdrawal of life-sustaining treatment. Patients who were comatose were less likely to receive these medications. Physicians and nurses cited treatment of pain, anxiety, and air hunger as the most common reasons, and hastening death as the least common reason, for administration of these medications. Hastening death was viewed as an "acceptable, unintended side effect" of terminal care by 91% of physician-nurse matched pairs. The mean dose of sedatives and analgesics administered nearly doubled as life-support was withdrawn, and the degree of escalation in dose did not correlate with clinician's views on hastening death. CONCLUSION: Clinicians frequently escalate the dose of sedatives or analgesics to dying patients as life-sustaining treatment is withdrawn, citing patient-centered reasons as their principle justification. Hastening death is seen as an unintended consequence of appropriate care. A large majority of physicians and nurses agreed with patient management and were satisfied with the care provided. Care of the dying patient after the forgoing of life-sustaining treatment remains underanalyzed and needs more rigorous examination by the critical care community.

Sedation for intractable distress of a dying patient: acute palliative care and the principle of double effect.

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded the Kenneth B. Schwartz Center at MGH. The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient, support to caregivers, and encourages the healing process. The Center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. The case presented is of a young man dying of recurrent epithelioid hemangioendothelioma, distressed with stridor and severe pain, whose poorly controlled symptoms were successfully treated with an infusion of propofol, titrated to provide effective comfort in the last few hours of the patient's life. The tenet of double effect, which allows aggressive treatment of suffering in spite of foreseeable but unintended consequences, is reviewed. The patient's parents were invited and contributed to the Rounds, providing compelling testimony to the power of the presence of clinicians at the time of death and the importance of open communication about difficult ethical issues.

Autopsy consent practice at US teaching hospitals: results of a national survey.

BACKGROUND: Autopsy rates continue to fall despite the enduring benefit of the procedure to families and medical science, yet there are few data about the consent process itself. OBJECTIVE: To evaluate the current practice of obtaining autopsy consent, by assessing the consent forms currently in use, the knowledge and attitudes of chief residents on the procedure, and the expert opinion of pathologists in those institutions. DESIGN: Cross-sectional survey. SETTINGS AND PARTICIPANTS: One hundred twenty-seven US teaching hospitals. RESULTS: Of all autopsy consent forms we surveyed, 84.7% contained 7 of 10 elements recommended by the College of American Pathologists. Only 7.1% of institutions supplied educational materials for the physician, as recommended by the College of American Pathologists. Overall, 50.1% of chief residents reported deficiencies in their knowledge of the autopsy procedure. Correspondingly, greater than 74.5% felt that educational materials would be beneficial for physicians and the family. Finally, 93.3% of chief residents believed that a limited autopsy should be offered to families, while 68 (90%) of 76 pathologists at these institutions believed that limited autopsies are an unsatisfactory alternative to the complete procedure. CONCLUSIONS: Chief residents at US teaching hospitals reported substantial deficiencies in their knowledge about autopsy and desire more training on the consent process. Autopsy consent forms are often lacking information that might help physicians and families in making an educated choice about autopsy. Teaching institutions need to reevaluate the training for the autopsy consent practice.