Painless Death Research Articles

Survey of staff and family members of patients in Bulgarian hospices on the concept of "good death".

The concept of a "good death" has been intensely discussed over the past decades. The objective of this study is to investigate this concept among staff and patients' relatives in 29 Bulgarian hospices and 5 palliative care units. Self-administered questionnaires were completed by 190 members of staff and 216 patients' relatives. Death without pain and suffering and death in one's sleep were leading concepts in both the groups. Staff preferred death in the presence of relatives, while relatives preferred fast and sudden death. Although we were able to define the common concept of a good death as painless and sudden death in one's sleep, death is unique phenomenon and good palliative care should be based on communication with patients about their idea of a good death.

Limitación del esfuerzo terapéutico: aproximación a una visión de conjunto

Over the past few decades, we have been witnessing that increasing fewer people pass away at home and increasing more do so within the hospital. More specifically, 20% of deaths now occur in an intensive care unit (ICU). However, death in the ICU has become a highly technical process. This sometimes originates excesses because the resources used are not proportionate related to the purposes pursued (futility). It may create situations that do not respect the person's dignity throughout the death process. It is within this context that the situation of the clinical procedure called "limitation of the therapeutic effort" (LTE) is reviewed. This has become a true bridge between Intensive Care and Palliative Care. Its final goal is to guarantee a dignified and painless death for the terminally ill.

Another Look at That Old Friend, Pneumonia

Before antibiotics, pneumonia was called “the old man's friend” for carrying the old and infirm to a swift and relatively painless death. Now that short-term survival after pneumonia is the rule, does the disease provide any …

The Use of Animal as Models: Ethical Considerations

The use of animals in scientific research is highly controversial. Older justifications, which referred to an immense gulf between human beings and other animals, can no longer be sustained in the face of a large body of scientific evidence concerning the similarities between human beings and other animals. The probability is very high that they are like us in many important ways, including in having a capacity to suffer. Because animals may suffer during research, their use must be justified. An appropriate justification will require that researchers can demonstrate that the expected benefits of the research, in terms of pure knowledge and medical applications, outweigh the suffering imposed. However, while the infliction of suffering on animal models must meet stringent conditions, research which involves the (painless) death of animals is often easier to justify, since few animals other than human beings possess the psychological capacities required to care about their future.

The Plight of Ethics

Since Kant, ethics has been synonymous with moral law, grounded in Reason. As Kant’s heirs, we are still grappling with a tension he sought to resolve through his appeal to a rational God, namely, between ethics and politics. “Politics says, ‘Be ye wise as serpents,’” remarks Kant: “Morality adds (as a limiting condition) ‘and guileless as doves’” (1795, 338). For Kant, both the serpent of politics and the dove of ethics are bound by the same moral duty that has its source in the freedom of our sovereign rational will. The perfection of this good will is possible not as individuals but only from the perspective of what Kant calls “Universal History from a Cosmopolitan Point of View,” which it turns out is a view from the cosmos, more specifically, from the perspective of the “dwellers from other planets” whom Kant imagines viewing us from their own place in the universe (1784, n. 2). As we know, Kant insists that the concept of duty cannot be in conflict with doing our duty—or that ought implies can: “It is patently absurd, having granted this concept of duty its authority, to want to say that one nevertheless cannot do it. For in that case this concept would of itself drop out of morals. . . . [H]ence, there can be no conflict of politics as doctrine of right put into practice, with morals, as theoretical doctrine of right” (1795, 338). But what if the reverse were true? What if ought implies cannot? What if our obligations always outstrip our intentions? What if the sovereign will is fundamentally beholden both to other people and to the Other The Plight of Ethics

Euthanasia: Evolving role of the psychiatrists in India

Byline: Bir. Chavan, Suravi. Patra The honorable Supreme Court of India passed a landmark judgment of legalizing passive euthanasia on 7 [sup]th March 2011. The 110-page long document which gave this verdict was delivered in response to a criminal writ petition filed on behalf of Aruna Ramchandra Shanbaug in 2009. The petitioner requested for withdrawal of feeding to bring an end to her suffering. She has been lying in a persistent vegetative state since last 36 years following attempt of sexual assault and strangulation by a ward boy when she was on duty at the K. E. M. Hospital. The staffs of the hospital have been providing her with supportive medical care since then. Justice Markandey Katju and Justice Gyan Sudha Mishra in their judgment commended the dedicated efforts of K. E. M. hospital in providing selfless continuous care to Aruna and dismissed the petition. The judgment accepted the significance of the doctrine of "parens patriae" while deciding the case where the affected person has lost the decision-making capacity. This doctrine recognizes the responsibility of the state in taking care of its citizens when they are in need of a father figure to take decision on their behalf. The bench felt that withdrawal of life-supporting measures cannot be left to the sole discretion of the treating physician, relative, care giver, or friend of a person. The judgment has laid provision for care givers of cognitively incapacitated persons to request for non-voluntary and passive euthanasia to the High Court. Till the legislation from the Parliament is in place, the judgment has cited the powers of article 226 of the constitution for such a provision. On receipt of any application for passive euthanasia, the High Court would appoint a board of doctors comprising a physician, a psychiatrist, and a neurologist to examine the patient based on which the court would take the decision about life-supporting treatment. Passive euthanasia is legalized in India in this process. [sup][1] Persistent vegetative state has resulted in Aruna being partially conscious and awake but unaware of her surroundings. Her higher mental functions as well as motor and sensory functions are compromised. The inability to experience self and the environment and the loss of capacity of voluntary control over self questions the very definition of being alive. Being alive is a continuous state of experience from the past to the future and the relationship with family, society, work, and culture rather than being a machine capable of carrying out biological functions. [sup][2] Mere presence of biological functioning cannot define life. The current clinical state of Aruna has sparked off the debate on euthanasia; is life unworthy of living worthy of ending? Is moral dimension of continuing life more important than quality of life? What would Aruna wish had she been capable of expressing her desire? Persistent vegetative state resulting from asphyxiating injury to brain has a poorer prognosis than a traumatic insult. [sup][3] With only 7% chance of improvement in the state of consciousness, the efficacy of current medical interventions remains questionable. Though these interventions can prolong life, their impact on quality of life is not encouraging. Many a times, these interventions are felt as merely prolonging the process of dying. Adding to this is the amount and extent of emotional and financial burden imposed on the care givers. Withdrawal of life-supporting treatment in such states is a difficult decision to take both by the treating physician as well as by the care givers. [sup][4] End of life decisions are complex with ethical, religious, moral, and legal implications. Autonomy and self-determinism have become the guiding principles of life. People have started talking about right to die. They have started deciding their time and mode of death. The whole idea is to have a comfortable painless death at a convenient time. …

Euthanasia: An Indian perspective.

In our society, the palliative care and quality of life issues in patients with terminal illnesses like advanced cancer and AIDS have become an important concern for clinicians. Parallel to this concern has arisen another controversial issue-euthanasia or “mercy –killing” of terminally ill patients. Proponents of physician-assisted suicide (PAS) feel that an individual's right to autonomy automatically entitles him to choose a painless death. The opponents feel that a physician's role in the death of an individual violates the central tenet of the medical profession. Moreover, undiagnosed depression and possibility of social ‘coercion’ in people asking for euthanasia put a further question mark on the ethical principles underlying such an act. These concerns have led to strict guidelines for implementing PAS. Assessment of the mental state of the person consenting to PAS becomes mandatory and here, the role of the psychiatrist becomes pivotal. Although considered illegal in our country, PAS has several advocates in the form of voluntary organizations like “death with dignity” foundation. This has got a fillip in the recent Honourable Supreme Court Judgment in the Aruna Shaunbag case. What remains to be seen is how long it takes before this sensitive issue rattles the Indian legislature.

P.1.c.045 Antinociceptive effect of levetiracetam in a mouse model of visceral pain

Hemlock was used as an analgesic in certain ethnopharmacological traditions and there has been no record about the antinociceptive effect of coniine which is the major alkaloid compound of Hemlock.The present study was undertaken to evaluate the possible antinociceptive activity of coniine.Antinociceptive activity of coniine was tested dose in Hotplate test (thermal pain model) and in Writhing test (chemical pain model) in different nociception models.Coniine caused a prolongation in reaction time in Hotplate test at 20 mg/kg dose. In addition, it was observed that coniine decreased the number of writhes in Writhing test. Both data indicated an antinociceptive effect of coniine. A rotarod test was also conducted in order to clarify, whether this activity was related with a loss of locomotion or with an analgesic activity. None of the chemical agents at those doses used in experiments caused a loss of locomotor activity. It was also shown that antinociceptive effect of morphine was potentialized by coniine which was inhibited by nicotinic receptor blocker mecamylamine (1 mg/kg).Coniine has antinociceptive effect via the nicotinic receptors. A pharmacological assessment about the painless death of Socrates due to Hemlock (coniine) toxicity has also been presented by using this data.

Cancer patients’ satisfaction with doctors and preferences about death in a university hospital in Turkey

ObjectiveTo determine the expectations and satisfaction levels of Turkish cancer patients regarding their doctors, their wishes about the place and process of dying and to elucidate factors affecting them. MethodsFor this cross-sectional study, a self-administered questionnaire was given to 150 cancer patients in 2009. ResultsAmong respondents, 63% stated that they would like to know all the details about their disease and they generally preferred a sudden, painless death, without any intervention at the last moment, but in a hospital. Almost all wanted a religious ceremony after their death. The question with the highest reported level of satisfaction was whether patients had complete trust in their doctors, whereas the least satisfaction was reported for doctors’ explanations during visits. Gender, tumour type and level of education had statistically significant effects on patient satisfaction. ConclusionThe majority of our cancer patients trusted doctors and wanted to learn more about the progress of their cancer, in contrast to the general tendency of their families to hide the diagnosis. The hospital is still the most preferred place for dying. Practice implicationsAlterations in communication may lead to disparities in patient outcomes; therefore, communication skill training should guide clinicians to recognise these tendencies.

Factors influencing the decision to use hanging as a method of suicide: qualitative study

Hanging is the most frequently used method of suicide in the UK and has high case fatality (>70%). To explore factors influencing the decision to use hanging. Semi-structured qualitative interviews with 12 men and 10 women who had survived a near-fatal suicide attempt. Eight respondents had attempted hanging. Data were analysed thematically and with constant comparison. Hanging was adopted or contemplated for two main reasons: the anticipated nature of a death from hanging; and accessibility. Those favouring hanging anticipated a certain, rapid and painless death with little awareness of dying and believed it was a 'clean' method that would not damage the body or leave harrowing images for others. Materials for hanging were easily accessed and respondents considered it 'simple' to perform without the need for planning or technical knowledge. Hanging was thus seen as the 'quickest' and 'easiest' method with few barriers to completion and sometimes adopted despite not being a first choice. Respondents who rejected hanging recognised it could be slow, painful and 'messy', and thought technical knowledge was needed for implementation. Prevention strategies should focus on countering perceptions of hanging as a clean, painless and rapid method that is easily implemented. However, care is needed in the delivery of such messages as some individuals could gain information that might facilitate fatal implementation. Detailed research needs to focus on developing and evaluating interventions that can manage this tension.

A survey of hospitals managing human rabies cases in India

A survey of 23 infectious diseases (ID) hospitals/ID wards of general hospitals was done during 2008-09 to assess the facilities for and management of rabies patients. All were Government hospitals and 0.5% of total beds was earmarked for rabies cases. The hospitals were mostly run by medical colleges (47.8%) and ID hospitals (30.4%) and located outside city limits (52.2%). The patients were admitted to 'rooms (39.1%)' and 'wards (43.5%)'. The general conditions of rabies sections i.e. sanitation and linen (65%), space and toilet (52% and 56%) and bed (47.8%) require improvements. There is a need to improve staff availability, use of personal protective wears, preventive vaccination of care providers and medicinal supplies. It is recommended to encourage hospitalization of human rabies cases to ensure a 'painless and dignified death' and this must be considered as a 'human rights' issue.

Antinociceptive activity of coniine in mice

Ethnopharmacological relevance Hemlock was used as an analgesic in certain ethnopharmacological traditions and there has been no record about the antinociceptive effect of coniine which is the major alkaloid compound of Hemlock. Aim of this study The present study was undertaken to evaluate the possible antinociceptive activity of coniine. Material and methods Antinociceptive activity of coniine was tested dose in Hotplate test (thermal pain model) and in Writhing test (chemical pain model) in different nociception models. Results Coniine caused a prolongation in reaction time in Hotplate test at 20 mg/kg dose. In addition, it was observed that coniine decreased the number of writhes in Writhing test. Both data indicated an antinociceptive effect of coniine. A rotarod test was also conducted in order to clarify, whether this activity was related with a loss of locomotion or with an analgesic activity. None of the chemical agents at those doses used in experiments caused a loss of locomotor activity. It was also shown that antinociceptive effect of morphine was potentialized by coniine which was inhibited by nicotinic receptor blocker mecamylamine (1 mg/kg). Conclusion Coniine has antinociceptive effect via the nicotinic receptors. A pharmacological assessment about the painless death of Socrates due to Hemlock (coniine) toxicity has also been presented by using this data.

Intractable Pain, Palliative Management and the Principle of Medical Futility

This monograph examines the issue of existential or psychological pain and how, heretofore, it has been dealt with by hospice or palliative care - concluding, as such, that terminal or deep sedation should be embraced more widely within the Ethic of Adjusted Care as a part of the compassionate management of the dying.The first element of palliative treatment in hospice care is symptom control - pharmacological and psychological - in the dying patient. Today, pain relief - be it physical, mental, social or spiritual - is being recognized more and more as a fundamental human right. If voluntary refusals by competent dying patients of hydration and nutrition are tolerated routinely by both the legal and medical professions, as well as society at large - even though these actions hasten death - then, surely, under the Doctrine of Mercy and/or Principle of Beneficence, assistance in relieving chronic, irremediable pain should be allowed when requested.The Principle of Medical Futility, supplemented by the Doctrine of Double Effect, can serve as a decisive tool for both physicians and judges when called upon to evaluate end-of-life care. If a patient is in a futile condition, efficacious treatment should be given even if the secondary effect of that assistance means hastening life's cruel and inhumane ending. Terminal sedation is just that: recognized treatment. It should not be confused, taxonomically, by denominating it as euthanasia, murder, or assisted suicide. Rather, it is but an act of self-determination.The time has come to step outside the mired and endless moral argumentation over the slippery slope consequence of validating a right, however exercised, to a good (painless) death and acknowledge - decisively - that standards of common decency, compassion and mercy demand nothing less.

Lethal Injection for Execution: Chemical Asphyxiation?

BackgroundLethal injection for execution was conceived as a comparatively humane alternative to electrocution or cyanide gas. The current protocols are based on one improvised by a medical examiner and an anesthesiologist in Oklahoma and are practiced on an ad hoc basis at the discretion of prison personnel. Each drug used, the ultrashort-acting barbiturate thiopental, the neuromuscular blocker pancuronium bromide, and the electrolyte potassium chloride, was expected to be lethal alone, while the combination was intended to produce anesthesia then death due to respiratory and cardiac arrest. We sought to determine whether the current drug regimen results in death in the manner intended.Methods and FindingsWe analyzed data from two US states that release information on executions, North Carolina and California, as well as the published clinical, laboratory, and veterinary animal experience. Execution outcomes from North Carolina and California together with interspecies dosage scaling of thiopental effects suggest that in the current practice of lethal injection, thiopental might not be fatal and might be insufficient to induce surgical anesthesia for the duration of the execution. Furthermore, evidence from North Carolina, California, and Virginia indicates that potassium chloride in lethal injection does not reliably induce cardiac arrest.ConclusionsWe were able to analyze only a limited number of executions. However, our findings suggest that current lethal injection protocols may not reliably effect death through the mechanisms intended, indicating a failure of design and implementation. If thiopental and potassium chloride fail to cause anesthesia and cardiac arrest, potentially aware inmates could die through pancuronium-induced asphyxiation. Thus the conventional view of lethal injection leading to an invariably peaceful and painless death is questionable.

Physician participation in lethal injection executions

Lethal injection has come under fire as less than the peaceful, painless death it appears. Reevaluation of the process has sparked examination of the role of doctors in state-sponsored executions. Physicians helped design the lethal injection protocol. Seventeen death penalty states require physician involvement and all practicing jurisdictions employ medical personnel. Doctors have signed death warrants, rendered inmates competent, provided intravenous access, monitored vital signs, administered lethal injections and declared death. Remarkably, lethal injections are administered remotely and neither physicians nor other execution personnel assess depth of anesthesia prior to injection of the painful lethal drugs. Recently physicians have helped precipitate an unprecedented public and judicial review of lethal injection through expert testimony in litigation and by publishing evidence of potential awareness in execution. In response, judges have ordered protocol modifications to extend further the tools and expertise of medicine into the execution chamber in order to ensure anesthesia. Physician involvement created and perpetuates the seriously flawed protocol of lethal injection. Physicians and particularly anesthesiologists now have the opportunity to redress the mistakes of the past, and inform the growing debate over whether and potentially how medicine should be used to kill.

Methods of filicide: stepparents and genetic parents kill differently.

Stepparents commit filicide at higher rates than do genetic parents. According to M. Daly and M. I. Wilson (1994), motivational differences generate differences in the methods by which stepparents and genetic parents kill a child. Using Canadian and British national-level databases, Daly and Wilson (1994) found that stepfathers were more likely than genetic fathers to commit filicide by beating and bludgeoning, arguably revealing stepparental feelings of bitterness and resentment not present to the same degree in genetic fathers. Genetic fathers, in contrast, were more likely than stepfathers to commit filicide by shooting or asphyxiation, methods which often produce a relatively quick and painless death. We sought to replicate and extend these findings using a United States national-level database of over 400,000 homicides. Results replicate those of Daly and Wilson (1994) for genetic fathers and stepfathers. In addition, we identified similar differences in the methods by which stepmothers and genetic mothers committed filicide. Discussion addresses stepparental psychology in light of the current research, limitations of the current study, and future directions for research on this topic.

Killing With Kindness: An Inquiry into the Routinized Destruction of Companion Animals

The destruction of millions of companion animals each year in animal shelters is often overlooked in conversations about animal rights, perhaps because these killings occur under the auspices of organizations committed to the welfare of animals and are necessitated by the acts and omissions of third parties. Moreover, such killings are universally justified by the assertion that a painless death is a lesser evil than other available alternatives. The entrenched belief that the alternatives are unambiguously worse has led to the interesting result that there has been little or no moral outcry against the widespread killing of companion animals in shelters. Alan Beck describes this curious phenomenon: For the animal welfare movement the major issue is not death, but suffering. Millions of dogs and cats are killed annually in animal shelters with the support of the humane movement, because of the perception that they are off dead than suffering the indignities of homelessness. It is interesting that the notion better off dead than underfed has never been challenged by an animal equivalent of the Right to Life movement protecting the human's absolute right to live regardless of the circumstances (18-19).

MANAGING PAIN AT THE END OF LIFE

There are many threats to a calm and peaceful passing, but none more distressing than unrelenting pain. Pain exists not only in the physical realm, but also in the psychological, social and spiritual senses. Discussion of barriers and responsibilities are important to assure that pain is appropriately treated. Effective pain treatment relies on communication among patients, families, and care providers. Nurses are a central force in this communication and must act as leaders and advocates in planning care and relieving pain in dying patients.

EM1: RISK ATTITUDE: ASSOCIATION WITH MAGNITUDE OF RISK AND PATIENT CHARACTERISTICS

BACKGROUND: Decision analytic models typically compare strategies using expected values, which assumes risk neutrality in all situations for all individuals. OBJECTIVE: Examine how risk attitude is affected by the magnitude of the risk involved, and by the sociodemographic characteristics of the patient. METHODS: A set of 5 related standard gambles was created. In all of them the patient has an asymptomatic disease that will cause painless death in 5 years. The only treatment is a pill that only works if taken immediately. If successful, the patient will live for 15 years. The 5 scenarios correspond to 0–4 years until death in the event of treatment failure. The probability of failure was varied to establish the break-even point. The expected break-even point was calculated based on expected values. Risk attitude was measured using the Risk Attitude Ratio (RAR), the ratio of the individual's break-even point to the expected break-even point. RAR = 1 indicates perfect risk neutrality, with lower values indicating risk adversity. Regression models for each scenario were constructed for RAR, with regressors based on age, race, sex, education, income and marital status. Additionally, a hierarchical linear model was constructed using data from all 5 scenarios. RESULTS: 167 people were surveyed. Significant risk adversity was observed in all scenarios. Mean break-even points ranged from .07–.35. When treatment failure meant immediate death, risk aversity was great with no statistically significant associations. As time until death increased, RAR increased (less risk averse) and was associated with sex, race and marital status. These associations were upheld in the overall model. Males and the previously married were less risk averse. African-Americans were more risk averse. CONCLUSIONS: Risk attitude varies according to the specifics of the gamble as well as sociodemographics. Assumptions of risk neutrality may be particularly poor in cases where treatment failure carries a severe penalty.

Nurses' and physicians' views about euthanasia

Nurses' and physicians' views about euthanasia were investigated using a questionnaire that was answered by 113 nurses and 83 physicians in the internal medicine and surgery inpatient services of Hacettepe University Adult Hospital, Ankara, Turkey. The data were evaluated with Chi-square statistical test and percentages. The study results showed that both nurses and physicians define euthanasia as "a person's right to die." Nurses responded that euthanasia may be appropriate with terminally ill elderly patients; however, physicians responded that it may be appropriate with patients at any age who are in the last stage of a terminal illness. Although both groups accepted euthanasia conditionally, they stressed that, in practice, the primary responsibility should be with patients and their relatives. When faced with a patient who wishes a painless death, nurses said that they feel helpless, anxious and guilty, and find themselves in a dilemma. However, physicians responded that they feel satisfied that they are doing the right thing in continuing the patient's medical therapy.