Ce numéro comprend les articles suivants : brain death at fifty: exploring consensus, controversy, and contexts ; would a reasonable person now accept the 1968 Harvard brain death report? A short history of brain death ; a path not taken: beecher, brain death, and the aims of medicine ; Beecher dépassé: fifty years of determining death, legally ; a conceptual justification for brain death ; brain death: a conclusion in search of a justification ; conceptual issues in DCDD donor death determination ; DCDD ddonors are not dead ; uncontrolled DCD: when should we stop trying to save the patient and focus on saving the organs? ; a defense of the dead donor rule ; the dead donor rule as policy indoctrination ; the public's right to accurate and transparent information about brain death and organ transplantation ; brain death and the law: hard cases and legal challenges ; rethinking brain death as a legal fiction: is the terminology the problem? ; respecting choice in definitions of death ; imposing death: religious witness on brain death ; death: an evolving, normative concept ; lessons from the case of Jahi McMath ; the case of Jahi McMath: a neurologist's view ; revisiting death: implicit bias and the case of Jahi MMath.
This chapter looks at stillbirth registration and levels of stillbirth mortality in 19th century Iceland from a Nordic comparative perspective....
In the first part I compare regulations on stillbirth registation and collection on statistics in Iceland with Danemark. The second part discusses the development of stillbirth mortality in both countries. This section also includes a comparison with Sweden.
OBJECTIVES: Physicians' decision-making in end-of-life (EOL) care includes many medical, ethical and juridical aspects. We studied the changes of these decisions over time and factors influencing them.
METHODS: A postal survey including two hypothetical patient scenarios was sent to 1258 Finnish physicians in 2015 and to 1182 in 1999. The attitudes, values and background factors of the physicians were also enquired.
RESULTS: The response rate was 56%. The physicians' decisions to choose palliative approaches over active or intensive care increased from 1999 to 2015 when a terminally ill prostate cancer patient had probable iatrogenic gastrointestinal bleeding (53% vs 59%, p=0.014) and waited to meet his son (46% vs 60%, p<0.001) or a minister (53% vs 71%, p<0.001). Training in EOL care independently increased palliative approaches. Patient's benefit (96% vs 99%, p=0.001), ethical values (83% vs 93%, p<0.001) and patient's (68% vs 86%, p<0.001) or physician's (44% vs 63%, p<0.001) legal protection were considered more influential to the decisions in 2015, while the family's benefit was regarded as less influential to the decisions than it was in 1999 (37% vs 25%, p<0.001). Physicians were more willing to give a hospice voucher for an advanced breast cancer patient in 2015 (34% vs 58%, p<0.001).
CONCLUSIONS: Our findings may reflect the transition to a stronger emphasis on patient-centred care and a stronger tendency to avoid futile therapies that have only short-term goals. The results highlight that education in all aspects of EOL care should be incorporated into the post-graduate training of medical specialties that take care of dying patients.
Health professionals have been known to override patients' advance directives. The most ethically problematic instances involve a directive's explicitly forbidding the administration of some life-prolonging treatment like resuscitation or intubation with artificial ventilation. Sometimes the code team is unaware of the directive, but in other instances, the override is done knowingly and intentionally with clinicians later pleading that it was done "in the patient's best interests." This article surveys a twenty-year period extending back to 1997 when ethicists began to question the legitimacy of overriding advance directives despite clinicians believing they had compelling reasons to do so. A legal and ethical analysis of advance directive overrides is provided as no court to date has awarded damages to plaintiffs who alleged their loved one suffered "wrongful life" following a successful life-prolonging intervention. A hypothetical scenario is especially discussed wherein a patient's DNR status is overridden because her cardiac arrest was caused by error whose effects might be reversible. The authors conclude with a strategy for mitigating certain vagaries associated with overriding advance directives, but suggest that until courts provide clinicians with clear guidelines and protections, violations of patients' advance directives are likely to continue.
Psychiatric advance directives (PADs) are legal documents that allow individuals with psychiatric illness to designate decisions, while competent, about their future psychiatric care were they to lose competency due to psychiatric illness in the future. Among other items, these documents often include preferences regarding a surrogate decision-maker, types of medications, doses and routes of medications, seclusion and restraints, electroconvulsive therapy, and instructions for care of their property while incapacitated. While the concept and legal recognition of PADs has existed in the United States for several decades, use of PADs by patients and familiarity with PADs among mental health providers remain limited. This column reviews the origin of PADs, discusses several commonly considered arguments for and against the use of these documents, and concludes with a discussion of how PADs are currently used in the United States and their potential future role in mental health treatment.
This work presents a historical analysis of death announcements (N = 1,443) posted in the New York Times between 1912 and 2002. Announcements were coded according to two main categories: the genre of the announcement and the presence of emotion words. Four distinct main genres emerged: death notices, memorials, recognition postings by organizations, and recognition postings by nonorganizational parties (friends and family). The proportion of death notices declined steadily from 1912 to 2002, while the proportion of announcements paying tribute to the deceased increased. The announcements were also analyzed in terms of emotion words used, and it is argued that the increasing frequency of emotion words used in the death announcements reflects a progressive emotionalization and psychologization of grief and loss.
This article examines the historical relationship between psychedelics and palliative care. Historians have contributed to a growing field of studies about how psychedelics have been used in the past, but much of that scholarship focused on interrogating questions of legitimacy or proving that psychedelics had therapeutic potential. Palliative care had not yet developed as medical sub-specialty, more often leaving dying care on the margins of modern, pharmaceutical-based treatments. As psychedelic researchers in the 1950s began exploring different applications for psychoactive substances such as LSD and mescaline, however, dying care came into clearer focus as a potential avenue for psychedelics. Before that application gained momentum in clinical or philosophical discussions, psychedelics were criminalized and some of those early discussions were lost. This article looks back at historical discussions about LSD's potential for easing the anxiety associated with dying, and considers how those early conversations might offer insights into today's more articulated discussions about psychedelics in palliative care.
With the pace of recent health care change, palliative care in the intensive care unit (ICU) will likely undergo its own transformation in the next three decades. A look back may help bring the future into clearer view.
[Début de l'article]
Understanding how informal care impacts formal care utilisation for home-based end-of-life patients is an important policy- and practice-relevant question. This paper aims to assess the relationship between informal and formal home care among home-based end-of-life patients and how this relationship has changed over the last decade and over the end-of-life trajectory. We focus on informal care provided by family members or friends, and three types of home-based formal care services: care by personal support workers, physician visits, and nurse visits. Using survey data collected in a home-based end-of-life care programme in Ontario, Canada from 2005 to 2016, we build a two-part utilisation model analysing both the propensity to use each type of formal care and the amount of formal care received by patients. The results suggest that informal care is a substitute for care by personal support workers, but a complement to physician visits and nurse visits. In the case of nurse visits, an increased complementary effect is observed in more recent years. For home-based physician and nurse visits, the complementary effect grows with patient's proximity to death. These results highlight the complexity of the relationship between informal and formal care among home-based end-of-life patients. Decision-makers need to take into account the relationship between informal care and different types of formal services when introducing future policies.
La prise en charge administrative et matérielle des foetus et des mort-nés tout au long de l'époque moderne se caractérise par la prédominance d'une définition religieuse des frontières de la vie, prédominance qui produit une invisibilisation complète des foetus et mort-nés, puisque ces derniers n'accèdent pas à la naissance sociale et spirituelle que constitue le baptême.
[Début de l'article]
This text is part of the chapter 7 of a special issue supplement called "Death and Dying in PICU" having Christopher S. Parshuram and Karen Dryden-Palmer as the guest editors. I present my personal perception regarding the modes of death and the dying process in Brazilian PICU over the last 30 years. A big change in this regard was observed in our country from the 1980s to nowadays. The PICU mortality rate decreased significantly from over 20% to below 5% as well as the modes of death being observed that the life support limitation is far the most frequent death process in the PICU. Palliative care, in the last 10 years, increased its coverage in our country and being frequently offered as a complementary care to terminal ill patients in the PICU.
But de l’article : Cette recherche interdisciplinaire est consacrée à l’évolution historique des pratiques funéraires en réponse aux demandes émotionnelles des parents en deuil d’un jeune enfant à partir de la naissance.
Méthodes : Revue des publications sur l’histoire des pratiques et les rites funéraires des jeunes enfants.
Résultats : On trouve des pratiques funéraires pour les enfants dès la Préhistoire. L’Antiquité est riche en monuments, épitaphes, objets funéraires réservés aux tout-petits. Ils signent la puissance économique ou politique des familles et montrent l’intensité de la souffrance des parents. Regret et nostalgie expriment la tristesse que l’enfant n’ait pu réaliser sa promesse de vie. Pour autant, les funérailles restent discrètes pour les enfants morts avant la pousse des dents. Malgré les infanticides qui semblent ne pas donner lieu à culpabilité ou à deuil, on ne peut pas conclure à l’indifférence des parents. Le Moyen Âge en Europe est surtout marqué par l’hégémonie de l’Église catholique qui refuse le repos de l’âme de l’enfant non baptisé. Le Limbus puerorum dans lequel errent les âmes ne satisfait pas les parents qui cherchent à tout prix le salut de leur enfant. Une possibilité de rédemption réside néanmoins dans les sanctuaires à répit.
Conclusion : La souffrance des parents est certaine dans toutes les périodes préhistoriques et historiques même si la mortalité élevée pourrait banaliser la mort des enfants. Elle s’exprime via les pratiques funéraires et la question de l’accès à l’au-delà, en raison de l’importance de la religion, ciment des sociétés antique et médiévale. Les rites sociaux sont recherchés pour leur soutien moral et leur inscription dans la société.
The question of whether to provide artificial nutrition and hydration (ANH) to a patient with terminal illness or at end of life has been debated over many years. Due to the nature of the question and the setting in which it presents, prospective trials are not feasible, and the health care professional is left to work with the patient and family to make decisions. This perspectives piece addresses the issue in a format designed to inform the reader as to the pertinent considerations around ANH. We briefly review significant historic, religious, ethical, and legal contributions to this discussion and physiologic underpinnings. We address the beliefs of patient, family, and health care providers surrounding this issue. Our goal is to provide a review of the considerations for health care providers as they address this issue with patients and families in the course of compassionate care.
Au 18e siècle, les cimetières autour des églises sont devenus insalubres
mais il faut attendre 1804 pour que Napoléon publie un décret sur les lieux servant de sépulture. Aucune inhumation n’aura lieu désormais dans les églises, temples, synagogues, hôpitaux… ni dans l’enceinte des villes et bourgs. Le cimetière doit être extérieur à la ville et il est désormais géré par la commune (et non plus par l’église) tout comme l’enregistrement des morts et des règles précises sont édictées pour le « déterrement », c’est-à-dire la collecte des os après la dissolution des chairs et leur regroupement dans un ossuaire.
[Début de l'article]
Background: The use of long-term care (LTC) is common in very old age and in the last years of life. It is not known how the use pattern is changing as death is being postponed to increasingly old age. The aim is to analyze the association between the use of LTC and approaching death among old people and the change in this association from 2000 to 2011.
Methods: The data were derived from national registers. The study population consists of 315 458 case-control pairs. Cases (decedents) were those who died between 2000 and 2011 at the age of 70 years or over in Finland. The matched controls (survivors) lived at least 2 years longer. Use of LTC was studied for the last 730 days for decedents and for the same calendar days for survivors. Conditional logistic regression analyses were performed to test the association of LTC use with decedent status and year.
Results: The difference in LTC use between decedents and survivors was smallest among the oldest (OR 9.91 among youngest, 4.96 among oldest). The difference widened from 2000 to 2011 (OR of interaction of LTC use and year increased): use increased or held steady among decedents, but decreased among survivors.
Conclusions: The use of LTC became increasingly concentrated in the last years of life during the study period. The use of LTC is also common among the oldest survivors. As more people live to very old age, the demand for LTC will increase.
BACKGROUND: I review the historical antecedents of the two key features of the bereavement exclusion (BE) for major depression (MD) criteria initially proposed in DSM-III: (i) a context-dependent approach to the evaluation of MD which required that the diagnosis be given only when course, symptoms and signs are 'out of proportion' to experienced adversities, and (ii) bereavement is the sole adversity for which this context-dependent approach should be utilized.
METHODS: A review of 49 textbook and review articles on depression or melancholia published 1880-1960.
RESULTS: Seventeen (35%) of the 49 texts advocated for a context-dependent approach to the diagnosis of MD. Most advocates relied on an intuitive clinical understanding of when the depressive features were v. were not commensurate with the experienced adversities. Several authors suggested that specific symptoms or course of illness could differentiate MD from 'normative' sadness. Others noted that patient reports of psychological causes of their depression should be treated skeptically. While death of loved ones was the most frequently noted specific adversity associated with MD, no author considered it qualitatively different from other stressors or suggested that it alone should be considered when diagnosing MD in a context-dependent manner.
CONCLUSIONS: A key underlying assumption of the BE criteria - a context-dependent approach to the diagnosis of MD- was advocated by a significant minority of earlier psychiatric diagnosticians, although problems in its clinical implementation were sometimes noted. No historical precedent was found for the application of the context-dependent approach only to bereavement, as proposed in DSM-III.