Dans le débat sur la fin de vie qui anime la société française, le citoyen est sommé d’avoir un avis bien tranché et de dire si, oui ou non, il est favorable à l’euthanasie. Mais sommes-nous bien "armés" pour penser la fin de vie ? Connaissons-nous les implications éthiques, les droits du patient et des familles, les dispositions légales autour des obligations des médecins et des soins palliatifs ?
En clarifiant, de façon méthodique et pédagogique, les notions fondamentales de finitude, souffrance, dignité et liberté, Jacques Ricot permet à chacun de mieux comprendre tous les enjeux philosophiques, sociétaux et juridiques de la fin de vie.
Dans cette 2e édition entièrement revue, l’auteur poursuit sa réflexion éthique en proposant plusieurs enseignements autour de la vie et de la mort de Vincent Lambert et en décrivant l’évolution récente du débat sur la légalisation de l’euthanasie.
Palliative care (PC) names as one of its central aims to prevent and relieve suffering. Following the concept of "total pain", which was first introduced by Cicely Saunders, PC not only focuses on the physical dimension of pain but also addresses the patient's psychological, social, and spiritual suffering. However, the goal to relieve suffering can paradoxically lead to a taboo of suffering and imply adverse consequences. Two scenarios are presented: First, PC providers sometimes might fail their own ambitions. If all other means prove ineffective terminal sedation can still be applied as a last resort, though. However, it may be asked whether sedating a dying patient comes close to eliminating suffering by eliminating the sufferer and hereby resembles physician-assisted suicide (PAS), or euthanasia. As an alternative, PC providers could continue treatment, even if it so far prove unsuccessful. In that case, either futility results or the patient might even suffer from the perpetuated, albeit fruitless interventions. Second, some patients possibly prefer to endure suffering instead of being relieved from it. Hence, they want to forgo the various bio-psycho-socio-spiritual interventions. PC providers' efforts then lead to paradoxical consequences: Feeling harassed by PC, patients could suffer even more and not less. In both scenarios, suffering is placed under a taboo and is thereby conceptualised as not being tolerable in general. However, to consider suffering essentially unbearable might promote assisted dying not only on an individual but also on a societal level insofar as unbearable suffering is considered a criterion for euthanasia or PAS.
The paper presents an account of suffering as a multi-level phenomenon based on concepts such as mood, being-in-the-world and core life value. This phenomenological account will better allow us to evaluate the hardships associated with dying and thereby assist health care professionals in helping persons to die in the best possible manner. Suffering consists not only in physical pain but in being unable to do basic things that are considered to bestow meaning on one's life. The suffering can also be related to no longer being able to be the person one wants to be in the eyes of others, to losing one's dignity and identity. These three types of suffering become articulated by a narrative that holds together and bestows meaning on the whole life and identity of the dying person. In the encounter with the patient, the health-care professional attempts to understand the suffering-experience of the patient in an empathic and dialogic manner, in addition to exploring what has gone wrong in the patient's body. Matters of physician assisted suicide and/or euthanasia-if it should be legalized and if so under which conditions-need to be addressed by understanding the different levels of human suffering and its positive counterpart, human flourishing, rather than stressing the respect for patient autonomy and no-harm principles, only. In this phenomenological analysis the notions of vulnerability and togetherness, ultimately connecting to the political-philosophical issues of how we live together and take care of each other in a community, need to be scrutinized.
"When death knocks at the door of our ward, we do not easily open the door", an intensivist once said. In the intensive care unit (ICU) and emergency department, care is strongly focused on cure and resuscitation. Notwithstanding the technological progress made in intensive and emergency medecine, a substantial number of the partients admitted to the ICU cannot be saved.
Witnessing end-of-life suffering of loved ones is an underappreciated stressor that may affect caregiver bereavement. We interviewed 61 spousal caregivers of hospice patients who died within the past 6–18 months. Higher rumination about suffering and lower feelings of relief was related to poorer well-being. Rumination by caregivers about end-of-life suffering was an important predictor of depression and complicated grief. Most caregivers viewed the death as at least in part a relief. One important focus of grief support may be to help caregivers find productive ways to avoid rumination and use other forms of coping and to acknowledge feelings of relief.
In this retrospective study, determinants of unbearable suffering in hospice patients who died due to euthanasia were analyzed. The four dimensions of suffering (physical, psychological, social, and existential) were used as a framework. 28 patients (5% of all admitted patients in nine years) were included. Most patients indicated 3–5 determinants, predominantly a combination of physical (96% of patients) and existential determinants (89%). Fatigue, anorexia, and dry mouth were the most prevalent and severe symptoms. Psychological (21%) and social determinants (4%) were much less often described. The results of this study may be used to assess determinants playing a role in euthanasia requests.
Introduction: the concept of total suffering is well known to palliative care, and it indicates that there are several complex and correlated factors, which contribute to a dynamic and unique experience of one's illness trajectory. Research on terminally ill patients' will to live (WtL) has revealed important insights on its fluctuations over time and its correlated factors. We report an N-of-1 case study with the aim of examining the concept of total suffering objectively, and the WtL trajectory over time, its fluctuations, as well as its possible correlation with other distressing symptoms in a terminally ill cancer patient.
Case Description: souffrA 72-year-old cancer patient who verbalized total suffering and a low WtL. We used the Edmonton Symptom Assessment Scale (ESAS), added an additional WtL question, and asked the patient to rate her suffering using the ESAS twice daily (morning and afternoon) for a period of 28 days. Spearman's correlation coefficients between all physical and psychosocial ESAS items were statistical significant in 34 of the 45 performed correlations (30 highly significantly correlations and 4 in a lesser degree). WtL trajectory was fluctuant through the course of the illness, and significant correlations between WtL and all ESAS items were found, except for shortness of breath and drowsiness (after Bonferroni correction). High positive correlations were found between WtL and ESAS total score and ESAS physical and psychological subscores.
Discussion: Developing evidence-based understanding of total suffering and WtL in the terminally ill will lead to better approaches to patients and their loved ones.
L'auteur propose une réflexion en cinq temps. Il revient, d'abord sur la complexité de ce qui est à réfléchir en insistant sur la notion d'incertitude comme présupposé éthique de toute réflexion-décision. Puis, il considère la notion de souffrance pensée au coeur de l'expérience du corps et de la vie. Ceci lui permet d'envisager la notion de souffrance spirituelle comme lieu d'inscription herméneutique du vécu de la souffrance sollicitant une sédation. La prise en compte de cette dimension spirituelle remet ensuite les notions d'interdisciplinarité et de compétence pour répondre à une demande de sédation. Ceci permet, au terme de ce parcours réflexif, de situer la demande rituelle comme modalité intersubjective d'entrée en sédation.
[Adapté de l'Intro.]
Background: Requests for physician-assisted death (PAD) in patients with cognitive impairment are complex and require careful consideration. Of particular difficulty is determination of whether the request is voluntary and well considered.
Results: Euthanasia and physician-assisted suicide (PAS) are both legal in The Netherlands, Luxemburg, Colombia, and Canada. Euthanasia is legal in Belgium, while PAS is legal in Switzerland and Oregon, Washington, Montana, Vermont, and California (USA). Upon a PAD request, evaluation of the capacity to consent medical treatment is relevant for the decision-making process, while evaluation of testamentary capacity is appropriate before an advance euthanasia directive is written. Anosognosia assessment throughout the Alzheimer's disease continuum provides essential and relevant information regarding the voluntary and well-considered nature of the PAD request; meanwhile, early assessment of hypernosognosia or subjective cognitive decline assists in formulation of a clinical prognosis. Furthermore, the assessment of physical and psychological suffering should incorporate verbal and nonverbal cues as well as consideration of the psychosocial factors that might affect due care criteria.
Conclusion: The clinical approach to a PAD request should consider the legal framework and the decision-making capacity, assess memory deficit awareness and the perception of suffering, and evaluate mental competency when considered pertinent.
This article argues that while the presence and influence of "futility" as a concept in medical decision-making has declined over the past decade, medicine is seeing the rise of a new concept with similar features: suffering. Like futility, suffering may appear to have a consistent meaning, but in actuality, the concept is colloquially invoked to refer to very different experiences. Like "futility," claims of patient "suffering" have been used (perhaps sometimes consciously, but most often unconsciously) to smuggle value judgments about quality of life into decision-making. And like "futility," it would behoove us to recognize the need for new, clearer terminology. This article will focus specifically on secondhand claims of patient suffering in pediatrics, but the conclusions could be similarly applied to medical decisions for adults being made by surrogate decision-makers. While I will argue that suffering, like futility, is not sufficient wholesale justification for making unilateral treatment decisions, I will also argue that claims of patient suffering cannot be ignored, and that they almost always deserve some kind of response. In the final section, I offer practical suggestions for how to respond to claims of patient suffering.
La présente étude expose le contexte d’origine de la loi relative à l’euthanasie et les circonstances dans lesquelles elle a été pensée et adoptée. Elle rend compte des principaux débats qui ont émaillé l’élaboration du texte de loi et des grands choix opérés. Ensuite, elle fait état des difficultés et controverses apparues sur le terrain de l’interprétation et du contrôle des conditions de la loi. Enfin, elle donne un aperçu des débats en cours et propositions de loi visant à étendre le champ d’application de la loi.
OBJECTIVES: To consider the impact of juvenile Huntington disease (JHD) from a biomedical, symptom burden, and total pain palliative care perspective.
METHODS: This case report was informed by a narrative review of the literature with inclusion of expert opinion from pediatric palliative care, an adult and pediatric neurologist, and a child psychiatrist. Audio-recorded qualitative interview and coauthorship with the pediatric patient's primary caregiver (his mother).
RESULTS: The JHD impacts all domains of child and family function.
SIGNIFICANCE OF RESULTS: Application of the concept of total pain to JHD informs and guides care for this complex, challenging condition.
INTRODUCTION: The prevention and relief of suffering are regarded as a goal at the end of life; therefore, suffering assessment at the end of life is essential. In this regard, we need instruments that allow us to evaluate this construct for gathering more evidence, as the assessment of suffering is increasingly used in research and the clinical setting. Many measures have been designed to assess this construct, and the selection of the most appropriate instrument is crucial. The aims of this systematic review are to (1) identify the measures assessing suffering in patients with advanced disease and their psychometric properties and (2) evaluate the methodological quality of studies on measurement properties.
METHODS AND ANALYSIS: The protocol of this systematic review was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols Guidelines. A systematic psychometric review of measures assessing suffering in patients with advanced disease and their psychometric properties will be carried out according to the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN). The search strategy will be performed following the Peer Review of Electronic Search Strategies. Searches will be conducted in Cumulative Index to Nursing and Allied Health Literature, Medline, PsycINFO, Cochrane Library, SciELO, Open Grey, Scopus, Web of Science and COSMIN database of systematic reviews, and it will be limited by time (1980-2018) and language (only literature in English and Spanish). Literature will be evaluated by two independent reviewers according to the COSMIN checklist, and measurement properties data of each study that meet the inclusion criteria will be scored independently by two researchers according to COSMIN quality ratings.
ETHICS AND DISSEMINATION: Ethical approval is not necessary for systematic review protocols. The results will be disseminated by publication in a peer-reviewed journal and presented at a relevant conference.
BACKGROUND: The population of end-stage renal failure (ESRF) receiving dialysis treatment is increasing worldwide. For most patients with ESRF, dialysis can extend their life. However, treatment can be demanding and time-consuming. Despite dialysis treatment, many patients continue to experience various sufferings.
METHODS: A qualitative study was conducted with semi-structured interviews to explore the experiences of suffering of ESRF patients on maintenance dialysis in Malaysia. The results were thematically analyzed.
RESULTS: Nineteen ESRF patients were interviewed. The themes and subthemes were: (I) physical suffering-physical symptoms and functional limitations, (II) psychological suffering-the emotions and thoughts of suffering, (III) social suffering-healthcare-related suffering and burdening of others and (IV) spiritual suffering-the queries of suffering.
CONCLUSIONS: These findings may help healthcare professionals to fill in the gaps in the delivery of best renal palliative care.
Trop souvent, les groupes de réflexion éthique peinent à mobiliser les soignants. Manque de temps, réticence du management, prise de parole difficile. les arguments ne manquent pas. Pourtant, leur participation active est indispensable au bon déroulement du questionnement éthique. Pour leur bien-être au travail, mais avant tout pour une meilleure prise en charge des patients.
Origine : BDSP. Notice produite par APHPDOC R0xGsF79. Diffusion soumise à autorisation
Cette communication a été présentée lors du Colloque "Laïcité et multiculturalisme dans la relation de soins : du texte à l'action" à l'Université Laval, le 16 octobre 2017. Il s'agissait d'une présentation de vingt minutes. Le style oral de la communication a été conservé.
Le 22 avril 2005, était promulgée la loi "relative aux droits des malades et à la fin de vie". Son examen au Sénat avait été tumultueux, mais le débat à l'Assemblée nationale avait été marqué par une grande sérénité et la volonté de dépasser les oppositions partisanes. Cela mérite d'être relevé et apprécié à sa juste valeur, d'autant que le temps d'élaboration de la loi avait été précédé par une période de profonde émotion collective entretenue par l'intense médiatisation d'un fait divers promu au rang de drame national.
Ce livre fait le point sur la réflexion éthique, philosophique et psychanalytique pour parvenir à appréhender la souffrance humaine face à l'approche de la mort tout en fournissant des repères sur ce que vit la personne en situation palliative.
A randomized controlled study was conducted to evaluate the efficacy of 20-minute mindful breathing in suffering reduction. Forty palliative care patients with an overall suffering score of 4 or above as measured with the Suffering Pictogram were recruited and randomly assigned to 20-minute mindful breathing or 20-minute supportive listening. There was statistically significant reduction of suffering score in both the groups. For Bispectral Index Score value, there was statistically significant difference between intervention and control. A 20-minute mindful breathing could be useful in the alleviation of suffering in palliative care.
Différentes analyses de la manière de représenter et d'appréhender la maladie ou la personne souffrante dans les arts, qu'il s'agisse de la littérature, du théâtre, de la musique, de la peinture, du cinéma ou encore des séries télévisées.