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Correspondence |

Clinical Guidelines and Clinicians' Intentions in End-Of-Life Care FREE TO VIEW

Mohamed Y. Rady, MD, PhD; Joseph L. Verheijde, MBA, PhD; Joan L. McGregor, PhD
Author and Funding Information

Affiliations: Mayo Clinic Hospital, Mayo Clinic Arizona Phoenix, AZ,  Arizona State University Tempe, AZ

Correspondence to: Mohamed Y. Rady, MD, PhD; e-mail: rady.mohamed@mayo.edu

*These authors contributed equally to this work.


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;135(6):1696-1697. doi:10.1378/chest.09-0084
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To the Editor:

Guidelines that broadly interpret the principle of double effect can enable the practice of consensual and nonconsensual euthanasia (ie, physician-assisted death) under the premise of palliation. Kuschner and colleagues1 implemented guidelines following alleged euthanasia in four ICU patients so as to avoid wide-ranging interpretations about end-of-life care. However, these guidelines can inherently generate more confusion about clinicians' intentions and actions when the recovery of transplantable organs is added as a treatment goal in patients dying in the ICU.1,2 Such guidelines are recommended as good palliative care, although transplantable organs may be recovered from donors before fulfilling the legal definition of death.3

Furthermore, Kuschner and colleagues1 state that “Opioids or benzodiazepines used to treat [discomfort] after withdrawal of ventilator support do not appear to hasten death. The important principle is that opioids and sedating medications should be titrated to achieve the desired effect of [comfort].” Titrating continuous infusions of opioids and/or sedatives for subjective symptoms such as “discomfort” and/or achieving “comfort” allow broad interpretations by clinicians of the desired effect and dosage.1,2 Such broadness reinforces the ambiguities favored mainly by advocates of conflating the practice of euthanasia and physician-assisted death (an intended death) with the practice of palliation (a foreseen death).4 The use of continuous (vs intermittent) infusions of opioids and sedatives can also cause ambiguities and uncertainties regarding intentions and causations allowing for psychological acceptance of euthanasia as palliation.5

One argument has been made6 to invoke the morally distinct action of “the devil's choice” for those venturing into practices conflating euthanasia and physician-assisted death with palliation. However, many religions and cultures condemn intentionally hastening death. Clinicians are reminded that:

The principle of double effect is at home in a tradition of morality which takes seriously the moral psychology of the one who acts. Therefore, a focus on intention (among other things) is included in any moral appraisal of human action … other things also matter, such as the moral nature or moral kind of an act (whether it is an act of deception or of honesty, of empathy or manipulation), the intention with which an act is performed (whether to alleviate pain or to end a person's life, to teach or to misguide), the motive with which an act is performed (whether out of kindness or contempt, generosity or selfishness), and the kind of person we become when we act in one way or another (a healer or a killer, a teacher or a liar).6

Intentions are private and often undisclosed. Neither the law nor practice guidelines can regulate the true intentions and safeguard the integrity of actions. Only bedside clinicians can.

Kuschner WG, Gruenewald DA, Clum N, et al. Implementation of ICU palliative care guidelines and procedures. Chest. 2009;135:26-32. [PubMed] [CrossRef]
 
Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med. 2008;36:953-963. [PubMed]
 
Miller FG, Truog RD. Rethinking the ethics of vital organ donations. Hastings Cent Rep. 2008;38:38-46. [PubMed]
 
Truog R. Not euthanasia, simply compassionate clinical care. Crit Care Med. 2008;36:1387-1388. [PubMed]
 
Douglas C, Kerridge IAN, Ankeny R. Managing intentions: the end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia. Bioethics. 2008;22:388-396. [PubMed]
 
McCabe H. End-of-life decision-making, the principle of double effect, and the devil's choice: a response to Roger Magnusson. J Law Med. 2008;16:74-84. [PubMed]
 

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References

Kuschner WG, Gruenewald DA, Clum N, et al. Implementation of ICU palliative care guidelines and procedures. Chest. 2009;135:26-32. [PubMed] [CrossRef]
 
Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med. 2008;36:953-963. [PubMed]
 
Miller FG, Truog RD. Rethinking the ethics of vital organ donations. Hastings Cent Rep. 2008;38:38-46. [PubMed]
 
Truog R. Not euthanasia, simply compassionate clinical care. Crit Care Med. 2008;36:1387-1388. [PubMed]
 
Douglas C, Kerridge IAN, Ankeny R. Managing intentions: the end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia. Bioethics. 2008;22:388-396. [PubMed]
 
McCabe H. End-of-life decision-making, the principle of double effect, and the devil's choice: a response to Roger Magnusson. J Law Med. 2008;16:74-84. [PubMed]
 
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