title: Sedation for intractable distress of a dying patient: acute palliative care and the principle of double effect.
abstract: 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.
authors.affiliation: Hematology-Oncology Department, Massachusetts General Hospital, Boston 02114-2617, USA.
authors.forename: E L
authors.initials: EL
authors.lastname: Krakauer
authors.forename: R T
authors.initials: RT
authors.lastname: Penson
authors.forename: R D
authors.initials: RD
authors.lastname: Truog
authors.forename: L A
authors.initials: LA
authors.lastname: King
authors.forename: B A
authors.initials: BA
authors.lastname: Chabner
authors.forename: T J
authors.initials: TJ
authors.lastname: Lynch
mesh_terms: D000328:Adult; D017028:Caregivers; D003657:Decision Making; D004992:Ethics, Medical; D005192:Family Health; D006390:Hemangioendothelioma / Q000150:complications*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D007400:Interprofessional Relations; D008297:Male; D009364:Neoplasm Recurrence, Local; D009369:Neoplasms / Q000150:complications* / Q000401:mortality / Q000523:psychology; D010148:Intractable Pain / Q000188:drug therapy*; D010166:Palliative Care; D013727:Terminal Care
chemical_list: D006993:Hypnotics and Sedatives