Over the past decade, increased attention has focused on the care of
dying patients. The role of the physician in caring for these
patients has been the subject of renewed interest and intense,
sometimes passionate, debate. Patient groups have formed to advocate
for the promotion of compassion in the care of the dying, and some of
these advocacy groups have asserted a fundamental right
to physician-assisted suicide. The US Supreme Court has ruled against
a constitutional right to physician-assisted suicide but has asserted
its willingness to reconsider the issue if it learned that dying
patients were not receiving appropriate, high-quality end-of-life care.
Given the US Supreme Court ruling, and the context of a population,
that, as it ages, is often fearful of being a burden to others,
suffering financial hardships, and experiencing pain and suffering,
many clinicians who work closely with dying patients are now trying
to shift the debate away from the rhetoric of advocacy groups for and
against physician-assisted suicide and toward the development of core
competencies in the care of the dying patient.
The Importance of Terminology
The article by Dr. Wein is a welcome addition to the burgeoning
medical literature on how best to face the challenge of caring for
patients at the end of life. We are pleased to see that Dr. Wein has
adopted the phrase that we coined, sedation in the imminently
dying, rather than the term, terminal sedation,
but suggest that the former should have been used consistently
throughout the article to prevent confusion. As Dr. Wein notes, the
term, terminal sedation, is best avoided because it
could be interpreted as meaning either sedation intended for
terminally ill patients or sedation for the purpose terminating the
Given the published data that Dr. Wein cites on the variations in the
refractoriness of symptom control near the end of life, sedation is
an important option that, when employed by competent practitioners,
can ensure a peaceful, comfortable death. We wish to emphasize that
dying cancer patients are commonly sedated before they die due to
complications of their disease and that any discussion of sedation in
the imminently dying must occur within this context. Dr. Wein fails
to recognize that, in the appropriate practice of palliative
medicine, sedation does not exist as a distinct entity for use in
patients who are otherwise comfortable or asymptomatic. Rather,
sedation is part of a continuum of good end-of-life care in patients
whose medical care is already complicated by a variety of symptoms
and often life-threatening medical issues.
Need to Apply Scientifically Validated Guidelines
In his discussion of refractory symptoms, Dr. Wein argues that
there are no fixed rules or infallible guidelines, and
quotes the comment of Dr. Wanzer and colleagues: The care of
the dying is an art. Although we agree that there is a certain
degree of art that still imbues the best of medical care,
we strongly support the use of scientifically validated guidelines
and are wary when discussions of how to care for the dying are not
subjected to the same evidence-based standards as are applied to
other common problems in medicine.
We do not seek to remove the art from the care of the dying but would
underscore the vital importance of adhering to standards as they are
developed and adopted. Dr. Weins review of the available
literature on useful medications for sedation is helpful, although
the lack of controlled trials argues strongly for the need for rigorous
scientific research on end-of-life care.
Dr. Wein provides a thoughtful review of the ethical principles of
double effect and proportionality and offers moral breathing
room for physicians, who, with consent and under certain
defined conditions, choose to relieve refractory suffering with
sedation. We agree with Dr. Weins conclusion that no good
argument can be made for equating terminal sedation (although, as
mentioned above, we prefer sedation in the imminently
dying) with physician-assisted suicide or euthanasia,
particularly since no data are available to support the notion that
sedation hastens death. The use of sedation under the conditions set
forth by Dr. Wein is part of the practice of competent palliative
medicine, and is consistent with well-established guidelines for the
relief of pain and suffering in terminally ill patients worldwide.
An Abysmal Report Card
Although controlled trials on many aspects of end-of-life care are
lacking, the data on how we as a medical community are faring in
caring for dying patients are unequivocal. Any discussion of the
merits of sedation vs physician-assisted suicide and the role of the
physician in general at the bedside of a dying patient must occur
against the backdrop of physicians abysmal report
card in this area.
We learned from the SUPPORT  data that 50% of patients dying in
acute-care hospitals die in pain. A physician survey sponsored by
the Eastern Cooperative Oncology Group (ECOG) revealed that 86% of
oncologists believe that the majority of American patients in pain
are undertreated. Only 5 of 126 medical schools in the United
States offer a separate, required course in the care of dying patients.
The recently published data on the inadequate coverage of death and
dying in medical textbooks, coupled with the general lack of
attention given to this area in medical education, compel all of us
who are concerned about end-of-life care to develop new educational
models. The Education for Physicians in End of Life Care (EPEC)
model developed by the American Medical Association is an important
advance and should be followed by other models, national conferences,
and competency standards for board examinations.
1. Burt RA: The Supreme Court speaks: Not assisted suicide, but a
Constitutional right to palliative care. N Engl J Med
2. Carver AC, Foley KM: Palliative care, in Holland JF, Frei E III,
Bast RC Jr., et al (eds): Cancer Medicine, 5th ed, 2000 (in press).
3. The SUPPORT principal investigators: A controlled trial to improve
care for seriously ill hospitalized patients: The study to understand
prognoses and preferences for outcomes and risks of treatments. JAMA
4. Von Roenn JH, Cleeland CS, Gonin R, et al: Physician attitudes and
practice in cancer pain management: A survey from the Eastern
Cooperative Oncology Group. Ann Intern Med 119:121-126, 1993.
5. Billings JA, Block S: Palliative care in undergraduate medical
education: Status report and future directions. JAMA 278:733-738, 1997.
6. Rabow MW, Hardie GE, Fair JM: End-of-life care content in 50
textbooks from multiple specialties. JAMA 283(6):771-778, 2000.