The Doctor’s Role in Decision making

Physicians, together with patients and their families, share the burden of decision making throughout the course of a terminal illness. As death nears, such decisions become increasingly difficult as the emotional gravity becomes magnified.

Decisions concerning life-prolonging treatment must be based on the ethical, legal and human rights principles.

Decisions concerned with Palliative sedation at end-of-life

Palliative sedation should be considered and discussed between the doctor, patient and his family, prior to the patient facing a situation of serious suffering. The drugs most preferred are benzodiazepines, especially midazolam, and barbiturates.

Managing Nutrition & Hydration of Patients

As a physician, it is important to initiate early discussions with the patient and family about the expected benefits and burdens of artificial nutrition and hydration, and thereby making an informed decision.

Managing Symptoms at End-of-Life

Physical symptoms like pain, delirium and shortness of breath often contribute to suffering at end-of-life. You may help patients and caregivers make difficult decisions regarding treatment and management of these symptoms.

Managing Pain: A pain rating scale or behavioural scale (in case the patient cannot self-report pain) can help you determine the type of intervention required. Morphine and other opioid pain killers may be used to control pain adequately only after informing the patient or caregiver of its effects beforehand.

Managing Delirium: Delirium occurs in 25 to 85% of terminally ill patients. Reducing risk factors for delirium along with avoiding situations that can precipitate it, like a noisy environment that disrupts sleep of the patient, can help manage delirium. Presence of familiar people can help reorient and relax the patient.

Managing Dyspnea: This is commonly observed in cancer patients (70%), AIDS (62%) and heart failure patients (75%). Assessing the patient helps identify the underlying cause and determine appropriate treatment and response to treatment. Oxygen may relieve dyspnea only if caused by hypoxia. Opioids like morphine may be used if required or agreed upon.

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