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Original Investigation |

Terminal Sedation and Euthanasia:  A Comparison of Clinical Practices FREE

Judith A. C. Rietjens, PhD; Johannes J. M. van Delden, MD, PhD; Agnes van der Heide, MD, PhD; Astrid M. Vrakking, MSc; Bregje D. Onwuteaka-Philipsen, PhD; Paul J. van der Maas, MD, PhD; Gerrit van der Wal, MD, PhD
[+] Author Affiliations

Author Affiliations: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands (Drs Rietjens, van der Heide, and van der Maas and Ms Vrakking); University Medical Center Utrecht, Julius Center for Health Sciences, Utrecht, the Netherlands (Dr van Delden); and Department of Public and Occupational Health and Institute for Research in Extramural Medicine, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands (Drs Onwuteaka-Philipsen and van der Wal).


Arch Intern Med. 2006;166(7):749-753. doi:10.1001/archinte.166.7.749.
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Published online

Background  An important issue in the debate about terminal sedation is the extent to which it differs from euthanasia. We studied clinical differences and similarities between both practices in the Netherlands.

Methods  Personal interviews were held with a nationwide stratified sample of 410 physicians (response rate, 85%) about the most recent cases in which they used terminal sedation, defined as administering drugs to keep the patient continuously in deep sedation or coma until death without giving artificial nutrition or hydration (n = 211), or performed euthanasia, defined as administering a lethal drug at the request of a patient with the explicit intention to hasten death (n = 123). We compared characteristics of the patients, the decision-making process, and medical care of both practices.

Results  Terminal sedation and euthanasia both mostly concerned patients with cancer. Patients receiving terminal sedation were more often anxious (37%) and confused (24%) than patients receiving euthanasia (15% and 2%, respectively). Euthanasia requests were typically related to loss of dignity and a sense of suffering without improving, whereas requesting terminal sedation was more often related to severe pain. Physicians applying terminal sedation estimated that the patient's life had been shortened by more than 1 week in 27% of cases, compared with 73% in euthanasia cases.

Conclusions  Terminal sedation and euthanasia both are often applied to address severe suffering in terminally ill patients. However, terminal sedation is typically used to address severe physical and psychological suffering in dying patients, whereas perceived loss of dignity during the last phase of life is a major problem for patients requesting euthanasia.

One of the classic themes of medical ethics concerns the moral acceptability of interventions to modify the dying process. The discussion about euthanasia is well known, but developments in the practice of palliative care give rise to new discussions about the ethical aspects of medical care at the end of life. One such issue is terminal sedation.

In the Netherlands, terminal sedation, defined as bringing the patient into deep sedation while forgoing artificial nutrition or hydration, was estimated to have been applied in 4% to 10% of all deaths in 2001.1,2 In one study,1 59% of all decisions to apply deep sedation were discussed with the patient. There are no specific legal rules concerning terminal sedation in the Netherlands. Euthanasia is defined as the administration of drugs with the explicit intention to end life at the patient's request, and it is legally accepted under certain conditions in Dutch law. In 2001, 2.6% of all deaths in the Netherlands were preceded by euthanasia.3

One of the characteristics of the debate about terminal sedation is that it is rather confused: people disagree about how it should be defined, the distinction between terminal sedation and euthanasia, and the conditions under which its use would be appropriate. Obviously, a discussion about terms often is also a discussion about norms: to call the sedation of a patient deep or palliative rather than terminal has implications for the moral evaluation of these actions. Terminal sedation is seen by some as euthanasia in disguise4,5 or as slow euthanasia,6 but according to others79 the 2 practices are worlds apart. The argument of the latter authors79 is that in case of terminal sedation, neither the physician nor the patient aims to cause death. They also claim that, when terminal sedation is used only in the very last phase of the illness, the cause of the patient's death is the underlying disease, not the withholding of food and fluids. Therefore, the argument goes, the patient's death is not the result of medical interventions, which should thus not be interpreted to be euthanasia. Finally, they claim that terminal sedation is used to address clinical problems other than those addressed by euthanasia.

In this article, we describe the extent to which these claims are reflected in the empirical data that are available on medical end-of-life decisions in the Netherlands. Cases of euthanasia and terminal sedation are compared for characteristics of the physicians and patients involved, of the decision-making process, and of the clinical course that followed the decision. Insight into the extent to which these practices can be distinguished based on their clinical characteristics may contribute to the debate about whether terminal sedation resembles euthanasia.

POPULATION

We interviewed a nationwide stratified sample of 410 physicians: 125 general practitioners, 77 nursing home physicians, and 208 clinical specialists (cardiologists; surgeons; and specialists in internal medicine, pulmonology, and neurology). The specialists involved in our study attended about 95% of all deaths in the Netherlands in 2001. The physicians representing the 5 selected clinical specialties attended 86% of all in-hospital deaths. The sample size was determined by the likelihood that these specialists had attended deaths and the likelihood that they had been involved with different types of end-of-life decisions. The respondents were selected according to the following criteria: They had to be in active practice at the time of the interview and to have actively practiced medicine within the registered specialty for the past 2 years in the same setting. All addresses were taken from the professional registries of the relevant specialties. To arrive at the desired number of 410 physicians (the number that proved to yield sufficient numbers of cases of euthanasia in previous studies10,11), we sampled 482 physicians. Seventy-two physicians (15%) declined to take part in the study: 17% of clinical specialists, 18% of general practitioners, and 3% of nursing home physicians. Face-to-face interviews were conducted by experienced part-time working or recently retired physicians who were trained to use the structured questionnaires. All interviews took place between March 2002 and October 2002. We applied strict rules to ensure the anonymity of all physicians and patients studied.

MEASUREMENT INSTRUMENTS

The interview schedule addressed experiences with end-of-life decision-making processes. Terminal sedation was defined as the administration of drugs to keep the patient in deep sedation or coma until death, without giving artificial nutrition or hydration. Questions about the practice of terminal sedation concerned the physician's most recent patient to have received terminal sedation (n = 211). Euthanasia was defined as the administration of drugs with the explicit intention of ending the patient's life at his or her explicit request. Questions about the practice of euthanasia concerned the physician's most recent patient to have received euthanasia during the period 1996 to 2002 (n = 123). Nursing home physicians were not interviewed about their most recent case of euthanasia because it is known that only 2% to 4% of all cases of euthanasia are performed by them.2 For both practices, we collected data on the patient's characteristics, such as age, sex, and main diagnosis. Type of physician was a proxy for place of death. Euthanasia is always provided at the request of the patient; for cases of terminal sedation, we asked the physicians whether they had discussed their decision to apply terminal sedation with the patient and relatives and whether the patient had requested terminal sedation. Discussion about and requests for terminal sedation could concern deep sedation, the forgoing of artificial nutrition or hydration, or both. For both practices, the most important reasons for the request of the patient were asked. The presence of 15 symptoms, despite treatment, was evaluated on a 5-point Likert scale. Furthermore, we asked whether other treatments aimed at curing or prolonging life were available at the time of the decision-making process, the physician's intention concerning the hastening of death, which drugs were used, the time interval between administering the drugs and the death of the patient, and the estimated degree of shortening of life. Our questionnaire was largely based on questionnaires that were used in previous studies.10,11 Its validity was enhanced by testing it in pilot interviews.

STATISTICAL ANALYSIS

The 5 response categories of the questions about symptoms (1, “symptom not present,” to 5, “symptom strongly present despite treatment”) were dichotomized into “symptom present despite treatment” (response categories 4 and 5) and “symptom not present” (response categories 1, 2, and 3). All percentages were corrected for missing values, which involved less than 5% of all cases for all variables. We used t tests, χ2 tests, and Fisher exact tests to identify differences between patients who received terminal sedation and patients who received euthanasia.

Of the 410 physicians interviewed, 96 reported that they had experience with both practices; 115, with terminal sedation only; and 97, with euthanasia only. The remaining 102 physicians did not have experience with either of these practices. General practitioners reported the majority of euthanasia cases (55%), whereas most cases of terminal sedation were reported by clinical specialists (49%). This means that 55% of the euthanasia cases were performed at home, whereas 49% of the terminal sedation cases occurred in a hospital.

Of the physicians' most recent cases, patients who received terminal sedation were, on average, older (mean age, 72 years) than patients who received euthanasia (mean age, 63 years) (Table 1). Of all patients receiving euthanasia, 88% had cancer; this percentage was 54% for patients receiving terminal sedation. In the latter group, cardiovascular diseases were also rather common (24%). In 61% of the cases, the physician had discussed the application of terminal sedation with the patient; in 34% of the cases, the patient had requested the terminal sedation; and in 27%, the physician had discussed the possibility of terminal sedation with the patient, and the patient agreed. Relatives were involved in the decision-making process in 93% of the cases. In 4% of all terminal sedation cases, there was no patient or family consent for applying deep sedation (data not shown). Euthanasia was by definition requested by the patient.

Table Graphic Jump LocationTable 1. Characteristics of Patients Who Received Euthanasia or Terminal Sedation*

Compared with patients who received euthanasia, those who received terminal sedation were more often reported to suffer from anxiety (37% vs 16%; P<.001), confusion (24% vs 2%; P<.001), depression (17% vs 10%; P = .06), bedsores (14% vs 3%; P = .002), loss of appetite (85% vs 72%; P = .003), and unclear consciousness (28% vs 0%; P<.001) and were more likely to be inactive (88% vs 74%; P = .001) (Table 2). In contrast, patients who received euthanasia suffered more often from nausea (38% vs 23%; P = .005) and vomiting (22% vs 10%; P = .004); if only symptoms that were strongly present were considered, patients receiving terminal sedation not only experienced these symptoms but also were significantly more often reported to have pain and dyspnea and more often felt very ill than patients receiving euthanasia (data not shown). Physicians reported in 86% of the cases of terminal sedation that no other potentially curing or life-prolonging treatments were available, whereas this percentage was lower for cases of euthanasia (77%, P = .04).

Table Graphic Jump LocationTable 2. Symptoms and Availability of Other Treatment Options at the Time of the Decision-Making Process*

Table 3 shows the most important reasons for patients to request either terminal sedation (n = 72) or euthanasia (n = 123), as reported by the physicians. Euthanasia requests were mostly related to patients' sense of suffering without improving (82%) and loss of dignity (63%); these percentages were lower for patients who requested terminal sedation (60% and 18%, respectively). In addition, physicians more often reported loss of independence (33%) and a feeling of immobility because of physical limitations (18%) as reasons for patients to request euthanasia compared with patients requesting terminal sedation (6% and 7%, respectively). Requests for terminal sedation were related to suffering from severe pain more often than were requests for euthanasia (57% vs 36%).

Table Graphic Jump LocationTable 3. Most Important Reasons* for Patients' Requests for Euthanasia or Terminal Sedation, According to Physicians

Of all cases in which physicians had administered terminal sedation, 17% involved an explicit intention of hastening death (Table 4). This explicit intention was related to the use of sedatives in 2% of the cases, to the forgoing of artificial nutrition or hydration in 14%, and to both in 1%. Euthanasia is by definition administered with the explicit intention to hasten death. For 60% of the patients, terminal sedation was performed by administering benzodiazepines (sometimes combined with morphine) and in most remaining patients by administering morphine only, whereas for 94% of the patients, euthanasia was performed by administering neuromuscular relaxants or barbiturates. Of all patients who received terminal sedation, 38% died within 24 hours and 96% within 1 week after the administration of the medication, whereas most patients receiving euthanasia died within 1 hour (94%) (P<.001). Physicians applying terminal sedation estimated that the patient's life had been shortened by 24 hours or less in 40% of the cases, and by more than 1 week in 27%. For euthanasia, these estimates were 1% and 73%, respectively (P<.001).

Table Graphic Jump LocationTable 4. Drugs Used, Intention of the Physician, Estimated Shortening of Life, and Time Between Administering Drugs and Death*

We performed all analyses for the subgroup of respondents who had experience with both practices to determine whether differences between both practices were associated with differences in physicians' pREFERENCES for these practices. Similarly, we performed all analyses only for patients with cancer to determine whether differences between both practices are mainly attributable to differences in diagnosis. These analyses resulted in similar distributions of the data.

The bottom line of both practices, terminal sedation and euthanasia, obviously is a patient who suffers severely from a fatal disease. However, there are marked differences. By definition, patients receiving euthanasia were actively involved in the decision-making process. This is true of only slightly more than half of the patients receiving terminal sedation, although relatives were almost always involved. Compared with the patients receiving euthanasia, patients who were terminally sedated were, on average, older, less often suffered from cancer and more often from cardiovascular disease, and less often died at home. Terminal sedation was more often used in patients with unclear consciousness, anxiety, and confusion and in the absence of other treatment options. Furthermore, patient requests for terminal sedation were more often based on pain than were requests for euthanasia, which were more often based on a sense of suffering without chance of improving and on a perceived loss of dignity and independence. The intent of the physician in cases of terminal sedation was less often to shorten life, and the shortening of life due to terminal sedation was limited. Thus, patients who are terminally sedated are generally sicker and closer to death than patients receiving euthanasia. Two findings may seem to contradict this conclusion: patients receiving euthanasia more often suffered from nausea and vomiting. However, terminal sedation is not obviously a medically appropriate answer to these symptoms. Furthermore, these symptoms may be closely connected to a sense of loss of dignity, which was a common reason for requesting euthanasia and not for requesting terminal sedation.

The finding that requests for euthanasia are often inspired by a sense of loss of dignity is described by others as well. Haverkate et al12 found that avoiding loss of dignity is one of the most important reasons to request euthanasia. In addition, during the first year of legalized, physician-assisted suicide in Oregon, the decision to request and use a prescription for lethal medication was associated with concern about loss of autonomy or control of bodily functions, not with fear of intractable pain.13 Euthanasia seems to be used as a response to a crucial loss of dignity, whereas terminal sedation is not. In a study14 within the Japanese population it was shown that respondents who reject continuous deep sedation at the end of life were significantly more likely to regard dignity and preparation for death as important compared with respondents who would appreciate continuous deep sedation at the end of life.

It was found that general practitioners more often than clinical specialists performed euthanasia, whereas clinical specialists more often performed terminal sedation than euthanasia. In the Netherlands, euthanasia is most often performed by general practitioners who typically attend patients who have cancer and die at home.2 General practitioners are generally involved in long-term care for patients, with patients registered to their practice for several years or more. Most euthanasia requests and practices are performed in this context. Terminal sedation, though, is more often practiced in a hospital for patients with cancer or cardiovascular diseases. In-hospital patients may more often have severe symptoms or extreme exacerbations of conditions that require the use of terminal sedation.

Pain was an important reason for patients to request terminal sedation and, to a somewhat lesser degree, euthanasia. Although previous reports15 have mentioned that state-of-the-art palliative care should substantially control pain in 90% of cases, it is also known that many terminal patients report pain at their end of life.16

It is sometimes suggested that terminal sedation may eliminate the need for euthanasia. Our findings indicate that terminal sedation and euthanasia often address quite different clinical problems. In the case of terminal sedation, severe physical and psychological suffering prompt the physician to sedate the patient, whereas for patients requesting euthanasia, perceived loss of dignity during the last phase of life is often a major problem. This distinction does not apply to all cases of terminal sedation and euthanasia. Thus, it is likely that for some patients, terminal sedation for refractory symptoms in the dying phase may serve as a relevant alternative for euthanasia.

Our study has several limitations. First, face-to-face interviews have the disadvantages of interviewer interpretations and socially acceptable rather than fully honest answers by respondents. We attempted to eliminate these biases by carefully selecting and training the interviewers and by ensuring strict anonymity of the respondents. Second, the respondents may have had difficulties recalling the patient's characteristics; however, recall bias was probably limited because most cases involved patients who died during the preceding 2 years. Third, the terms terminal sedation and euthanasia can evoke different connotations and interpretations in respondents. We tried to avoid this problem by providing very specific definitions of the terms. In addition, not including cases of euthanasia performed by nursing home physicians may have led to some bias. However, this effect may be limited because it is known that in the Netherlands only 2% to 4% of all cases of euthanasia are performed by nursing home physicians.2

We conclude that terminal sedation and euthanasia are both applied to address severe suffering in terminally ill patients. However, terminal sedation is typically used to address severe physical and psychological symptoms in dying patients to avoid further suffering, while the patient or the patient's representatives may accept loss of control of the dying process. For patients requesting euthanasia, perceived loss of dignity during the last phase of life is a major problem. In these cases, patients may consider control of the dying process of utmost importance.

Correspondence: Judith A. C. Rietjens, PhD, Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, the Netherlands (j.rietjens@erasmusmc.nl).

Accepted for Publication: October 21, 2005.

Author Contributions: Dr Rietjens had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Financial Disclosure: None.

Funding/Support: This study was supported by a grant from the Ministry of Health, Welfare, and Sports and the Ministry of Justice, Den Haag.

Role of the Sponsors: The sponsors approved the study design but were not involved in the collection, analysis, or interpretation of the data, or in the preparation, review, or approval of the manuscript.

Acknowledgment: We thank the members of the steering committee designated by the Ministry of Health and Ministry of Justice for their continuous support throughout the study, the physicians who provided the study data, the interviewers, the chairman of the Royal Dutch Medical Association, and the Chief Inspector for Health Care for their support of the study.

Rietjens  JAvan der Heide  AVrakking  AMOnwuteaka-Philipsen  BDvan der Maas  PJvan der Wal  G Physician reports of terminal sedation without hydration or nutrition for patients nearing death in the Netherlands. Ann Intern Med 2004;141178- 185
PubMed Link to Article
van der Wal  Gvan der Heide  AOnwuteaka-Philipsen  BDvan der Maas  PJ Medical Decision-Making at the End of Life: Practice and Notification Procedure Euthanasia [in Dutch].  Utrecht, the Netherlands de Tijdstroom2003;
Onwuteaka-Philipsen  BDvan der Heide  AKoper  D  et al.  Euthanasia and other end-of-life decisions in the Netherlands in 1990, 1995, and 2001. Lancet 2003;362395- 399
PubMed Link to Article
Kuhse  H Why terminal sedation is no solution to the voluntary euthanasia debate. Tännsjö  TedTerminal Sedation Euthanasia in Disguise? Dordrecht, the Netherlands Kluwer Academic Publishers2004;
Quill  TELo  BBrock  DW Palliative options of last resort: a comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. JAMA 1997;2782099- 2104
PubMed Link to Article
Billings  JABlock  SD Slow euthanasia. J Palliat Care 1996;1221- 30
PubMed
Callahan  D The artefactual fallacy. Tännsjö  TedTerminal Sedation Euthanasia in Disguise? Dordrecht, the Netherlands Kluwer Academic Publishers2004;
Tännsjö  T A substitute for euthanasia? Tännsjö  TedTerminal Sedation Euthanasia in Disguise? Dordrecht, the Netherlands Kluwer Academic Publishers2004;
Emanuel  LL Facing requests for physician-assisted suicide: toward a practical and principled clinical skill set. JAMA 1998;280643- 647
PubMed Link to Article
van der Maas  PJvan Delden  JJPijnenborg  L Euthanasia and other medical decisions concerning the end of life: an investigation performed upon request of the Commission of Inquiry into the Medical Practice Concerning Euthanasia. Health Policy (New York) 1992;21vi- x, 1-262
van der Maas  PJvan der Wal  GHaverkate  I  et al.  Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996;3351699- 1705
PubMed Link to Article
Haverkate  IOnwuteaka-Philipsen  BDvan Der Heide  AKostense  PJvan Der Wal  Gvan Der Maas  PJ Refused and granted requests for euthanasia and assisted suicide in the Netherlands: interview study with structured questionnaire. BMJ 2000;321865- 866
PubMed Link to Article
Chin  AEHedberg  KHigginson  GKFleming  DW Legalized physician-assisted suicide in Oregon: the first year's experience. N Engl J Med 1999;340577- 583
PubMed Link to Article
Morita  THirai  KOkazaki  Y PREFERENCES for palliative sedation therapy in the Japanese general population. J Palliat Med 2002;5375- 385
PubMed Link to Article
Max  MCleary  JFerrell  BFoley  KPayne  RShapir  B Treatment of pain at the end-of-life: a position statement from the American Pain Society. American Pain Society Web site. Available at: www.ampainsoc.org/advocacy/treatment.htm. Accessed June 15, 2004
Desbiens  NAWu  AW Pain and suffering in seriously ill hospitalized patients. J Am Geriatr Soc 2000;48 ((5 suppl)) S183- 186
PubMed

Figures

Tables

Table Graphic Jump LocationTable 1. Characteristics of Patients Who Received Euthanasia or Terminal Sedation*
Table Graphic Jump LocationTable 2. Symptoms and Availability of Other Treatment Options at the Time of the Decision-Making Process*
Table Graphic Jump LocationTable 3. Most Important Reasons* for Patients' Requests for Euthanasia or Terminal Sedation, According to Physicians
Table Graphic Jump LocationTable 4. Drugs Used, Intention of the Physician, Estimated Shortening of Life, and Time Between Administering Drugs and Death*

References

Rietjens  JAvan der Heide  AVrakking  AMOnwuteaka-Philipsen  BDvan der Maas  PJvan der Wal  G Physician reports of terminal sedation without hydration or nutrition for patients nearing death in the Netherlands. Ann Intern Med 2004;141178- 185
PubMed Link to Article
van der Wal  Gvan der Heide  AOnwuteaka-Philipsen  BDvan der Maas  PJ Medical Decision-Making at the End of Life: Practice and Notification Procedure Euthanasia [in Dutch].  Utrecht, the Netherlands de Tijdstroom2003;
Onwuteaka-Philipsen  BDvan der Heide  AKoper  D  et al.  Euthanasia and other end-of-life decisions in the Netherlands in 1990, 1995, and 2001. Lancet 2003;362395- 399
PubMed Link to Article
Kuhse  H Why terminal sedation is no solution to the voluntary euthanasia debate. Tännsjö  TedTerminal Sedation Euthanasia in Disguise? Dordrecht, the Netherlands Kluwer Academic Publishers2004;
Quill  TELo  BBrock  DW Palliative options of last resort: a comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. JAMA 1997;2782099- 2104
PubMed Link to Article
Billings  JABlock  SD Slow euthanasia. J Palliat Care 1996;1221- 30
PubMed
Callahan  D The artefactual fallacy. Tännsjö  TedTerminal Sedation Euthanasia in Disguise? Dordrecht, the Netherlands Kluwer Academic Publishers2004;
Tännsjö  T A substitute for euthanasia? Tännsjö  TedTerminal Sedation Euthanasia in Disguise? Dordrecht, the Netherlands Kluwer Academic Publishers2004;
Emanuel  LL Facing requests for physician-assisted suicide: toward a practical and principled clinical skill set. JAMA 1998;280643- 647
PubMed Link to Article
van der Maas  PJvan Delden  JJPijnenborg  L Euthanasia and other medical decisions concerning the end of life: an investigation performed upon request of the Commission of Inquiry into the Medical Practice Concerning Euthanasia. Health Policy (New York) 1992;21vi- x, 1-262
van der Maas  PJvan der Wal  GHaverkate  I  et al.  Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996;3351699- 1705
PubMed Link to Article
Haverkate  IOnwuteaka-Philipsen  BDvan Der Heide  AKostense  PJvan Der Wal  Gvan Der Maas  PJ Refused and granted requests for euthanasia and assisted suicide in the Netherlands: interview study with structured questionnaire. BMJ 2000;321865- 866
PubMed Link to Article
Chin  AEHedberg  KHigginson  GKFleming  DW Legalized physician-assisted suicide in Oregon: the first year's experience. N Engl J Med 1999;340577- 583
PubMed Link to Article
Morita  THirai  KOkazaki  Y PREFERENCES for palliative sedation therapy in the Japanese general population. J Palliat Med 2002;5375- 385
PubMed Link to Article
Max  MCleary  JFerrell  BFoley  KPayne  RShapir  B Treatment of pain at the end-of-life: a position statement from the American Pain Society. American Pain Society Web site. Available at: www.ampainsoc.org/advocacy/treatment.htm. Accessed June 15, 2004
Desbiens  NAWu  AW Pain and suffering in seriously ill hospitalized patients. J Am Geriatr Soc 2000;48 ((5 suppl)) S183- 186
PubMed

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