Revue médicale suisse
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Patients with advanced illness and their caregivers request information at all stages of the disease process. They experience fear of pain, of indignity, of abandonment and of the unknown. ⋯ Each patient hospitalized in palliative care unit should be informed about advances directives and be encouraged to complete them. However, it is of importance to respect patients' pace and to accept that some may not want to be involved in such process.
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Efficacy of treatments used in patients at the end-of-life must be evaluated according to ethical issues and specificities of the palliative population, i.e.: major vulnerability, difficulties to obtain informed consent, fragility of balance between research and clinical role, problems to evaluate risks and benefits of palliative care research. Improvements in the use of opioids have come from clinical research. Treatment of delirium has improved thanks to clinical trials conducted in cancer and AIDS patients. Emerging themes in palliative medicine now come with alleviating moral distress and utility of psychotherapeutic approach as well as the place of spirituality measured through quality-of-life evaluation.
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Palliative care was shown to be beneficial but too few patients have access to it. Barriers are a bad identification of patients, and a lack of knowledge as to their needs and the way palliative care can provide for them. There are communication difficulties. ⋯ Expertise in palliative care was acquired with cancer patients and is not always suited to other patients' needs. Patients themselves are sometimes reluctant to turn to palliative care because it reminds them of cancer and an impending death. Doctors' education is warranted to improve access to and quality of palliative care.
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Patients at the end-of-life may present with refractory symptoms which cannot be adequately relieved despite the use of all traditional means. When refractory symptoms lead to intolerable suffering, palliative sedation is a last recourse temporary or definitive treatment. While discussing ethical issues, clinical practice dimensions of palliative sedation are explored in this article.