Forum.
Recommendations for determining intractability
Each patient’s case must be considered individually and carefully (Lanuke 2003). The following recommendations are adapted from Cherny and Portenoy’s model (3) unless otherwise specified and will not apply in all situations. .
Principle: use a systematic and exhaustive process for treating the target symptom before considering sedation.
- Medical considerations
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- A rigorous diagnostic process appropriate to the patient’s condition and wishes has been conducted to determine the most likely etiology of the symptom (Krakauer; Levy)
- Assessments have used established or standardized criteria whenever possible (Fains PM 2000)
- In the patient’s current setting, all available symptom-targeted medications, procedures, or interventions have been attempted or considered; all such interventions have been ineffective, have produced unacceptable side effects, have been ruled out as too burdensome or risky for the patient, or have been refused by the patient
- Transfer to another location where additional interventions or experts may be available is not possible, is too burdensome for the patient, or has been refused by the patient
- Opportunities for expert consultation (including remote electronic communication) have been exhausted
- Final determination of intractability is confirmed in a multidisciplinary care conference whenever possible
- Patient considerations
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- Patient reports that current symptom management lacks sufficient efficacy and the symptom has become intolerable
- Patient refuses certain relevant symptom-targeted treatments
- Patient refuses, or is too ill for, transfer to a setting in which additional interventions or experts are available
- Patient is unable to tolerate further trials of symptom-targeted interventions
- Patient requests sedation or indicates degree of distress by requesting clinician assisted death
Cherny & Portenoy’s model {{407 Cherny,N.I. 1994; }} for distinguishing intractable from difficult symptoms remains the most clear and comprehensive available. It appears, however, to have been written from the perspective of carers in a major medical center where a wide range of therapies and specialists are available. Levy & Cohen (2005) invoke Cherny & Portenoy’s definition of intractable, but also recognize that location and healthcare professional variables impact the determination of intractability. The recommended comprehensive and exhaustive process of assessment and treatment (C & P) may need to be foreshortened in a location with fewer available resources. Even when such resources might be logistically available, they may be effectively excluded as options by financial constraints or by patient, clinician, or institutional philosophy about their appropriateness or desirability in end-of-life care. Emotional exhaustion on the part of physicians is linked with a tendency to turn to sedation (7; Perusilli; Morita), but confidence in the appropriate treatment for specific symptoms decreases the likelihood of turning prematurely to sedation for symptom management (7,45,47,51,52, Levy).
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