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In Reply: We agree with the points made by Drs Del Fabbro and Bruera about factors leading to increased pain expression, the value of opioid rotation, and the option of intravenous methadone.

Dr Kuschner asks for a more detailed rationale for the use of palliative sedation with terminally ill patients, which we acknowledge is more controversial than with moribund patients. If a patient is expected to survive only a few hours or days, palliative sedation for intractable symptoms is not controversial. However, the longer a patient is expected to survive, the more time clinicians have to evaluate options before concluding that the terminally ill patient's distress is refractory and resorting to palliative sedation. Specific prognostic time frames for the appropriate use of palliative sedation are complicated by physicians' inability to predict death accurately and to assess distress objectively. Moreover, the possibility of foregoing a longer period of life heightens concerns . . . [Full Text of this Article]

Bernard Lo, MD
bernie@medicine.ucsf.edu
Program in Medical Ethics
University of San Francisco School of Medicine
San Francisco, Calif

Gordon Rubenfeld, MD, MSc
Division of Pulmonary and Critical Care Medicine
Department of Medicine
University of Washington
Seattle

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