Current interventional options for palliative care for patients with advanced-stage cholangiocarcinoma

Primary biliary tract tumors are malignancies that originate in the liver,bile ducts,or gallbladder.These tumors often present with jaundice of unknown etiology,leading to delayed diagnosis and advanced disease.Currently,several palliative treatment options are available for primary biliary tract tumors.They include percutaneous transhepatic biliary drainage(PTBD),biliary stenting,and surgical interventions such as biliary diversion.Systemic therapy is also commonly used for the palliative treatment of primary biliary tract tumors.It involves the administration of chemotherapy drugs,such as gemcitabine and cisplatin,which have shown promising results in improving overall survival in patients with advanced biliary tract tumors.PTBD is another palliative treatment option for patients with unresectable or inoperable malignant biliary obstruction.Biliary stenting can also be used as a palliative treatment option to alleviate symptoms in patients with unresectable or inoperable malignant biliary obstruction.Surgical interventions,such as biliary diversion,have traditionally been used as palliative options for primary biliary tract tumors.However,biliary diversion only provides temporary relief and does not remove the tumor.Primary biliary tract tumors often present in advanced stages,making palliative treatment the primary option for improving the quality of life of patients.

Rôles et vécus des pharmaciens d’officine dans les soins palliatifsàdomicile en France Role and Experience ofCommunity Pharmacists in Home Palliative Care in France

The need for home palliative care is increasing in allWestern countries.Community pharmacists are local professionals whose role in end-of-life care at home remains poorly understood.The aim of this study is to understand how community pharmacists see their role in end-of-life home care in France,and to analyze their experiences of this care.An online questionnaire was distributed to community pharmacists working in France between December 2022 and March 2023.Of the 136 respondents to the questionnaire,87%had accompanied at least one patient at the end of life in the 3 months preceding the survey.Therapeutic education(88%of respondents),psychological support for caregivers(85%of respondents),securing treatment(82%of respondents)and monitoring therapeutic compliance(80%of respondents)are the behaviors validated by the greatest number of participants.The majority of professionals surveyed had a positive overall experience of managing patients at the end of life.These results pave the way for pharmacists to better support end-of-life patients at home.

Palliative care for end-stage liver disease and acute on chronic liver failure:A systematic review

BACKGROUND End stage liver disease(ESLD)represents a growing health concern characterized by elevated morbidity and mortality,particularly among individual ineligible for liver transplantation.The demand for palliative care(PC)is pronounced in patients grappling with ESLD and acute on chronic liver failure(ACLF).Unfortunately,the historical underutilization of PC in ESLD patients,despite their substantial needs and those of their family caregivers,underscores the imperative of seamlessly integrating PC principles into routine healthcare practices across the entire disease spectrum.AIM To comprehensively investigate the evidence surrounding the benefits of incorporating PC into the comprehensive care plan for individuals confronting ESLD and/or ACLF.METHODS A systematic search in the Medline(PubMed)database was performed using a predetermined search command,encompassing studies published in English without any restrictions on the publication date.Subsequently,the retrieved studies were manually examined.Simple descriptive analyses were employed to summarize the results.RESULTS The search strategies yielded 721 references.Following the final analysis,32 fulllength references met the inclusion criteria and were consequently incorporated into the study.Meticulous data extraction from these 32 studies was undertaken,leading to the execution of a comprehensive narrative systematic review.The review found that PC provides significant benefits,reducing symptom burden,depressive symptoms,readmission rates,and hospital stays.Yet,barriers like the appeal of transplants and misconceptions about PC hinder optimal utilization.Integrating PC early,upon the diagnosis of ESLD and ACLF,regardless of transplant eligibility and availability,improves the quality of life for these patients.CONCLUSION Despite the substantial suffering and poor prognosis associated with ESLD and ACLF,where liver transplantation stands as the only curative treatment,albeit largely inaccessible,PC services have been overtly provided too late in the course of the illness.A comprehensive understanding of PC's pivotal role in treating ESLD and ACLF is crucial for overcoming these barriers,involving healthcare providers,patients,and caregivers.

Palliative care with adequate pain relief challenges the need for euthanasia legislation

Background:In today’s society the ongoing discussion about euthanasia triggers emotionally charged debates surrounding the delicate balance between valuing life and respecting an individual’s autonomy.With the persistence of this debate,there has been the emergence of the concept of the so-called alternative:palliative care.Positioned as a substitute for euthanasia,palliative care aims to alleviate suffering in terminally ill patients without engaging in the ethical dilemmas associated with euthanasia.Methods:This paper explores the facets of palliative care highlighting its core objectives such as providing adequate pain relief as a compassionate alternative to euthanasia.Results:By examining palliative care as a comprehensive approach to end of life support,this study challenges the perceived necessity of euthanasia and advocates,for compassionate and dignified end of life experiences.Conclusion:In conclusion,palliative care emerges as a viable and ethically sound alternative to euthanasia,emphasizing the importance of compassionate end-of-life care and pain management.

Attitudes of nursing students about palliative care:an analysis of influencing factors

Background:As the population continues to age and the number of people suffering from incurable diseases,such as malignant tumors and Alzheimer’s disease,increases,the need for quality end-of-life care is becoming more and more prominent.Nursing students,as a reserved talent in the nursing field,have an attitude towards palliative care that will directly affect the quality of care for future terminal patients.Methods:This descriptive and cross-sectional survey was conducted from November 2020 to January 2021.A stratified sampling method randomly selected 1168 undergraduate and postgraduate nursing students as respondents.Students’attitudes were measured using a revised palliative care attitude questionnaire.Results:The palliative care attitude score was 7.233±1.812 with a score of 72.3%and a median score of 7.50 with a range of 0-10.63.10%of the nursing students had an attitude score of 7 or more and only 2.40%of the nursing students had a negative attitude towards palliative care.The results showed that gender,grade level,health status,and attitudes toward the nursing profession affected nursing students’attitudes toward palliative care(P<0.05).Conclusion:Currently,Chinese nursing students have better attitudes towards palliative care,but are less likely to want to pursue a career in palliative care in the future.Medical schools can take into account their actual gradual opening of palliative care courses,using a variety of teaching methods to stimulate the interest of nursing students to learn and improve their willingness to palliative care services.

Palliative long-term abdominal drains vs large volume paracenteses for the management of refractory ascites in end-stage liver disease

BACKGROUND Long-term abdominal drains(LTAD)are a cost-effective palliative measure to manage malignant ascites in the community,but their use in patients with end-stage chronic liver disease and refractory ascites is not routine practice.The safety and cost-effectiveness of LTAD are currently being studied in this setting,with preliminary positive results.We hypothesised that palliative LTAD are as effective and safe as repeat palliative large volume paracentesis(LVP)in patients with cirrhosis and refractory ascites and may offer advantages in patients’quality of life.AIM To compare the effectiveness and safety of palliative LTAD and LVP in refractory ascites secondary to end-stage chronic liver disease.METHODS A retrospective,observational cohort study comparing the effectiveness and safety outcomes of palliative LTAD and regular palliative LVP as a treatment for refractory ascites in consecutive patients with end-stage chronic liver disease followed-up at our United Kingdom tertiary centre between 2018 and 2022 was conducted.Fisher’s exact tests and the Mann-Whitney U test were used to compare qualitative and quantitative variables,respectively.Kaplan-Meier survival estimates were generated to stratify time-related outcomes according to the type of drain.RESULTS Thirty patients had a total of 35 indwelling abdominal drains and nineteen patients underwent regular LVP.The baseline characteristics were similar between the groups.Prophylactic antibiotics were more frequently prescribed in patients with LTAD(P=0.012),while the incidence of peritonitis did not differ between the two groups(P=0.46).The incidence of acute kidney injury(P=0.014)and ascites/drain-related hospital admissions(P=0.004)were significantly higher in the LVP group.The overall survival was similar in the two groups(log-rank P=0.26),but the endpoint-free survival was significantly shorter in the LVP group(P=0.003,P<0.001,P=0.018 for first ascites/drain-related admission,acute kidney injury and drain-related complications,respectively).CONCLUSION The use of LTAD in the management of refractory ascites in palliated end-stage liver disease is effective,safe,and may reduce hospital admissions and utilisation of healthcare resources compared to LVP.

Hospice and Palliative Care in China's Mainland:History,Current Status and Challenges

The concept of End-of-Life Care(EOLC)came into China in the late1980s.However,hospice and palliative care in medical practice develope slowly.In recent years,profesionals,patients and their families,as well as government begin to attach importance to it.There is a hospice and palliative care movement now in China.This article gives an overview of the progress and the current status in multiple aspects of hospice and palliative care in China's Mainland,and points out the barriers and challenges for its further development in the future.

Recognition of Palliative Care in Chinese Clinicians:How They Feel and What They Know

Objective To investigate doctors'feelings when providing medical care to end-stage patients,and their understanding as well as reflection about theoretical concepts of palliative medicine.Methods Questionnaires were delivered through a social networking platform to1500clinicians of different specialties in10proviences of China.It covered issues of background information,self-assessment of familiarity to palliative care,prior training history,emotional attitude toward end-stage patients,and the reflections on clinical practice.Logistic regression analysis and chi-square test were used to analyse the categorical variables.Results There were379clinicians who completed the questionnaires and submitted successfully.Among them,66.8%(253/379)had attended palliative care training courses more than twice;66.8%(253/379)clinicians percieved powerless feeling when facing end-stage patients.We found that the education on palliative medicine was significantly associated to doctors'better comprehension on the concept of palliative care(OR=6.923,P=0.002).Doctors who were more familiar with palliative medicine were less likely to perceive powerless feelings(χ^2=13.015,P<0.001),and would be more likely to concern about patients and their family members in their clinical work(χ^2=28.754,P<0.001,χ^2=24.406,P<0.001).Conclusion The powerless feeling is prevalent in Chinese doctors when facing end-stage patients.Palliative care help them overcome the negative feelings and act more caring in clinic.More careful designed educational strategies that adapt to Chinese actual situation are needed to improve doctors'cognition on palliative care.

Physicians’Perception of Palliative Care Consultation Service in a Major General Hospital in China

Objectives The in-hosptial palliative care consultation(PCC) is emerging as a routine service in some medical center in China. The current study evaluated how physicians in primary care team and consultation team perceive the PCC service for the purpose of investigating the effectiveness of this consultation model in a general hospital.Methods In-hosptial palliative care consultations have been carried out at Peking Union Medical College Hosptial by a dedicated consultation team, and 37 consultations were completed in 2016. A questionnaire was designed for physicians in terms of its benefits to patients,their family as well as the primary care team. Physicians who applied for consultation in 2016 formally(requested from the department other than the Geriatrics) and informally(by rotating residents and unemployed visiting doctors in geriatric department) were invited to participate in the survey by scanning a two dimentional code on social networking platform.Results There were 103 physicians participated in the survey, including primary care physicians from the department of Internal Medicine(n=8), Gynaecology(n=16) and Surgery(n=13), rotating residents(n=30), visiting doctors(n=16) in Geriatric department, and PCC team members(n=20). 94.0% of the non-PCC physicians agreed that PCC relieved the suffering of patients; 89.2% thought PCC improved the quality of patients' life; there were 91.6%, 95.2%, 90.4% physicians who felt it relieved the anxiety of patients, of family members and of care providers, respectively. There were 96.4% physicians who felt it could ease the tension in physician-patient relationship; 97.6% felt it lower the risk for medical negligence, and 96.4% of doctors who applied for PPC felt satisfied with PCC service in terms of process and achieving objectives of consultation. More primary-team physician agree "PCC service helps the physicians better understand palliative care" than PCC members(97.6% vs. 80%, P<0.05), while both were interested in learning more on palliative medicine(100% vs. 96.4%, P>0.05).Conclusion Palliative care consultation service in a general hospital is efficacious and acclaimed.The primary care physicians and the PCC members hold positive attitudes to the benefits that the PCC services bring to patients, family members, and physicians themselves. PCC for terminal patients in a general hospital may serve as a good modle for promotion of palliative care in China.

palliative care and end-stage colorectal cancer management:The surgeon meets the oncologist

Colorectal cancer (CRC) is a common neoplasia in the Western countries, with considerable morbidity and mortality. Every fifth patient with CRC presents with metastatic disease, which is not curable with radical intent in roughly 80% of cases. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV CRC patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy (CHT). This latter have allowed for a dramatic increase in survival, whereas the role of colonic and liver surgery is nowadays matter of debate. Although any generalization is difficult, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases. In asymptomatic patients, new CHT regimens allow today long survival in selected patients, also exceeding two years. The role of colonic resection in this group has been challenged in recent years, as it is not clear whether the resection of primary CRC may imply a further increase in survival, thus justifying surgery-related morbidity/mortality in such a class of short-living patients. Secondary surgery of liver metastasis is gaining acceptance since, under new generation CHT regimens, an increasing amount of patients with distant metastasis initially considered non resectable become resectable, with a significant increase in long term survival. The management of CRC emergency patients still represents a major issue in Western countries, and is associated to high morbidity/mortality. Obstruction is traditionally approached surgically by colonic resection, stoma or internal by-pass, although nowadays CRC stenting is a feasible option. Nevertheless, CRC stent has peculiar contraindications and complications, and its long-term cost-effectiveness is questionable, especially in the light of recently increased survival. Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma. Bleeding and other CRC-related symptoms (pain, tenesmus, etc.) may be managed by several mini-invasive approaches, including radiotherapy, laser therapy and other transanal procedures.

Inoperable esophageal cancer and outcome of palliative care

AIM:To determine the outcome of esophageal cancer patients referred for palliative care,in Gorgan and Gonbad gastrointestinal clinics,northeast of Iran. METHODS:This cross-sectional study was done on inoperable esophageal cancer cases referred to gastrointestinal clinics in Gorgan and Gonbad city(2005-2006) . Demographic data were collected during the procedure and cases were followed up every one month. Improvement proportion was calculated with 95% confidence interval,to determine the rate of improvement. Survival analysis and Kaplan-Meier methods were used to estimate the duration of palliative care effectiveness. RESULTS:We recruited 39 cases into the study. Squamous cell carcinoma was the most prevalent(92.3%) . The middle third of the esophagus was involved predominantly(51.3%) . Dilation was the most preferred method(89.7%) and stenting was done in 4 cases. Decreasing dysphagia score was not related to palliation method or pathology type of carcinoma. Age of the patients was significantly related to the improvement of dysphagia score. Mean survival time was 137.6 d and median was 103 d. CONCLUSION:Results of this study showed a low survival rate after palliative care in esophageal cancer cases despite dysphagia scores' improvement after dilating or stenting.

Quality of life and palliative care needs of elderly patients with advanced heart failure

Objective To examine the quality of life and palliative care needs of elderly patients with advanced heart failure （HF）. Methods This was a correlation descriptive study conducted at a 650-bed sub-acute hospital. Patients who were aged 65 or over, diagnosed with HF of New York Heart Association Class III or IV symptoms, and mentally sound were eligible to the study. The Edmonton Symptom Assessment Scale, the overall quality of life single item scale, and the McQill Quality of Life Questionnaire （MQoL）, were used for measurement. Multi- ple regression analysis was performed to determine factors for predicting quality of life. Results A convenience sample of 112 patients was recruited. Their age was 81.5 ± 8.5 years. The three most distressing symptoms reported by the patients were tiredness （5.96 ± 2.78）, drowsiness （5.47± 2.93）, and shortness of breath （5.34 ± 2.96）. Their mean overall quality of life single item scale score was 4.72 ± 2.06 out of 10. The mean MQoL physical subscale score was the lowest （4.20 ± 1.767）, whereas their mean psychological subscale was the highest （7.14 ±2.39）. However, in a multivariate analysis model, quality of life was significantly associated with existential wellbeing, physical wellbeing, psychological wellbeing and educational level. Conclusions The findings highlight that spiritual concerns are significant palliative care needs among elderly patients with advanced HF, in addition to symptom management. This is in line with the argument that palliative care that places great emphasis on holistic care should be integrated to the care of this group of patients.

Value-based Practice:Integration of Cancer Rehabilitation and Palliative Care in Oncology Services

Value-based care model has been evolving to organize medical services around the patient and provide the full cycle of care for a medical condition.The full cycle of care model encompasses inpatient,outpatient,rehabilitation as well as supportive care such as palliative care and nutrition support.Cancer rehabilitation and palliative care have emerged as two important parts of value-based practice for oncology patients.More clinical evidence suggests that early intervention of oncology rehabilitation program and palliative care are likely to improve the patient outcome and reduce the overall medical cost for the patient and his or her family as well as for medical service providers.Although interest has been raised in Chinese oncologists,but effectiveness of incorporating these two services in clinical practices has not been adequately demonstrated.An understanding of scope of cancer rehabilitation and palliative care may help facilitate the integration of both into the oncology care continuum in efforts to improve patients'physical,psychological,cognitive,functional health and quality of life.

Implement the Palliative Care in Medical Practice of a Tertiary Comprehensive Hospital in China

The locations and modalities of palliative care services to patients with severe/end-stage illness can be diverse,ranging from general hospitals to home-based care.The concept of palliative care hasn't been fully applied to medical practice by care providers in China's Mainland,where the seriously ill or terminal patients mainly receive medical care in hospitals.The implementation of palliative care in medical practice has developed greatly in Peking Union Medical College hospital in terms of clinical patient care,education,and research.This article gives an overview of it,and the experiences in team building,promotion,support seaking and fund raising were also discussed in this article.We hope to explore an effective dilivering model of palliative care for end-stage patients that is adaptive to Chinese culture and social environment.

Traumatic brain injury and palliative care:a retrospective analysis of 49 patients receiving palliative care during 2013–2016 in Turkey

Traumatic brain injury（TBI）,which is seen more in young adults,affects both patients and their families.The need for palliative care in TBI and the limits of the care requirement are not clear.The aim of this study was to investigate the length of stay in the palliative care center（PCC）,Turkey,the status of patients at discharge,and the need for palliative care in patients with TBI.The medical records of 49 patients with TBI receiving palliative care in PCC during 2013–2016 were retrospectively collected,including age and gender of patients,the length of stay in PCC,the cause of TBI,diagnosis,Glasgow Coma Scale score,Glas gow Outcome Scale score,Karnofsky Performance Status score,mobilization status,nutrition route（oral,percutaneous endoscopic gastrostomy）,pressure ulcers,and discharge status.These patients were aged 45.4 ± 20.2 years.The median length of stay in the PCC was 34.0 days.These included TBI patients had a Glasg ow Coma Scale score ≤ 8,were not mobilized,received tracheostomy and percutaneous endoscopic gastrostomy nutrition,and had pressure ulcers.No difference was found between those who were discharged to their home or other places（rehabilitation centre,intensive care unit and death） in respect of mobilization,percutaneous endoscopic gastrostomy,tracheostomy and pressure ulcers.TBI patients who were followed up in PCC were determined to be relatively young patients（45.4 ± 20.2 years） with mobilization and nutrition problems and pressure ulcer formation.As TBI patients have complex health conditions that require palliative care from the time of admittance to intensive care unit,provision of palliative care services should be integrated with clinical applications.

Palliative care needs and symptom burden in younger and older patients with end-stage renal disease undergoing maintenance hemodialysis:A cross-sectional study

Objectives:To investigate the current situation of palliative care needs and the symptom burden in patients with end-stage renal disease(ESRD)undergoing maintenance hemodialysis(MHD),and to explore whether there are differences between younger and older patients.Methods:This cross-sectional study was conducted in the hemodialysis centers of two tertiary hospitals from November 2021 to June 2022.Participants were selected by convenience sampling.Sociodemographics,clinical characteristics,the Palliative Care Outcome Scale(POS),the Dialysis Symptom Index(DSI),and health-related quality of life(EQ-5D-3L)were used for evaluation.Descriptive statistics,between-group comparisons,and correlation analysis were used to analyze the data.Results:A total of 236 patients were enrolled,including 118 younger and 118 older patients.The total median(P25,P75)POS score was 16.0(12.0,23.0),and the score was higher in older patients(P<0.01).The mean total number of symptoms in MHD patients was 15.04±5.06,and the overall median symptom severity score was 59.0(52.0,71.0);these scores were higher in the older group(P<0.01).The most common symptom was dry mouth(91.5%),followed by itching(83.1%),and dry skin(82.2%).Additionally,palliative care needs were significantly associated with symptom burden and health-related quality of life(HRQOL).Conclusions:The results showed that patients with ESRD undergoing MHD have a significant symptom burden and moderate palliative care needs,which are more severe in older patients.Therefore,interdisciplinary teams should be formed to actively manage patients’symptoms and meet the physical,psychological,social,and spiritual needs related to palliative care to improve patients’HRQOL.

Underutilization of palliative care services in the liver transplant population

AIM To evaluate use of palliative care services in patients with end-stage liver disease who do not have access to liver transplant.METHODS Evaluated were end-stage liver disease patients who were removed from the liver transplant wait-list or died prior to transplant at a single transplant center over a 2-year period. Those who were removed due to noncompliance or ultimately transplanted elsewhere were excluded from this study. Patient characteristics associated with palliative care consultation were assessed using logistic regression analysis.RESULTS Six hundred and eighty-three patients were listed for liver transplant in 2013-2014 with 107(16%) dying(n = 62) or removed for clinical decompensation prior to liver transplant(n = 45): Median age was 58 years, and the majority were male(66%), Caucasian(53%), had Child C cirrhosis(61%) or hepatocellular carcinoma(52%). The palliative care team was consulted in only 18 of the 107 patients(17%) who died or were removed, 89% of which occurred as inpatients. Half of these consultations occurred within 72 h of death. In univariable analysis, patients of younger age, white race, and higher end-stage liver disease scores at time of listing and delisting were more likely to receive palliative care services. Only younger age [Odds ratio(OR) = 0.92; P = 0.02] and Caucasian race(OR = 4.90; P = 0.02) were still associated with integration of palliative care services through multivariable analysis.CONCLUSION Palliative care services are grossly underutilized in older, non-white patients with cirrhosis on the liver transplant wait-list. We encourage early integration of these services into clinical decision-making in the transplant population, with further studies aimed at understanding barriers to consultation.

Running a Volunteer Program for Palliative Care in a Chinese Hospital:Our Practice and Experience

The establishment and development of volunteer team are very important in the whole process of palliative care.The concept and practice of palliative care have been developed in Peking Union Medical College Hospital(PUMCH)since the end of2012.Great progress has been made in different aspects.Volunteers play an extremely important role in the development of palliative care in PUMCH.The whole work began with the establishment of volunteer teams.This article introduces the process of the establishment and development of palliative care volunteer team in PUMCH,aiming to provide practical references for hospitals in China's Mainland to develop their own palliative care volunteer team.

Palliative care for acute kidney injury patients in the intensive care unit

Patients with acute kidney injury(AKI) in the intensive care unit(ICU) are often suitable for palliative care due to the high symptom burden. The role of palliative medicine in this patient population is not well defined and there is a lack of established guidelines to address this issue. Because of this,patients in the ICU with AKI deprived of the most comprehensive or appropriate care. The reasons for this are multifactorial including lack of palliative care training among nephrologists. However,palliative care in these patients can help alleviate symptoms,improve quality of life,and decrease suffering. Palliative care physicians can determine the appropriateness and model of palliative care. In addition to shared decision-making,advance directives should be established with patients early on,with specific instructions regarding dialysis,and those advance directives should be respected.

Characteristics of Nursing Care for Terminally Ill Patients in Hospice/Palliative Care Unit

The purpose of this study was to clarify the characteristics of nursing care for patient with terminally ill in the hospice/palliative care units. Semi-structured interviews on “communication, care, spiritual pain care and prediction of worsening of symptoms” were conducted, incorporating items indicated as important principles of palliative care by Lugton et al. Sixteen nurses at five hospice/ palliative care facilities in urban areas of Japan were surveyed in 2013, and results were analyzed qualitatively. Following characteristics by hospice/palliative care nurses (HPN) were categorized as [HPN sharing meaningful time with the patient] and [HPN’s continual attempts to understand the world in which the patient lives] in the communication;as [HPN providing comfortable care so that patients can value their last moments] and [HPN’s efforts to attend to patients so they can die as they hope to] in the care;and as [HPN’s observation in a range that does not interfere with the patient’s comfort] and [HPN senses that something is different from before] in the prediction of worsening of symptoms. Common characteristic was 【HPN’s support for patients approaching a natural death】. In this study, spiritual pain care was included in the communication and care, and could not be extracted alone. It was suggested that an HPN provides communication, care and prediction of worsening of symptoms with excellent judgment and technological competency, while placing importance on offering support for the patient’s natural death.