Palliative Sedation

Palliative sedation is the use of medicine to bring about a state of unconsciousness or near-unconsciousness in a terminally ill person who is near death and has refractory and severe symptoms. Refractory symptoms are those that are unable to be managed through any other means. The purpose of palliative sedation is to provide comfort and relief from unendurable symptoms at the end of life.

The use of palliative sedation involves legal and ethical issues and concerns. These issues focus on the association of palliative sedation with euthanasia and physician-assisted suicide, as well as the withholding of life-sustaining treatments, such as food and fluids. In addition, there are concerns about what constitutes refractory symptoms, and whether nonphysical symptoms would meet the criteria to justify palliative sedation.

Overview

Two kinds of palliative sedation are used. They vary based on their intent and the levels of sedation that result. Proportionate palliative sedation (PPS) uses the minimum level of sedation necessary to relieve refractory symptoms. The level of sedation may be progressively increased based on the patient’s level of distress or discomfort. Its intent is to provide relief of refractory symptoms while maintaining consciousness as long as possible. Palliative sedation to unconsciousness (PSU) is sedation with the intended result of relief from refractory symptoms through unconsciousness. PPS is used more frequently than PSU and has widespread ethical support among medical professionals. PSU is rarely used and is considered more controversial among medical professionals and the public.

The most common medications used in palliative sedation are benzodiazepines, neuroleptics, and barbiturates. Anesthetics, such as propofol, also may be used. Other pain-relieving medications, such as opioids, may be used simultaneously.

Palliative sedation is considered a last resort. It is only used when a person has refractory symptoms and all other methods of relieving them have been exhausted. Refractory symptoms are those that have been clinically assessed as being unable to be managed in any other way. For example, a terminally ill person with cancer may have severe pain. If that pain can be alleviated through the administration of opioids or other medications, palliative sedation would not be an option. If, however, all available treatments have been tried and the patient is still experiencing unbearable suffering, palliative sedation is a warranted option.

Another requirement is that a person must be near death, not just terminally ill. Because palliative sedation results in limited consciousness or unconsciousness, it is only used in situations in which there is no chance of reversing a person’s terminal illness or providing other treatment to prolong life. It is used at the point when the patient’s desire for relief of suffering is greater than the patient’s desire for awareness or consciousness.

The patient or patient’s health care proxy must give informed consent to the sedation. A do-not-resuscitate order also is required. The medication must be administered in an inpatient medical facility or a setting with continuous care licensed nurses for the first twenty-four hours.

Palliative sedation usually includes the withdrawal of hydration and nutrition, but these may be provided in varying levels based on the patient’s condition.

Legal and Ethical Issues

Palliative sedation has been used for decades. Since the 1990s, there has been a greater focus on addressing and clarifying the legal and ethical concerns related to its use, and it has gained more acceptance among medical professionals and the public. Numerous health care associations have issued policy statements on its use.

While the legal status of palliative sedation has not been determined by US courts, the US Supreme Court’s ruling in Washington v. Glucksberg (1997) gave support for its legality. In her concurring opinion, Justice Sandra Day O’Connor wrote, "There is no dispute that dying patients in Washington and New York can obtain palliative care, even when doing so would hasten their deaths."

Ethical concerns about palliative sedation often arise from the perception that palliative sedation is identical to euthanasia or physician-assisted suicide, although it is neither. Palliative sedation does not cause death, nor does it hasten death. The difference between palliative sedation and assisted suicide and euthanasia is intent. Unlike assisted suicide and euthanasia, the purpose of palliative sedation to relieve suffering at the end stage of the dying process, not to cause death.

Other ethical concerns center around the unconscious state of a person who has been administered a palliative sedative. Stronger doses of palliative sedation results in unconsciousness, at which time the patient lacks the ability to make his or her desires known. The person also ceases to be aware of others and the environment, essentially losing the ability to interact with others and make voluntary decisions. For many people, having as much control and awareness as possible at the end of life is a priority. They want to hold on to the awareness of life as much as possible and do not want sedation. For others, having control over how they die is more important. They want the right to determine what type of medical treatment they desire and when it should be administered. They want to decide when the relief from suffering is more important than awareness.

One of the most controversial issues of palliative sedation is the withdrawal of nutrition and artificial fluids. Some people claim this hastens death, although studies have refuted that claim. Most patients near death lose the desire to drink and eat, and providing them hydration and nutrition generally provides no benefit.

Another controversial issue is determining when palliative sedation is an appropriate medical treatment. There is general consensus among medical professionals that palliative sedation is appropriate and ethical only for physical refractory symptoms. Less consensus exists as to whether it is merited for persons with existential suffering, such as loneliness or a lack of meaning in life. Few physicians use palliative sedation to relieve suffering in the absence of physical symptoms.

Bibliography

Lawson, Mary. "Palliative Sedation." Clinical Journal of Oncology Nursing 15.6 (2011): 589–90. Print.

McCusker, Martha, et al. "Palliative Care for Adults." Institute for Clinical Systems Improvement. ICSI, Nov. 2013. Web. 22 May 2015.

"Palliative Care: An Explanation of Palliative Care." National Hospice and Palliative Care Organization. NHPCO, n.d. Web. 22 May 2015.

"Palliative Care in Cancer." National Cancer Institute. Natl. Cancer Inst., Mar. 2010. Web. 22 May 2015.

Quill, Timothy E., Bernard Lo, Dan W. Brock, and Alan Meisel. "Last-Resort Options for Palliative Sedation." Annals of Internal Medicine 151.6 (2009): 421–24. Print.

Raho, Joseph A. "Palliative Sedation: A Review of the Ethical Debate." Academia.edu. Academia.edu, 2014. Web. 22 May 2015.

Wolf, Michael T. "Palliative Sedation in Nursing Anesthesia." American Association of Nurse Anesthetists Journal 81.2 (2013): 113–17. Print.