Definition and Epidemiology
Palliative sedation remains somewhat contentious, due to:
- lack of a consistent and universal definition,
- disparity in clinical use,
- ethical and moral apprehensions,
- confusion regarding sedative medications,
- and a paucity of well-controlled research.
Palliative sedation has not been universally and definitively defined (Beel
2002, Cowan 2002), making interpretation,
comparison, and extrapolation of many studies and case analyses problematic.
Many clinicians argue that palliative sedation does not necessarily mandate sedation to total unconsciousness and, instead, suggest there are variable degrees of sedation as well as duration of sedation.
Working definition of palliative sedation:
Palliative sedation may be more clearly defined and clinically characterized as the primary intention of deliberately inducing a temporary or permanent light-to-deep sleep, but not deliberately causing death, in patients with terminal illness and specific refractory symptoms.
- The primary intent is to sedate the dying patient so that s/he may not experience and suffer due to specific refractory and intractable symptoms.
- The intent is NOT to deliberately hasten the dying process.
- Be aware that palliative sedation can be considered if and ONLY if :
- The patient is dying (as documented in the medical records by the attending physician based on supportive documentation).
- The patient is experiencing unendurable suffering that is not amenable to any standard palliative treatment measures.
Other common definitions of palliative sedation:
| Definition 1 |
Palliative sedation is the intentional administration of sedative
drugs in dosages and combinations required to reduce the consciousness of
a terminal patient as much as necessary to adequately relieve one or more
refractory symptoms.
|
| Definition 2 |
The
Hospice and Palliative Nurses Association (http://www.hpna.org/position_PalliativeSedation.asp.)
defines palliative sedation as the monitored use of medications intended
to induce varying degrees of unconsciousness, but not death, for relief
of refractory and unendurable symptoms in imminently dying patients. |
| Definition 3 |
The
American Academy of Hospice and Palliative Medicine forgoes a formal
definition but suggests the use of sedating medications is intended to decrease
a patient's level of consciousness to mitigate the experience of suffering,
but not to hasten the end of life. |
Intent v. Outcome
The intent of Palliative Sedation is the relief of intractable
suffering caused by refractory symptom(s) and not to deliberately end the life
of the terminally ill patient.
The specific outcome of palliative sedation is to intentionally
sedate the patient to a point where the patient is unaware of the problematic
symptom that was causing the intractable suffering.
In writing about this topic, U.S. Supreme Court Justice Sandra Day O'Connor,
have endorsed the practice, arguing that "a patient who is suffering from
a terminal illness and who is experiencing great pain has no legal barrier to
obtaining medication, from qualified physicians, to alleviate that suffering,
even to the point of causing unconsciousness and hastening death."
Differentiating Palliative Sedation from Physician
Assisted Suicide
| |
Palliative sedation |
Physician assisted suicide (PAS) |
Intent |
Alleviating intractable suffering of a terminally ill
patient primarily by sedation. Hastening death is not a primary
or intended outcome. |
Alleviating intractable suffering of a terminally ill
patient by providing them with medication that the patient may then take
to hasten their own deaths.
Hastening death is a primary and intended outcome. |
Informed consent |
Required |
Required |
Where is it legal currently
British
Medical Association. Physician assisted suicide: the law. |
All the states in USA |
Currently only in Oregon.
Available to a select subset of terminally ill patients who can request
for PAS.
Under consideration in California. |
Although palliative sedation is unquestionably a valuable and efficacious palliative
intervention and was fundamentally sanctioned by the United States Supreme Court
decision opposing a constitutional right to physician-assisted suicide (Rousseau
2001, Orentlicher 1997, Vacco
v Quill 1997 Washington v Glucksberg 1997),
its use remains somewhat nebulous, with a reported incidence ranging from 2%
to 52% (Rousseau 2000, Quill
1997, Ventafridda 1990).
The wide variance in the use of palliative sedation is probably due to:
- lack of a universal definition of palliative sedation,
- the retrospective nature of many studies,
- lack of consensus on the definition of a refractory symptom (particularly
refractory existential suffering),
- ethical and moral concerns, and
- cultural and ethnic diversity (Rousseau
1999, 2000, 2001)
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