Palliative Sedation, Ethical Issues

Palliative Sedation, an Ethical Issue

Hadi Taleb

Doctor of Nursing Practice Student

University of Massachusetts, Amherst

        For majority of terminal patients, there reaches a point at which the goals of care shift from the primary focus of prolonging life and treating the condition to improving the quality of their remaining life. These patients are managed through palliative care. Palliative sedation is one of the core hallmarks of palliative care which despite its importance raises most of the principal ethical controversies surrounding management of terminal patients (Celleruis & Henry, 2010). In some imminently terminal patients, it is usually impossible to assuage the pain and suffering which often becomes refractory and intolerable. Palliative sedation is adopted to relieve these patients of the pain and suffering by making the symptoms tolerable. Forlornly, palliative sedation is associated with unintended shortening of life, a factor that contributes to ethical controversies surrounding the practice (Cassell & Rich, 2010). This paper will present an overview of palliative sedation, how it affects the healthcare delivery and review epidemiologic data to show the significance of the practice.

        Palliative sedation is the monitored use of sedatives in terminal patients, as a last resort, to induce some level of consciousness adequate to effectively relieve intractable pain and refractory symptoms. The symptoms are usually irreversible, unremitting and cannot be relieved through other clinical or palliative care interventions; thus, sedation is necessary till the death of the patient (Bruce, Hendrix & Gentry, 2006). The goal of palliative sedation is to relieve these symptoms by inducing consciousness to the minimum level at which the refractory symptoms and pain are tolerable. There is no intention to hasten death of the terminal patient although in some cases there is the potential of hastening death when palliative sedation is initiated. The three factors which are considered key when initiating palliative care are degree of suffering, presence of refractory symptoms and imminence of death. Quill et al. (2009) outline that imminence of death means that death of the patient is anticipated soon – usually within two weeks. Palliative sedation can be given to all patients including geriatrics and pediatrics. Among the drugs used in palliative sedation include anesthetics, neuroleptics, benzodiazepines and barbiturates. The drugs chosen depends the cost, environment and preference of the team and the family.

Palliative sedation can be grouped into three categories depending on the level of level of sedation; ordinary, proportionate and sedation to unconsciousness. According to Celleruis and Henry (2010) ordinary sedation is given to relieve mild discomforts and anxiety, proportionate sedation is given to patients requiring higher amount of sedatives to achieve comfort while sedation to unconsciousness is given to patients with refractory symptoms. The principle is that the patient is titrated with the sedatives until the desired relieve of symptoms is achieved. Therefore, it is possible to maintain the patient in a conscious state and in contact with caregivers and family until the symptoms become intractable. Historically, studies have revealed that all forms of palliative sedation are effective forms of treatment, with between 71% and 92% efficacy rates (Muller-Bursch, Andres & Jehser, 2003). The perspective of proportionate titration has helped increase the acceptance of palliative sedation as an option for treatment. Although data on continuous sedation to unconsciousness is limited, few available studies show that 89% of palliative care experts acknowledge that palliative sedation is necessary in management of end-of-life patients and 77% had provided it in the preceding year (Boston, Bruce & Schreiber, 2011). Three other retrospective and one prospective reviews show that the prevalence of palliative sedation range from 2% to 60% with variation based on cultures and settings (Muller-Bursch, Andres & Jehser, 2003). Common indications for sedation in these studies were pain, delirium, dyspnea, nausea and vomiting.