Palliative sedation, also known as sedation for intractable distress in a dying patient or terminal sedation, is a sort of palliative practice aiming to relieve distress in terminal patients who have a life expectancy that ranges of no more than hours to days. It has been estimated that 5% of terminally ill patients cannot be relieved of their pain despite the use of massive doses of opioid medications. Because this group would otherwise die in agony, palliative sedation has evolved.
There is broad clinical, ethical, and legal consensus that palliative sedation is appropriate at the end of life to treat intractable and intolerable symptoms such as extreme pain, dyspnea, nausea, and vomiting as long as the intent is to treat patient symptoms and not to hasten death. Palliative sedation is an order of interventions implementing sedatives and opioid medications to relieve the physical pain, distress, and agony of a dying patient at the end of life. In some cases, the patient must be sedated into unconsciousness to relieve pain. In these situations, palliative sedation is legally acceptable when the following three points are met: 1) the administered medication offers legitimate patient benefits, 2) the intention is not to kill, and 3) patient's death is imminent (days or hours, not weeks or months).
There is no maximum dose; the pharmacology of sedatives and opioids used for palliation of intractable pain and suffering requires titration to effect. The proper dose is the dose that is sufficient to relieve the pain and the suffering. It is accepted that physicians can administer medications to relieve pain or another suffering, even if doing so poses some increased risk of death. Under the principle of “double effect” (discussed below), the risk of death is acceptable as long as the medication is used in a clinically reasonable effort to treat the patient’s pain. Remember, the intention is not to kill, and thus, it goes without saying that lethal medications (e.g., paralytic agents or bolus potassium chloride) must not be given. Also, the withdrawal of artificial hydration and nutrition must not be presumed but occurs only by patient request. A key distinction between palliative sedation and euthanasia or physician-assisted suicide is that the specific goal is to address the intractable symptoms of the patient and not to hasten death. See generally: Sidney Wanzer, et al., “The Physician’s Responsibility Toward Hopelessly Ill Patients: A Second Look,” 320 NEJMed 844, 1989.
In general, no laboratory workup is required when a patient already has a confirmed diagnosis and is in palliation. For example, measuring levels of creatinine to assess renal function does not change palliation therapy. Similarly, imaging studies are not done, unless there is a need for documentation or one suspects a treatable condition like pneumonia.
The most challenging complication is crossing the line between providing pain relief and causing death. The guiding precept for the clinical practice of palliative sedation is a doctrine that has its roots in Catholic theology: the principle of double effect. In an ideal world, issues related to pain management at the end of life would be separate from the issue of physician-assisted suicide. Unfortunately, the debate over the use of opioids in palliative sedation has led to this unfortunate link. Dr. Timothy Quill focused attention on euthanasia in New York by disclosing in 1991 that he had prescribed a lethal dose of barbiturate for a cancer patient who was terminally ill. See Vacco v. Quill, 117 S. Ct. 2293, & Timothy Quill, “Death With Dignity: A Case of Individualized Decision Making,” 324 NEJMed 691, 1991.
At the heart of the ethical debate over palliative sedation is the differentiation between sedation for intractable symptoms and euthanasia. The distinction lies in the intent. Palliative sedation intends to relieve an intractable distress, whereas euthanasia intends to end life. The principle of double effect is the ethical justification for palliative sedation. It is used when it is impossible to avoid the undesirable effects of the narcotics (i.e., respiratory depression) because it helps us choose between two actions when neither choice is what we desire. The principle of double effect makes the distinction between an intended effect and an unintended effect of an intervention. The double effect holds that intentionally causing death is not acceptable, but prescribing high doses of opioids and/or sedatives to relieve pain is, even if the resulting death is foreseen. See Sulmasy DP, and Pellegrino ED, “The Rule of Double Effect: Clearing Up the Double Talk,” 159(6) Arch Intern Med 545-50, 1999.
Additional support for the ethical correctness of palliative sedation comes from several authoritative sources, including the AMAs policy on Physician-Assisted Suicide (Code of Ethics E-2.211) which states in part:
“…Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer Instead… patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.”
And, from The Ethical and Religious Directives for Catholic Health Care Services:
“Patients should be kept as free of pain as possible so that they may die comfortably and with dignity…Medicine capable of alleviating or suppressing pain may be given to a dying person, even if this therapy may indirectly shorten the person’s life so long as the intent is not to hasten death…”
The legal acceptance of palliative sedation comes in part from the analysis of Justice Sandra Day O’Connor in the United States Supreme Court case of Vacco v. Quill (op.sit.):
“…dying patients have a constitutional right to alleviate their suffering, but such a right would not imply a right to assisted suicide since patients can obtain medications to relieve their suffering even to the point of causing unconsciousness and hastening death.”
In the past, some physicians have been reluctant to provide the large doses of opioids necessary for pain relief in terminally ill patients. Many, perhaps most, of these patients have significant opioid tolerance because of longstanding treatment of cancer or other types of pain with narcotics, and physicians are justifiably concerned that the provision of large doses of narcotics will be misconstrued. In the past, legal presumptions of intent could be drawn from an evaluation of the dose of an administered narcotic alone, without consideration of the setting, degree of tolerance, and amount of pain. More enlightened jurisdictions now specifically permit a physician who uses opiate therapy to relieve severe chronic intractable pain at the end of life to prescribe a dosage deemed “medically necessary.”
Providing palliative care requires an interprofessional team approach. In fact, today most healthcare institutions have a palliative management team that assesses patients for palliation. The team usually consists of a physician, nurse, pharmacist, pain specialist, a religious figure and a member from the ethics committee. Palliative care for each patient is individualized based on symptoms. For pain relief, the WHO 3-stepladder approach is often used. Once the pain medication is administered, the patient is reassessed for pain and breakthrough pain. The nurse and the pharmacist are vital members of the team because they both closely monitor the patient for adverse effects and effectiveness of the medications. Today, in addition to pharmacological methods to relieve pain, there are also non-pharmacological methods available that include radiation, radiofrequency ablation, use of heat, ice or coolant sprays. Finally, no matter what type of pain relieving method is selected, the patient must be provided with psychological assurance that he or she will not suffer. A consult with a mental health counselor is highly recommended even before the pain treatment is initiated. (Level V)
There are many studies showing that palliative care has enormous benefits beyond even pain control. Evidence-based studies reveal that when pain relief is provided in an interprofessional fashion, it enhances the bond between the patient/family and caregiver and relieves the anxiety. In addition, studies show that interventions that relieve emotional stress at the same lead to better pain control. (Level V)
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