A qualitative study on continuous deep sedation until death as an alternative to assisted suicide in Switzerland

Abstract

Background According to the European Association for Palliative Care, decisions regarding palliative sedation should not be made in response to requests for assisted dying, such as euthanasia or assisted suicide. However, several studies show that continuous deep sedation until death (CDSUD) – a particular form of sedation – has been considered as an alternative to these practices in some countries. In Switzerland, where assisted suicide is decriminalized and CDSUD is not legally regulated, no studies have comprehensively investigated their relation. Our study aimed to identify and describe the experience among palliative care physicians of CDSUD as a potential alternative to assisted suicide in the French-speaking part of Switzerland. Methods We performed an exploratory multicentre qualitative study based on interviews with palliative care physicians in the French-speaking part of Switzerland and conducted linguistic and thematic analysis of all interview transcripts. The study is described in accordance with COREQ guidelines. Results We included 10 interviews conducted in four palliative care units. Our linguistic analysis shows four main types of sedation, which we called ‘rapid CDSUD’, ‘gradual CDSUD’, ‘temporary sedation’ and ‘intermittent sedation’. CDSUD (rapid or gradual) was not considered an alternative to assisted suicide, even if a single situation has been reported. In contrast, ‘temporary’ or ‘intermittent sedation’, although not medically indicated, was sometimes introduced in response to a request for assisted suicide. This was the fact when there were barriers to an assisted suicide at home (e.g., when transfer home was impossible or the patient wished not to burden the family). Conclusion These preliminary results can guide clinical, ethical, linguistic and legal reflection in this field and be used to explore this question more deeply at the national and international levels in a comparative, interdisciplinary and multiprofessional approach. They can also be useful to update Swiss clinical guidelines on palliative sedation in order to include specific frameworks on various sedation protocols and sedation as an alternative to assisted suicide. Potential negative impacts of considering palliative sedation as an alternative to assisted suicide should be nuanced by open and honest societal debate.

Physicians’ Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study

“…Our study suggests that the practice of CDS is empirically intertwined with the practice of assisted dying, which corroborates previous studies [9,[56][57][58][59][60][61][62]. More specifically, our findings indicate that in some cases, consideration of assisted dying is diverted to CDS due to the professional stigma of assisted dying among some of the physician population, the procedural requirements of the assisted dying legislation, and the gaps in this legislation in terms of excluding certain patient groups.…”

Palliative Sedation—The Last Resort in Case of Difficult Symptom Control: A Narrative Review and Experiences from Palliative Care in Switzerland

“…For patients who express a wish for assisted suicide, it is discussed whether palliative sedation should be offered as an alternative. We find that, on the contrary, palliative sedation should be an independent treatment with a focus on relieving symptoms [19].…”

Existential suffering as a motive for assisted suicide: difficulties, acceptability, management and roles from the perspectives of Swiss professionals

“…The acceptability of palliative sedation for refractory existential suffering also raises controversial issues that have been explored in the literature recently. (4,12,13,32) A 2020 review (12) reports that “physicians do not hold clear views or agree if and when palliative sedation for existential suffering is appropriate” and that clinicians continue to be more favorable to palliative sedation for physical pain than for existential suffering. Ultimately, whether or not we are open to palliative sedation, it is our duty as clinicians, as stated by the SAMS (Swiss Academy of Medical Sciences) to have explored this suffering and to have proposed alternatives.…”