Addressing the Concerns Surrounding Continuous Deep Sedation in Singapore and Southeast Asia: A Palliative Care Approach

Abstract

The application of continuous deep sedation (CDS) in the treatment of intractable suffering at the end of life continues to be tied to a number of concerns that have negated its use in palliative care. Part of the resistance towards use of this treatment option of last resort has been the continued association of CDS with physician-associated suicide and/or euthanasia (PAS/E), which is compounded by a lack clinical guidelines and a failure to cite this treatment under the aegis of a palliative care approach. I argue that reinstituting a palliative care-inspired approach that includes a holistic review of the patient's situation and the engagement of a multidisciplinary team (MDT) guided by clearly defined practice requirements that have been lacking amongst many prevailing guidelines will overcome prevailing objections to this practice and allow for the legitimization of this process.

The practice of terminal discharge: Is it euthanasia by stealth?

“…Dependent once more upon the employ of case specificity and context sensitivity and determinations of intractability of suffering ensures that CDPS is applied only when it is proportional to the exigency of the situation and the particular needs of the case. 42,44,53 Application of CDPS to circumnavigate awareness of suffering through the application of iatrogenic induction of unconsciousness will ameliorate suffering and negate the necessity for contemplation of life-abbreviating measures. 44 Yet we accept that CDPS cannot be seen to be as the panacea to what ails terminal discharge.…”

“…42,44,53 Application of CDPS to circumnavigate awareness of suffering through the application of iatrogenic induction of unconsciousness will ameliorate suffering and negate the necessity for contemplation of life-abbreviating measures. 44 Yet we accept that CDPS cannot be seen to be as the panacea to what ails terminal discharge. When suffering is existential and the solution is demise at home, when suffering is due to the suffering of loved ones who must balance their own needs with those of the patient in the hospital, when a deeply obtunded state is not consistent with the particular goals of care of the patient and when a prolonged stay in hospital replete with compromises to comfort in the form of statutory cannulations and monitoring, alternatives to CDPS are called for and terminal discharges may be seen on balance to be an acceptable compromise.…”

Distancing sedation in end-of-life care from physician-assisted suicide and euthanasia

“…Yet, it is not our intention to defend the term CSD but rather, the concept that it stands for. We will show that the practice that Lipuma refers to is both defunct and unlike Krishna (19) Primary sedative agents in CSD On the issue of drug selection, Lipuma's attention is focused on the employment of barbiturates as the primary agent in inducing CSD, given that its use for induction of deep sedation is both risky and disproportional to the exigencies of the situation. Lipuma's motive for doing so is to crystallise the intention to hasten death.…”

“…(19) Prevailing guidelines on PS pivot upon the principle of proportionality and the temperate and monitored employment of sedation. (4,34) The endpoint of treatment is in fact the effective amelioration of diagnosed intractable suffering in the safest, most proportionate, effective and effi cient means, using the lowest possible doses to do so.…”

The involvement of cancer patients in the four stages of decision-making preceding continuous sedation until death: A qualitative study

“…[5][6][7] One of the most debated end-of-life practices is palliative sedation, particularly when it is used continuously until death. [8][9][10][11] It entails the use of medication intended to induce a state of decreased consciousness until death to relieve the burden of symptoms that cannot be controlled adequately by conventional palliative treatment. 12,13 Guidelines emphasize that the decision to initiate sedation should be made in accordance with the wishes of the patient and be preceded by their consent or the consent of a surrogate decisionmaker if they lack decision-making capacity.…”