Deciding about continuous deep sedation: physicians’ perspectives

Abstract

Although guidelines restrict the use of continuous deep sedation to patients with refractory physical symptoms and a short life-expectancy, its use is not always restricted to these conditions. A focus group study of physicians was conducted to gain more insight in the arguments for and against the use of continuous deep sedation in several clinical situations. Arguments in favour of continuous deep sedation for patients with a longer life-expectancy were that the overall clinical situation is more relevant than life-expectancy alone, and that patients' wishes should be followed. Continuous deep sedation for patients with predominantly emotional/existential suffering was considered appropriate when physicians empathize with the suffering. Further, some physicians indicated that they may consider the use of sedation in the context of a euthanasia request. Arguments were that the option of continuous deep sedation is a better alternative; it may comfort some patients when their thoughts about potential future suffering become unbearable. Further, some considered continuous deep sedation as less burdening or a bother to perform. We conclude that physicians' decision-making about continuous deep sedation is characterized by balancing the interests of patients with their own feelings. Accordingly, the reasons for its use are not unambiguous and need further debate.

Nurses’ Perceptions of Palliative Sedation in a Scottish Hospice

“…This study supported previous research that found decisions were collaborative, driven by patient's wishes, and supported by family and the multidisciplinary team. 21,22 Other studies had found that the setting, individual values, and culture could impact decisions, 23,24 but at this site, nurses perceived the culture as supportive and collaborative, and consensus was reached easily, which contradicted some previous findings. 25 …”

Continuous palliative sedation until death: practice after introduction of the Dutch national guideline

“…It is regarded as an indispensable treatment to alleviate intolerable refractory symptoms, but it diminishes the patient's ability to communicate in the last days of life 8 10 11. Although it is argued that continuous sedation does not shorten life when its use is restricted to the patient's last days of life,12 13 physicians sometimes indicate using it with the intention of hastening death 14–16. These issues illustrate that the clinical decision-making about continuous sedation until death is very precarious, and have stimulated the development of frameworks and guidelines regarding this very delicate part of medical practice 10 17–19…”

Considerations of physicians about the depth of palliative sedation at the end of life

“…Nevertheless, it is used frequently: comparable nationwide studies in Europe show frequencies of 2.5% to 16% of all deaths. [6][7][8] An important reason for continuous deep sedation being thought of as controversial is the possible association of this practice with the hastening of death, [9][10][11] although it is also argued that palliative sedation does not shorten life when its use is restricted to the patient's last days of life. 12,13 Guidelines for palliative sedation often advise physicians to titrate sedatives, 2,3,14 which means that the dosages of sedatives are adjusted to the level needed for proper relief of symptoms.…”