Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments

Abstract

Palliative sedation (PS) is the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. Although uncommon, some patients undergoing aggressive symptom control measures still have severe suffering from underlying disease or therapy-related adverse effects. In these circumstances, use of PS is considered. Although the goal is to provide relief in an ethically acceptable way to the patient, family, and health care team, health care professionals often voice concerns whether such treatment is necessary or whether such treatment equates to physician-assisted suicide or euthanasia. In this review, we frame clinical scenarios in which PS may be considered, summarize the ethical underpinnings of the practice, and further differentiate PS from other forms of end-of-life care, including withholding and/or withdrawing life-sustaining therapy and physician-assisted suicide and euthanasia. © 2010 Mayo Foundation for Medical Education and ResearchOn completion of this article, you should be able to (1) P alliative sedation (PS) refers to the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. The practice of PS has gained attention in the literature during the past 20 years. In 1994, Cherny and Portenoy 1 first offered an algorithm for determining appropriate indications for use of PS. During the late 1990s, several important court cases in the United States brought the issue of PS to the forefront and clarified the legality of the right to palliation at end of life. 2,3 Studies have shown that PS is effective, with efficacy rates ranging from 71% to 92%, 4 usually defined as the patient, family, or physician's perceived relief of refractory physical symptoms. In many settings, PS is uncommon, although a recent review revealed considerable variability in the prevalence of PS in the United States and other countries. 4 When PS is used, it is a measure of last resort rather than general care. Although required infrequently, PS is an important palliative tool with which clinicians should be familiar. PrActIcAl ISSueSThe following sections explore issues of the application of PS. Detailed guidelines for practicing PS, although beyond the scope of this article, have been published. 5

To Switch off or not to Switch Off? Case Report and Ethical Issues on Defibrillator Deactivation in End-Of-Life Patients

“…Palliative sedation therapy is the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness [10,11]. The relief of suffering is achieved by reducing the level of consciousness so as to reduce the awareness of the distress to a tolerable level [13].…”

“…There are not data in literature on how sedating a patient in end-of-life and in ES. Most centers use midazolam for palliative sedation in end-of-life patients because of the drug's short half-life, the moderate adverse effects, the ease intravenous or subcutaneous administration and the generally good efficacy [11]. Propofol is used in patients refractory to opioids and midazolam [11].…”

“…Most centers use midazolam for palliative sedation in end-of-life patients because of the drug's short half-life, the moderate adverse effects, the ease intravenous or subcutaneous administration and the generally good efficacy [11]. Propofol is used in patients refractory to opioids and midazolam [11]. Clinicians should use the minimal dose of sedatives needed to achieve acceptable relief of suffering [11].…”

“…Propofol is used in patients refractory to opioids and midazolam [11]. Clinicians should use the minimal dose of sedatives needed to achieve acceptable relief of suffering [11]. It is important to stress that the use of such drugs may result useful not only in pain relief but also in treating the arrhythmia: short-acting anesthetic such as propofol and benzodiazepines have been associated with the suppression of VT, because of the physical and emotional stress that patient experiences on ES perpetuate arrhythmias [3,12].…”

Integration of Palliative Care in the Context of Rapid Response

“…On the other hand, even if death is hastened as an unintended consequence of analgesia or sedation for a patient whose care is focused exclusively on comfort, the doctrine of "double eff ect" allows treatment intended to control symptoms. 46 Th e RRT should involve the patient and family, if possible, as well as all members of its own interdisciplinary team to fi nd the optimal combination of symptom relief and physiologic stability consistent with the patient's goals of care.…”