Reflections on palliative sedation

Abstract

‘Palliation sedation’ is a widely used term to describe the intentional administration of sedatives to reduce a dying person’s consciousness to relieve intolerable suffering from refractory symptoms. Research studies generally focus on either ‘continuous sedation until death’ or ‘continuous deep sedation’. It is not always clear whether instances of secondary sedation (i.e. caused by specific symptom management) have been excluded. Continuous deep sedation is controversial because it ends a person’s ‘biographical life’ (the ability to interact meaningfully with other people) and shortens ‘biological life’. Ethically, continuous deep sedation is an exceptional last resort measure. Studies suggest that continuous deep sedation has become ‘normalized’ in some countries and some palliative care services. Of concern is the dissonance between guidelines and practice. At the extreme, there are reports of continuous deep sedation which are best described as non-voluntary (unrequested) euthanasia. Other major concerns relate to its use for solely non-physical (existential) reasons, the under-diagnosis of delirium and its mistreatment, and not appreciating that unresponsiveness is not the same as unconsciousness (unawareness). Ideally, a multiprofessional palliative care team should be involved before proceeding to continuous deep sedation. Good palliative care greatly reduces the need for continuous deep sedation.

Palliative sedation and medical assistance in dying: Distinctly different or simply semantics?

“…However, if the intended action is not actually resulting in the relief of suffering, is the action still considered good? His claim is based on his own experiences in providing deep sedation to pediatric patients undergoing procedures where a "nontrivial minority" are able to recall conversations that happened while they were sedated and also report having felt "pain, fear or anxiety without the ability to express their symptoms" during the procedure while under moderate or deep sedation (Kon, 2011, p. 41 (Leboul et al, 2017;Twycross, 2019). For example, Kon (2011) asserts that "it is unquestionable that some patients receiving moderate or deep sedation also suffer and are unable to express their suffering to providers" (p. 41).…”

“…For example, Kon (2011) asserts that "it is unquestionable that some patients receiving moderate or deep sedation also suffer and are unable to express their suffering to providers" (p. 41). His claim is based on his own experiences in providing deep sedation to pediatric patients undergoing procedures where a "nontrivial minority" are able to recall conversations that happened while they were sedated and also report having felt "pain, fear or anxiety without the ability to express their symptoms" during the procedure while under moderate or deep sedation (Kon, 2011, p. 41 (Leboul et al, 2017;Twycross, 2019). It has been suggested that there is limited understanding of the physiological mechanisms that occur in processing pain or distressing symptoms in patients who are unconscious (Carvalho et al, 2011).…”

Controlling Death. Highlights from Harvard Medical School Annual Bioethics Conference

“…When we talk about proportionate palliative sedation (PPS), the objective is to relieve suffering and medication is used continuously in the minimum amount needed to achieve this, being progressive increased if needed. On the other hand, PSU implies an intended reduction in consciousness (Twycross, 2019) and is used when patients find symptoms intolerable or wants to be in control. Medication is installed in a dosage to achieve unresponsiveness and remains until patient's death.…”

“…"Continuous sedation until death at the patient's request is obviously different from palliative sedation" (Serey, 2019). Interpreting Twycross (2019), as the patient is unconscious, he cannot eat or drink by mouth, and this may lead to hasten death -biological life; also, PSU ends a person's ability to interact -biographical life. One may question whats is the difference between PSU and euthanasia.…”

“…If we think in a cartesian way, one could say that you just have to act according to the law to be understood as acting right. However, "uncritical use of guidelines can result in a 'onesize-fits-all' mentality'' as wrote Twycross (2019). Another issue of concern is the training of the team that should involve not only technical aspects of the last resources options, but also consider legal, emotional and interdisciplinary support to those practitioners.…”