“Suffering” in Palliative Sedation: Conceptual Analysis and Implications for Decision Making in Clinical Practice

Abstract

Palliative sedation is an increasingly used and, simultaneously, challenging practice at the end of life. Many controversies associated with this therapy are rooted in implicit differences regarding the understanding of "suffering" as a prerequisite for palliative sedation. The aim of this study is to inform the current debates by a conceptual analysis of two different philosophical accounts of suffering-1) the subjective and holistic concept and 2) the objective and gradual concept-and by a clinical-ethical analysis of the implications of each account for decisions about palliative sedation. We will show that although the subjective and holistic account of suffering fits well with the holistic approach of palliative care, there are considerable challenges to justify limits to requests for palliative sedation. By contrast, the objective and gradual account fits well with the need for an objective basis for clinical decisions in the context of palliative sedation but runs the risk of falling short when considering the individual and subjective experience of suffering at the end of life. We will conclude with a plea for the necessity of further combined conceptual and empirical research to develop a sound and feasible understanding of suffering, which can contribute to consistent decision making about palliative sedation.

Using sedative substances until death: A mortality follow-back study on the role of healthcare settings

“…Today it is not clear what 'unbearable suffering' means and when a symptom is considered refractory, particularly in case of existential suffering. [29][30][31] The observation that pain was associated with the use of continuous deep sedation furthermore might explain the age differences we found. Although older patients seem more likely to experience unbearable pain symptoms, previous studies have shown that younger hospitalized patients are more likely to report pain and more likely to receive pain medication.…”

“…Today it is not clear what ‘unbearable suffering’ means and when a symptom is considered refractory, particularly in case of existential suffering. 29–31…”

What’s suffering got to do with it? A qualitative study of suffering in the context of Medical Assistance in Dying (MAID)

“…What are the moral claims of intolerable suffering? [ 4 ]. Bozzaro and Shildmann [ 4 ] argued that the answers to these questions are determined by the underlying assumptions about the nature of suffering.…”

“…[ 4 ]. Bozzaro and Shildmann [ 4 ] argued that the answers to these questions are determined by the underlying assumptions about the nature of suffering. They distinguished two typologies of suffering that form these underlying assumptions: a subjective/holistic one informed by the work of Cassell [ 5 ] and an objective/gradual one informed by the work of van Hooft [ 6 , 7 ].…”

Physicians’ perceptions of palliative sedation for existential suffering: a systematic review

“…The complex nature of existential suffering (ES)4–7 continues to fuel the controversy about whether it is a main indication for PS or not (especially if physical pain is under control) 8–10. Distinguishing kinds of suffering is problematic in itself, and objective or subjective assessment of different kinds of suffering is a hotly debated topic in the medical literature 11. The definition of ES is elusive, because the boundaries between it and other kinds of suffering (psychological, social and spiritual) are blurred 12.…”