Question

What ethical concerns are raised by the practice of palliative or terminal sedation?

Answer 1

The terms "palliative sedation" "terminal sedation," "total sedation," or "controlled sedation" denotes the control of refractory symptoms in patients near the end of life by the use of sedation. The AAHPM position statement described the palliative sedation as the use of sedating medications in order to minimize a patient’s level of consciousness to alleviate the experience of suffering, but not to accelerate the end of life.

The HPNA position statement explains the palliative sedation as the one in which the controlled utilization of medications or sedatives to induce varying levels of unconsciousness, for alleviating the refractory and unendurable symptoms in near dying patients, but not death.

The requirements of palliative sedation are

1. Terminally ill patient at near the end of life

2 . the damages and difficulties are defiant to medical care

3. the palliative sedation must aim at controlling patient's suffering and not to hurry the patient's death.

Ethical Issues

The bioethical principles behind the use of palliative sedation are the autonomy, beneficence, and the doctrine of double effect, to alleviate the sufferings.

Autonomy :

Autonomy represents the person's right to make healthcare decisions in accordance with their personal values, beliefs, and goals. The individual experiences of suffering can be defined only by the person experiencing it and the autonomous person or their surrogate must be able to select healthcare options to reduce the extent of suffering. The limitations on autonomy are justifiable if the harm caused by an exercise of that autonomy is more than the advantages.

Beneficence :

The ethical principle of beneficence ensures the care to benefit the patient’s and improve their well-being. The relief of suffering will be beneficial to the patient and hence is an ethical action. One ethical concern of the palliative sedation as a treatment is that it prohibits the patient from changing his or her decision or expressing any change of thought on it. Doctors like Dr Shaver opined that palliative sedation could be more beneficial to the caregivers including family than to the patient. The patient can no longer communicate his thoughts on palliative sedation.

Informed consent:

The concept of informed consent also becomes complex, as there is no convincing evidence that sedation controls or minimizes the symptoms of suffering. Many clinicians raised concerns on endangerment of the rights of vulnerable populations as the truly autonomous choice relating to a method of death is impossible particularly in case of vulnerable populations.

The doctrine of double effect:

It is often applied to the palliative treatments for patients nearing the end of life. As per the doctrine of double effect the intention of the treatment determines the ethical validity of it. It supports the intent of terminal sedation while the patient remains alive and which is to alleviate the symptoms of pain and suffering, even though the death is foreseeable.

The concerns like the difficulty to define existential suffering because of limited therapeutic guidelines makes the palliative sedation controversial. In this setting, the goal and intent of sedation become even more complex. Interdisciplinary consultation must be needed to guide the palliative sedation.