Terminal-Palliative Sedation in End-of-Life Care
A Comparison of Terminal Sedation and Euthanasia in Hospice Care
Jul 28, 2009
The national debate over terminal illness, "death panels" and the quality and quantity of end-of-life care has brought the practice of palliative sedation to light perhaps as never before.
Terminal or palliative sedation, according to researchers at University Medical Center, in Rotterdam, The Netherlands, is the administering of drugs to keep a dying, suffering patient continuously in deep sedation or coma until death, without giving artificial nutrition or hydration. An essential component of TS is the withdrawal of all treatment, including food and oral and intravenous fluids, so that death occurs as soon as possible. According to Annals of Internal Medicine, death by dehydration normally occurs within several days, but may take 3 to 4 weeks. "Terminal dehydration can be made painless but not swift."
The definition of euthanasia is more ambiguous. The Rotterdam researchers define it as the deliberate administering of a lethal drug at the request of a patient with the explicit intention to hasten death.*
In an April, 1992, article titled "Decisions Near the End of Life," published in JAMA, the Journal of the American Medical Association (AMA), euthanasia is defined more broadly as an "act or practice of causing death for reasons of mercy of persons that are hopelessly sick or injured." The AMA distinguishes between "voluntary" or"involuntary" euthanasia depending on whether the individual gives consent, and "active" if the individual's death is caused by an intentional act, or "passive" if life support systems are withdrawn.
When is Terminal-Palliative Sedation Used?
The authors of "Palliative Sedation in End-of-Life-Care," an article published in the November/December 2006 issue of the Journal of Hospice & Palliative Nursing, believe four factors should be present for a patient to be considered for terminal-palliative sedation, also sometimes called continuous sedation:
- The patient should have a terminal diagnosis.
- The patient should have symptoms that are unbearable and refractory (resistant to treatment).
- A do not resuscitate (DNR) order must be in effect.
- Death must be imminent (within hours to days), although this can be challenging to determine.
How Terminal-Palliative Sedation Proceeds
Several drugs are used for terminal sedation, usually a benzodiazepine or barbiturate, alone and in combination, in the home or at a hospice or medical facility. Midazolam is the most common. Sedative drugs are not analgesics: they are not intended to relieve pain but rather to induce a sleepy or coma-like state. The sedative is started at the lowest appropriate dose and gradually adjusted upward to the least amount that provides relief or control of the refractory symptoms. An adequate dose that relieves suffering often renders the patient unconscious.
Terminal-palliative sedatives are central nervous depressants with anesthetic properties and are potentially lethal. According to Torbjorn Tännsjö, author of Terminal Sedation: Euthanasia in Disguise [Springer, 2004], "Their therapeutic span ranges from light sedation to unconsciousness, to various anaesthetic levels, and even to the cessation of vital functions, i.e. death."
Terminal-Palliative Sedation in Hospice Care
Hospice philosophy generally advocates treatment that neither hastens death nor attempts to cure the underlying terminal illness. In appropriately administered terminal sedation, the patient is sedated and death ensues quickly from the underlying illness, not from the sedative itself. If a terminally sedated patient is actively dying, he or she often expires quickly as a natural result of the terminal illness.
However, during the course of hospice and hospital ICU-administered TS, food and/or fluids are often withheld. Then, if the illness lingers, death frequently occurs not from the natural disease process but from starvation or dehydration and subsequent circulatory collapse. In such cases, terminal sedation is not strictly palliative care, but rather what the AMA defines as passive euthanasia. Terri Schiavo, whose 2005 death-by-litigation garnered worldwide attention, succumbed not to an illness or terminal disease. Ms. Schiavo died from starvation and dehydration 13 days after a Florida court ordered her feeding tube permanently removed.
Terminal-palliative sedation may be considered by some a humane treatment when suffering is unbearable and death is imminent. But no one can ever accurately predict the duration of anyone's final hours, as British experience with the practice has demonstrated. Patients and family should understand that a terminally sedated patient may die from dehydration or starvation, or the TS drug itself, before the underlying terminal illness can cause natural death. There is no single or unified hospice philosophy with regard to withholding or withdrawing life-sustaining food and fluids from a dying individual. Hospice belief systems vary widely: some providers merely suggest denial of nutrition as an option, while others openly promote or encourage stopping all food and fluids, which may effectively hasten death. But patients and family are under no obligation to yield to such persuasion, and they may object and decline forced starvation/dehydration.
The American hospice movement is to some degree rooted in a tolerance for euthanasia. Florence S. Wald, the former Yale University nursing school dean who brought hospice to the United States from Britain, started the first American hospice unit and is sometimes called "the mother of American hospice, "felt that a "range of options should be available to the patient, and this should include assisted suicide." (Washington Post / November 14, 2008)
Resource: Choosing Hospice: Is It Right For You?
* "Terminal sedation and euthanasia: a comparison of clinical practices", Archives of Internal Medicine, 2006 Apr 10;166(7):749-53
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