Palliative Sedation Therapy Research Paper
Erica Lottes
Professor Mary Pat Henehan, MPH, MA, DMin, RN, LMFT
Washington University in Saint Louis, George Warren Brown School
Palliative Sedation Therapy
Introduction Palliative care endeavors to relieve pain and offer comfort for people in the final stage of their life. In the final days, some patients may suffer from refractory symptoms. A widely accepted definition of refractory symptom is ‘symptom for which all possible treatment has failed, or it is estimated that no methods are available for palliation within the time frame and the risk-benefit ration that the patient can tolerate,’ (Maltoni et al., 2009). For patients who experience refractory symptoms a legal treatment option is palliative sedation. Palliative sedation …show more content…
or palliative sedation therapy (PST) is the use of sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness (Maltoni et al., 2009). The most common physical symptoms cited in the literature for palliative sedation are severe pain, dyspnea, vomiting, and delirium.
Psychological and existential distress as symptoms involving the need for palliative sedation is very controversial. The research and literature on palliative sedation therapy is not extensive. In the early to mid-2000s, researchers all over the world began publishing more systematic research on the use of sedation (de Graeff & Dean, 2007). Systematic research found there are limited amount of guidelines for clinical practice and prevalence of patients requiring sedation varied widely among studies-due to different definitions and cultural beliefs. Although the medical field does not have any formal recommendations or guidelines from nationally esteemed organizations, patients have been increasingly requesting the medical intervention. In the years 2000–2002, there was an increase in the request for sedation in the final days of life from 19% to 34% by the patients themselves, documented in personal statements or advance directives (Muller-Busch, Andres & Jehser, 2003). Requests for sedation are increasingly more common, but the ethical implications may rise to conflicts between patients ' wishes to hasten death and physicians ' intentions to provide the best care and not to shorten life. This …show more content…
paper will argue that palliative sedation therapy is a legal and ethically sound medical treatment and also present the counterargument against the use of palliative sedation therapy.
Argument for Palliative Sedation Therapy (PST)
For most patients nearing the end of life, there comes a point where the goals of care evolve from an emphasis on prolonging life to maximizing the quality of life and palliative care becomes the priority. Providing adequate relief of symptoms for dying patients is one of the hallmarks of good palliative care (Veterans Health Administration, 2007). Yet for some patients, even aggressive, high-quality palliative care fails to provide relief. For patients who suffer from severe pain, dyspnea, vomiting, or other symptoms that prove refractory to treatment, palliative sedation therapy is an appropriate intervention of last resort. There is broad professional agreement palliative sedation is a clinically and ethically appropriate response when patients who are near death suffer severe, unremitting symptoms. The National Hospice and Palliative Care Organization and the American Academy of Hospice and Palliative Medicine support the use of sedation to treat otherwise unrelievable suffering at the end of life, and the practice has been endorsed by the End-of-Life Care Consensus Panel of the American College of Physicians (ACP), American Society of Internal Medicine (ASIM), and the American Medical Association (AMA). Additionally, in the 1997 cases Washington v. Glucksberg and Vacco v. Quill, the Supreme Court recognized the legality of providing pain relief in palliative care even if doing so might shorten life, provided the intention was to relieve pain (Battin, 2008).
Although PST is legally sound, ethical tension often centers around the following topics: the distinction of PST from physician-assisted suicide and euthanasia, the unavoidable morbidity (loss of social function and risk of life-shortening adverse effects) of PST, and the use of PST for psychological and existential suffering (Battin, 2008; Oncol, 2009; Hallenbeck, 2000; Maltoni et al., 2009; Veterans Health Administration, 2007).
Professionals from many disciplines argue PST is distinct from physician-assisted suicide and euthanasia because of the intention behind the intervention. In PST the intention is to relieve intolerable suffering, the procedure is to use a sedating drug for symptom control, and the successful outcome is the alleviation of distress. In euthanasia the intention is to kill the patient, the procedure is to administer a lethal drug and the successful outcome is immediate death.
To address the issue of PST hastening death, there is an argument that the intervention is still ethically justified by referring to the ‘Doctrine of Double Effect.’ This doctrine, from Thomas Aquinas, asserts that an action in the pursuit of a good outcome is acceptable, even if it achieved through means with an unintended but foreseeable negative outcome, if that negative outcome is outweighed by the good outcome (Hallenbeck, 2000). When applied to the use of PST, relief of intolerable symptoms (desired good outcome) through use of medications that will likely cause loss of social interaction and may hasten death (unintentional but foreseeable possible consequence) is ethically acceptable. Since rigorous research on whether PST actually does hasten death through randomized experiments is obviously unethical, scholars and professionals used this argument for many years. However, Maltoni et al. (2009) creatively found a way to evaluate overall survival in two cohorts of hospice patients. The two cohorts were (a) patients submitted to palliative sedation and (b) the other managed as per routine hospice practice. Both cohorts were matched for age, class, gender, reason for hospice admission and Karnofsky performance status. The study did not reveal any important differences in survival between patients who received no sedatives and those who received different doses of sedatives. Furthermore, an analysis of the use of sedatives confirm that sedation to complete unconsciousness is a less common procedure than more moderate sedation (Maltoni et al., 2008; Muller-Busch, Andres & Jehser, 2003). These results and other literature shows in populations of patients undergoing palliative care, sedation does not have a negative impact on survival and that the doctrine of double effect is not even needed to justify the use of sedation.
Finally, this section will address the use of PST for psychological and existential distress. A panel of 29 international experts (United Kingdon, The Netherlands, Belgium, France, Germany, Switzerland, Finland, Canada the United States, Argentina, South Africa, Israel, Japan, Australia and New Zealand) in palliative medicine with clinical experience performed a systematic review of the literature and discussed many issues related to PST and published their recommendations. These experts believe that PST for psychological or existential distress should be initiated only under exceptional circumstances and only after consultations with experts in this area-ideally, a palliative care team (de Graeff & Dean, 2007). Therefore, experts in the field all over the world recognize the need for clinicians to utilize PST to relieve intolerable suffering of terminally ill patients imminently facing death.
Argument against Palliative Sedation Therapy (PST) Resembling other topics involving the intersection of life/death and medical interventions, there are several arguments objecting the use of PST. It’s important to note, opponents often use the term “terminal sedation” instead of palliative sedation therapy. One of the main arguments opposing PST states that PST violates the principle of the wrongness of killing, or the sanctity of life (Battin, 2008). During the process of PST, it’s common to withhold the administration of fluids and nutrition. Patients who are sedated to the degree which they cannot eat or drink and without artificial nutrition and hydration will die, arguably always before they would have died otherwise. If respect for sanctity of life means that a patient’s life should not be caused to end, but rather that death must occur only as the result of the underlying disease process, then palliative sedation therapy, without artificial nutrition, does not honor that principle. Another challenging concern to PST is the possibility of abuse.
People on both sides of the argument recognize additional factors may influence the determination of refractory symptoms and if the case calls for PST. For example, several studies indicate wide varying practices of PST among physicians based on personal factors-philosophy about a good death, beliefs about the effect of PST on survival, medical practice, experience, religious practice and fatigue and levels of burnout can result in increased use of PST (de Graeff & Dean, 2007). Studies from other countries indicate that administration of sedating medication with the clear intent of hastening death is commonplace (Chiu, Hu, Lue, Cheng & Chen, 2001). This is described as a ‘slow euthanasia,’ and is morally equivalent to euthanasia which is maleficent and undercuts the medical profession’s integrity. Since the use of PST is open to much abuse, it becomes a slippery slope and physicians will begin killing other
patients. Finally, opponents argue autonomy cannot be honored in decisions to use terminal sedation due to pain impairing consent (Battin, 2008). If patients are suffering from severe pain which other interventions has failed to relieve, reflective and unimpaired consent may no longer be possible. Palliative sedation therapy may end pain, but also ends life; immediately ends sentient life and possibly social interaction and then removing artificial nutrition and hydration ends biological life. Opponents claim the assumption that sedation is used to end pain without the intention of ending life, the patient cannot be asked for consent to end her life but only to relieve her pain (Battin, 2008). Since the focus of consent is on avoiding pain and not causing death, autonomy is undercut whether the patient’s capacity for reflection is impaired by severe pain or not. Conclusion When all other treatments fail to relieve suffering in the imminently dying patient, PST is a valid, legal, ethically sound palliative care option. Unfortunately, its practice is open to misuse or even abuse. It is evident the medical field needs recommendations based on available evidence and/or experience of health care professionals who deal with dying patients daily. Consultation with palliative care experts should be mandatory; PST requires careful process of decision making, emotions, preferences and wishes of the patients, patient’s family, and health care team should be carefully assessed. Frequently, to relieve the distress of the patient PST does not require reduction of consciousness to a level where communication is no longer possible; thus, using titrated doses of sedatives and emphasizing the importance of adequate monitoring is vital.
Studies have shown that PST is effective, with efficacy rates ranging from 71% to 92%, usually defined as the patient, family, or physician’s perceived relief of refractory physical symptoms (Olsen, Swetz & Mueller, 2010). In many settings, PST is uncommon, although a recent review revealed considerable variability in the prevalence of PST in the United States and other countries (Claessens, Menten, Schotsmans & Broeckaert, 2008). The debate of utilizing PST is healthy and just in a democratic society; however, physicians need to be familiar with the scholarly evidence available and be provided guidelines and recommendation to verify they are knowledgeable and competent to provide this accepted medical practice.
References
Battin, M. P. (2008). Terminal sedation: Pulling the sheet over our eyes. Hastings Center Report, 38(5), 27-30. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=jlh&AN=2010076394&site=ehost-live&scope=site
Cantor, M. (2006). The ethics of palliative sedation (Ethics Committee National Center for Ethics in Health Care Veterans Health Administration Department of Veterans Affairs. (Ethics in Palliative Sedation)
Cherny, N. (2009). The use of sedation to relieve cancer patients ' suffering at the end of life: Addressing critical issues. Annals of Oncology, 20(7), 1153-1155. doi:10.1093/annonc/mdp302 Chiu, Hu, Lue, Cheng & Chen. (2001). Sedation for refractory symptoms of terminal cancer patients in Taiwan. Journal of Pain and Symptom Management, 21:467-472.
Claessens, Menten, Schotsmans, Broeckaert. (2008). Palliative sedation: a review of the research literature. Journal of Pain and Symptom Management. 36:310-333.
Graeff, A. D., & Dean, M. (2007). Palliative sedation therapy in the last weeks of life: A literature review and recommendations for standards. Journal of Palliative Medicine, 10(1), 67-85. doi:10.1089/jpm.2006.0139
Hallenbeck, J. L. (2000). Terminal sedation: Ethical implications in different situations. Journal of Palliative Medicine, 3, 313-320.
Maltoni, M., Pittureri, C., Scarpi, E., Piccinini, L., Martini, F., Turci, P., et al. (2009). Palliative sedation therapy does not hasten death: Results from a prospective multicenter study doi:10.1093/annonc/mdp048
Muller-Busch, H., Andres, I., & Jehser, T. (2003). Sedation in palliative care - a critical analysis of 7 years experience. BMC Palliative Care, 2(1), 2. Retrieved from http://www.biomedcentral.com/1472-684X/2/2
Olsen, M. L., Swetz, K. M., & Mueller, P. S. (2010). Ethical decision making with end-of-life care: Palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clinic Proceedings, 85(10), 949-954. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=54592678&site=ehost-live&scope=site
Oncol, A. (2009). The use of sedation to relieve cancer patients’ suffering at the end of life: addressing critical issues 20 (7): 1153-1155.doi: 10.1093/annonc/mdp302
Professor Mary Pat Henehan, MPH, MA, DMin, RN, LMFT
Washington University in Saint Louis, George Warren Brown School
Palliative Sedation Therapy
Introduction Palliative care endeavors to relieve pain and offer comfort for people in the final stage of their life. In the final days, some patients may suffer from refractory symptoms. A widely accepted definition of refractory symptom is ‘symptom for which all possible treatment has failed, or it is estimated that no methods are available for palliation within the time frame and the risk-benefit ration that the patient can tolerate,’ (Maltoni et al., 2009). For patients who experience refractory symptoms a legal treatment option is palliative sedation. Palliative sedation …show more content…
or palliative sedation therapy (PST) is the use of sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness (Maltoni et al., 2009). The most common physical symptoms cited in the literature for palliative sedation are severe pain, dyspnea, vomiting, and delirium.
Psychological and existential distress as symptoms involving the need for palliative sedation is very controversial. The research and literature on palliative sedation therapy is not extensive. In the early to mid-2000s, researchers all over the world began publishing more systematic research on the use of sedation (de Graeff & Dean, 2007). Systematic research found there are limited amount of guidelines for clinical practice and prevalence of patients requiring sedation varied widely among studies-due to different definitions and cultural beliefs. Although the medical field does not have any formal recommendations or guidelines from nationally esteemed organizations, patients have been increasingly requesting the medical intervention. In the years 2000–2002, there was an increase in the request for sedation in the final days of life from 19% to 34% by the patients themselves, documented in personal statements or advance directives (Muller-Busch, Andres & Jehser, 2003). Requests for sedation are increasingly more common, but the ethical implications may rise to conflicts between patients ' wishes to hasten death and physicians ' intentions to provide the best care and not to shorten life. This …show more content…
paper will argue that palliative sedation therapy is a legal and ethically sound medical treatment and also present the counterargument against the use of palliative sedation therapy.
Argument for Palliative Sedation Therapy (PST)
For most patients nearing the end of life, there comes a point where the goals of care evolve from an emphasis on prolonging life to maximizing the quality of life and palliative care becomes the priority. Providing adequate relief of symptoms for dying patients is one of the hallmarks of good palliative care (Veterans Health Administration, 2007). Yet for some patients, even aggressive, high-quality palliative care fails to provide relief. For patients who suffer from severe pain, dyspnea, vomiting, or other symptoms that prove refractory to treatment, palliative sedation therapy is an appropriate intervention of last resort. There is broad professional agreement palliative sedation is a clinically and ethically appropriate response when patients who are near death suffer severe, unremitting symptoms. The National Hospice and Palliative Care Organization and the American Academy of Hospice and Palliative Medicine support the use of sedation to treat otherwise unrelievable suffering at the end of life, and the practice has been endorsed by the End-of-Life Care Consensus Panel of the American College of Physicians (ACP), American Society of Internal Medicine (ASIM), and the American Medical Association (AMA). Additionally, in the 1997 cases Washington v. Glucksberg and Vacco v. Quill, the Supreme Court recognized the legality of providing pain relief in palliative care even if doing so might shorten life, provided the intention was to relieve pain (Battin, 2008).
Although PST is legally sound, ethical tension often centers around the following topics: the distinction of PST from physician-assisted suicide and euthanasia, the unavoidable morbidity (loss of social function and risk of life-shortening adverse effects) of PST, and the use of PST for psychological and existential suffering (Battin, 2008; Oncol, 2009; Hallenbeck, 2000; Maltoni et al., 2009; Veterans Health Administration, 2007).
Professionals from many disciplines argue PST is distinct from physician-assisted suicide and euthanasia because of the intention behind the intervention. In PST the intention is to relieve intolerable suffering, the procedure is to use a sedating drug for symptom control, and the successful outcome is the alleviation of distress. In euthanasia the intention is to kill the patient, the procedure is to administer a lethal drug and the successful outcome is immediate death.
To address the issue of PST hastening death, there is an argument that the intervention is still ethically justified by referring to the ‘Doctrine of Double Effect.’ This doctrine, from Thomas Aquinas, asserts that an action in the pursuit of a good outcome is acceptable, even if it achieved through means with an unintended but foreseeable negative outcome, if that negative outcome is outweighed by the good outcome (Hallenbeck, 2000). When applied to the use of PST, relief of intolerable symptoms (desired good outcome) through use of medications that will likely cause loss of social interaction and may hasten death (unintentional but foreseeable possible consequence) is ethically acceptable. Since rigorous research on whether PST actually does hasten death through randomized experiments is obviously unethical, scholars and professionals used this argument for many years. However, Maltoni et al. (2009) creatively found a way to evaluate overall survival in two cohorts of hospice patients. The two cohorts were (a) patients submitted to palliative sedation and (b) the other managed as per routine hospice practice. Both cohorts were matched for age, class, gender, reason for hospice admission and Karnofsky performance status. The study did not reveal any important differences in survival between patients who received no sedatives and those who received different doses of sedatives. Furthermore, an analysis of the use of sedatives confirm that sedation to complete unconsciousness is a less common procedure than more moderate sedation (Maltoni et al., 2008; Muller-Busch, Andres & Jehser, 2003). These results and other literature shows in populations of patients undergoing palliative care, sedation does not have a negative impact on survival and that the doctrine of double effect is not even needed to justify the use of sedation.
Finally, this section will address the use of PST for psychological and existential distress. A panel of 29 international experts (United Kingdon, The Netherlands, Belgium, France, Germany, Switzerland, Finland, Canada the United States, Argentina, South Africa, Israel, Japan, Australia and New Zealand) in palliative medicine with clinical experience performed a systematic review of the literature and discussed many issues related to PST and published their recommendations. These experts believe that PST for psychological or existential distress should be initiated only under exceptional circumstances and only after consultations with experts in this area-ideally, a palliative care team (de Graeff & Dean, 2007). Therefore, experts in the field all over the world recognize the need for clinicians to utilize PST to relieve intolerable suffering of terminally ill patients imminently facing death.
Argument against Palliative Sedation Therapy (PST) Resembling other topics involving the intersection of life/death and medical interventions, there are several arguments objecting the use of PST. It’s important to note, opponents often use the term “terminal sedation” instead of palliative sedation therapy. One of the main arguments opposing PST states that PST violates the principle of the wrongness of killing, or the sanctity of life (Battin, 2008). During the process of PST, it’s common to withhold the administration of fluids and nutrition. Patients who are sedated to the degree which they cannot eat or drink and without artificial nutrition and hydration will die, arguably always before they would have died otherwise. If respect for sanctity of life means that a patient’s life should not be caused to end, but rather that death must occur only as the result of the underlying disease process, then palliative sedation therapy, without artificial nutrition, does not honor that principle. Another challenging concern to PST is the possibility of abuse.
People on both sides of the argument recognize additional factors may influence the determination of refractory symptoms and if the case calls for PST. For example, several studies indicate wide varying practices of PST among physicians based on personal factors-philosophy about a good death, beliefs about the effect of PST on survival, medical practice, experience, religious practice and fatigue and levels of burnout can result in increased use of PST (de Graeff & Dean, 2007). Studies from other countries indicate that administration of sedating medication with the clear intent of hastening death is commonplace (Chiu, Hu, Lue, Cheng & Chen, 2001). This is described as a ‘slow euthanasia,’ and is morally equivalent to euthanasia which is maleficent and undercuts the medical profession’s integrity. Since the use of PST is open to much abuse, it becomes a slippery slope and physicians will begin killing other
patients. Finally, opponents argue autonomy cannot be honored in decisions to use terminal sedation due to pain impairing consent (Battin, 2008). If patients are suffering from severe pain which other interventions has failed to relieve, reflective and unimpaired consent may no longer be possible. Palliative sedation therapy may end pain, but also ends life; immediately ends sentient life and possibly social interaction and then removing artificial nutrition and hydration ends biological life. Opponents claim the assumption that sedation is used to end pain without the intention of ending life, the patient cannot be asked for consent to end her life but only to relieve her pain (Battin, 2008). Since the focus of consent is on avoiding pain and not causing death, autonomy is undercut whether the patient’s capacity for reflection is impaired by severe pain or not. Conclusion When all other treatments fail to relieve suffering in the imminently dying patient, PST is a valid, legal, ethically sound palliative care option. Unfortunately, its practice is open to misuse or even abuse. It is evident the medical field needs recommendations based on available evidence and/or experience of health care professionals who deal with dying patients daily. Consultation with palliative care experts should be mandatory; PST requires careful process of decision making, emotions, preferences and wishes of the patients, patient’s family, and health care team should be carefully assessed. Frequently, to relieve the distress of the patient PST does not require reduction of consciousness to a level where communication is no longer possible; thus, using titrated doses of sedatives and emphasizing the importance of adequate monitoring is vital.
Studies have shown that PST is effective, with efficacy rates ranging from 71% to 92%, usually defined as the patient, family, or physician’s perceived relief of refractory physical symptoms (Olsen, Swetz & Mueller, 2010). In many settings, PST is uncommon, although a recent review revealed considerable variability in the prevalence of PST in the United States and other countries (Claessens, Menten, Schotsmans & Broeckaert, 2008). The debate of utilizing PST is healthy and just in a democratic society; however, physicians need to be familiar with the scholarly evidence available and be provided guidelines and recommendation to verify they are knowledgeable and competent to provide this accepted medical practice.
References
Battin, M. P. (2008). Terminal sedation: Pulling the sheet over our eyes. Hastings Center Report, 38(5), 27-30. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=jlh&AN=2010076394&site=ehost-live&scope=site
Cantor, M. (2006). The ethics of palliative sedation (Ethics Committee National Center for Ethics in Health Care Veterans Health Administration Department of Veterans Affairs. (Ethics in Palliative Sedation)
Cherny, N. (2009). The use of sedation to relieve cancer patients ' suffering at the end of life: Addressing critical issues. Annals of Oncology, 20(7), 1153-1155. doi:10.1093/annonc/mdp302 Chiu, Hu, Lue, Cheng & Chen. (2001). Sedation for refractory symptoms of terminal cancer patients in Taiwan. Journal of Pain and Symptom Management, 21:467-472.
Claessens, Menten, Schotsmans, Broeckaert. (2008). Palliative sedation: a review of the research literature. Journal of Pain and Symptom Management. 36:310-333.
Graeff, A. D., & Dean, M. (2007). Palliative sedation therapy in the last weeks of life: A literature review and recommendations for standards. Journal of Palliative Medicine, 10(1), 67-85. doi:10.1089/jpm.2006.0139
Hallenbeck, J. L. (2000). Terminal sedation: Ethical implications in different situations. Journal of Palliative Medicine, 3, 313-320.
Maltoni, M., Pittureri, C., Scarpi, E., Piccinini, L., Martini, F., Turci, P., et al. (2009). Palliative sedation therapy does not hasten death: Results from a prospective multicenter study doi:10.1093/annonc/mdp048
Muller-Busch, H., Andres, I., & Jehser, T. (2003). Sedation in palliative care - a critical analysis of 7 years experience. BMC Palliative Care, 2(1), 2. Retrieved from http://www.biomedcentral.com/1472-684X/2/2
Olsen, M. L., Swetz, K. M., & Mueller, P. S. (2010). Ethical decision making with end-of-life care: Palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clinic Proceedings, 85(10), 949-954. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=54592678&site=ehost-live&scope=site
Oncol, A. (2009). The use of sedation to relieve cancer patients’ suffering at the end of life: addressing critical issues 20 (7): 1153-1155.doi: 10.1093/annonc/mdp302