Palliative Terminal Sedation: Is it Ethical?
Palliative care is treatment rendered to relieve the pain and suffering of an illness through the means of medications and other techniques both in situations where active treatment for the underlying illness is being carried out or in situations where there is no medical treatment to provide a cure and simply patient comfort care is the intent of the healthcare providers.
Palliative terminal sedation is a technique of providing palliative care to terminally ill patients who despite attempts at other methods of palliative treatment fail to get relief from pain and suffering. The technique involves administering drugs that maintain unconsciousness when treatments to reduce pain and suffering in the conscious patient has failed, as they occasionally do. The intent of those who provide palliative terminal sedation is the relief of the suffering by rendering the patient unconscious and not to cause the death of the patient which death when it occurs is generally attributed to the patient’s underlying fatal illness. With palliative terminal sedation, however, it might be found that the arrival of death may be accelerated but this is not the intent of the providers.
The question that has ethical implications is whether palliative terminal sedation is actually a form of euthanasia or physician-assisted suicide (PAS). Euthanasia is illegal in the United States. PAS is not accepted as professionally ethical by many and, of course, in the United States PAS is illegal except for its restricted and controlled application in the state of Oregon. The difference between euthanasia, PAS and palliative terminal sedation is clearly one of intent of the provider. In euthanasia, directly producing death at the request of the patient is the intent of the physician. With PAS, the intent is to provide the patient a means to end their own life (suicide). With palliative terminal sedation, the intent is to produce unconsciousness which finally relieves the patient of pain and suffering. Causing death or accelerating death is not the intent.
An interesting article supporting this view can be found in the January 2008 issue of the Journal of Palliative Medicine (Volume 11 Number 1 p76-81 by MARK F. CARR, Ph.D. and GINA JERVEY MOHR, M.D. in an article titled “Palliative Sedation as Part of a Continuum of Palliative Care”. (Note: the link is to the full article which was free at the time of this posting but may not be available free in the future.)
Do all my visitors accept the notion that palliative terminal sedation is an ethical practice for the physician’s treatment of a terminally ill patient? ..Maurice.
posted by Maurice Bernstein, M.D. @ 9:58:00 PM
3 comments
3 Comments:
Yes I believe that under the circumstances you describe palliative sedation is an ethical choice, but only with the permission of the patient or family/personal representative. Informed consent is an absolute must in this type of situation.
In fact, I believe that it is highly unethical to allow any patient to needlessly suffer in pain when the means to relieve that pain exist and they consent.
It is also my sincere belief that there needs to be a controlled method of PAS such as we have in Oregon available to terminal patients to allow them the right of self determination in deciding whether to allow their condition to deteriorate to this point - but that's a subject for another topic.....
I certainly have no ethical problem with it as long as certain safeguards are met, such as rigorous informed consent and use only in terminal cases.
Of course in many states there would be a legal problem with this such as the recent transplant case in California. It's too legally complicated for me to ever consider doing as a physician.
In the UK , it is used in the NHS to get rid of elderly patients who are time consuming and expensive to treat. Few are 'terminally ill' - and interestingly, the General Medical Council of GB do not actually have a working definition of what 'terminally ill' is! See what happened at the Gosport War Memorial Hospital - 90 elderly patients who were only in hospital for rehabilitation, and were in no pain at all - all given morphine in overdose, all died. Their poor families are still fighting for an Inquest into the matter ten years later. Elderly and particularly elderly Working Class patients are deliberately being told their 'cancer is untreatable' - some aren't even given biopsies before the death sentence is passed. It is all too easy to get rid of inconvenient and costly patients in this way - and a total anathema to anyone who calls themselves a medical practitioner. The consent has to be 'truly informed consent', and the single important safeguard I would introduce would be for the patient to be given a device that they operated themselves to terminate their own lives. As things stand, its just too open to abuse to allow this
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