I have recently already covered this topic in a March 2008 posting
. This type of sedation, particularly its use in terminally ill patients, has been open to criticism as either a form of physician-assisted suicide or euthanasia. However, as with much of the rationalizations in medicine (and I guess politics), the results of an act are defined more by intent than by outcome. To get a fuller understanding of the arguments please read the full report which can be accessed through the link below.
The subject Report 5 Sedation to Unconsciousness in End-of-Life Care
, is one of a series of 8 Reports of the Council of Ethical and Judicial Affairs (CEJA) of the American Medical Association and is the last of the series to be posted here. The previous seven have now all been posted. These reports have not yet been adopted as AMA policy; they will be discussed and debated in June 2008. If they receive the support of the majority of the delegates from the state and specialty societies, they will become policy. Anyone, including the general public, can provide testimony on CEJA reports either in person at the meeting or by writing to firstname.lastname@example.org.
I have presented each Report as a separate thread on this blog. By clicking on the link above, you can gain access to the specific wording of this particular Report. 1 through 6 are to be Amendments to the Constitution and Bylaws of the American Medical Association. Reports 7 and 8 are for Informational purposes . Why should the public be interested in these reports? They are part of the ethics of the system of medicine in the United States and may be reflected elsewhere in the world. Through the practice of medicine by all physicians, the rules presented in these reports can be applied to and may affect all patients. You may write directly your comments to CEJA at the e-mail address above and, of course, you are certainly welcome to post your comments on this particular Report here.
Here is the Conclusion and Recommendations of the Report:
Palliative sedation to unconsciousness is an important tool in the armamentarium of palliative medicine. For patients whose illnesses are terminal and end stage, palliative sedation to unconsciousness can ameliorate such intractable symptoms as delirium, pain, dyspnea, nausea, and vomiting. It is medically and ethically acceptable under specific, relatively rare circumstances. Because palliative sedation to unconsciousness is intended to be maintained until the patient’s death, it should be used only as a therapy of last resort for relief of severe, unrelenting clinical symptoms after the failure of other aggressive interventions, including psycho-social support.7 It is important to ensure that patients are indeed at the end stage of a terminal illness and that other forms of symptom-specific treatment are not effective. It is most appropriate as part of a multi-disciplinary mode of palliative care that addresses the whole patient in the context of that patient’s family system, spiritual beliefs and values. It is not appropriate for suffering that is mainly existential.
The Council on Ethical and Judicial Affairs recommends that the following be adopted and that the remainder of this report be filed.
The duty to relieve pain and suffering is central to the physician’s role as healer and is an obligation physicians have to their patients. Palliative sedation to unconsciousness is the administration of sedative medication to the point of unconsciousness in a terminally ill patient. It is an intervention of last resort to reduce severe, refractory pain or other distressing clinical symptoms that do not respond to aggressive symptom-specific palliation. It is an accepted and appropriate component of end-of-life care under specific, relatively rare circumstances. When symptoms cannot be diminished through all other means of palliation, including symptom-specific treatments, it is the ethical obligation of a physician to offer palliative sedation to unconsciousness as an option for the relief of intractable symptoms. When considering the use of palliative sedation, the following ethical guidelines are recommended:
(1) Patients may be offered palliative sedation when they are in the final stages of terminal illness. The rationale for all palliative care measures should be documented in the medical record.
(2) Palliative sedation to unconsciousness may be considered for those terminally ill patients whose clinical symptoms have been unresponsive to aggressive, symptom-specific treatments.
(3) Physicians should ensure that the patient and/or the patient’s surrogate have given informed consent for palliative sedation to unconsciousness.
(4) Physicians should consult with a multidisciplinary team, including an expert in the field of palliative care, to ensure that symptom-specific treatments have been sufficiently employed and that palliative sedation to unconsciousness is now the most appropriate course of treatment.
(5) Physicians should discuss with their patients considering palliative sedation the care plan relative to degree and length (intermittent or constant) of sedation, and the specific expectations for continuing, withdrawing or withholding future life-sustaining treatments.
(6) Once palliative sedation is begun, a process must be implemented to monitor for appropriate care.
(7) Palliative sedation is not an appropriate response to suffering that is primarily existential, defined as the experience of agony and distress that may arise from such issues as death anxiety, isolation and loss of control. Existential suffering is better addressed by other interventions. For example, palliative sedation is not the way to address suffering created by social isolation and loneliness; such suffering should be addressed by providing the patient with needed social support.
(8) Palliative sedation must never be used to intentionally cause a patient’s death.
Recommendation 5 states “Physicians should discuss with their patients considering palliative sedation the care plan relative to degree and length (intermittent or constant) of sedation, and the specific expectations for continuing, withdrawing or withholding future life-sustaining treatments.”
I think, what is missing from the Recommendations but should be emphasized is that the withholding or withdrawal of life-supporting treatments, including hydration and nutrition is not and should not be considered part of the act of palliative or terminal sedation itself.