Intractable end-of-life suffering and the ethics of palliative sedation

Palliative sedation (sedation to unconsciousness) as an option of last resort for intractable end-of-life distress has been the subject of ongoing discussion and debate as well as policy formulation. A particularly contentious issue has been whether some dying patients experience a form of intractable suffering not marked by physical symptoms that can reasonably be characterized as "existential" in nature and therefore not an acceptable indication for palliative sedation. Such is the position recently taken by the American Medical Association. In this essay we argue that such a stance reflects a fundamental misunderstanding of the nature of human suffering, particularly at the end of life, and may deprive some dying patients of an effective means of relieving their intractable terminal distress.

Medical house officers' attitudes toward vigorous analgesia, terminal sedation, and physician-assisted suicide

In 2000, the authors surveyed 236 medical house officers in three internal medicine residency programs in Connecticut to assess attitudes toward vigorous analgesia, terminal sedation, and physician-assisted suicide. The goal was to identify associations between these attitudes and training, demographic, and religious factors. The results of the study indicated that most medical house officers supported vigorous analgesia, the majority supported terminal sedation, but only a minority supported physician-assisted suicide. Some house officers' attitudes toward terminal sedation and assisted suicide may have been influenced by their religious commitments and the pressures of training.

Practical guide to palliative sedation

Terminally ill patients want assurance that their symptoms will be controlled as death approaches. Most patients can have a peaceful death with standard palliative care. Some patients approaching death, however, have refractory symptoms such as pain, dyspnea, nausea, and agitated delirium. Palliative sedation (PS), the use of medications to induce sedation in order to control refractory symptoms near death, is a therapeutic option for these patients. The reported frequency of PS use varies greatly, ranging from 5% to 52% of the terminally ill. One concern with PS is its effect on survival. Data suggest that PS does not lead to immediate death, with the median time to death after initiating PS being greater than 1 to 5 days. A number of medications have been used for PS, but midazolam is most commonly reported. PS is distinct from euthanasia because the intent of PS is relief from suffering without death as a required outcome.

Synthesis of research and evidence on factors affecting the desire of terminally ill or seriously chronically ill persons to hasten death

Review of empirical studies indicates that suicide is more common in persons suffering from some physical illnesses (e.g., epilepsy, head injuries, Huntington's Chorea, gastrointestinal diseases, AIDS, and cancer), but other chronic diseases and disabilities have not been linked to increased suicide risk (e.g., blindness, senile dementia, multiple sclerosis, and other physical handicaps). The timing of increased suicide risk varies in different illnesses from early presymptomatic stages to the terminal phase. Difficulties in reliably determining when someone is “terminally ill” and problems of the competence of persons with a poor prognosis complicate empirical investigations of euthanasia, assisted suicide, and the desire to hasten death. The role of family and caregivers in end of life decisions needs further clarification. Researchers have found that pain and suffering and quality of life variables may be linked to the desire to die prematurely, particularly in cancer patients. Others find that clinical depression is a major factor. But, since depression is often present, we do not know why a small minority of depressed patients desire and choose to hasten death. Support for alternative hypotheses is examined, including the role of pre-morbid suicidality and depression, individual differences in coping strategies and indirect consequences of the illness. There is a need to clarify links between attitudes, which is the major variable studied, and actual behaviors and decisions. Furthermore, we need theoretical and empirical links between studies of suicide, which is linked to clinical depression and characterized by ambivalence and studies of euthanasia, which is often depicted as rational and with little ambivalence. Evaluative research should be conducted to determine if interventions to reduce the desire for a premature death by suicide, euthanasia, or assisted suicide are effective. In the light of this review, we present several considerations for those involved in proposing changes in public policy concerning euthanasia and assisted suicide.

Symptom assessment and management

This article reviews how to assess and manage several symptoms commonly encountered by neurologists who care for patients with advanced illness. Scientifically validated guidelines are reviewed and practical advice is offered on how to manage pain, nausea and vomiting, dyspnea, and respiratory secretions at the end of life. The role of the neurologist as a provider of end of life care is discussed including suggestions for communicating with patients and families. This article concludes with a review of when sedation may be offered within the purview of good palliative care to patients who are imminently dying.

The impact of delirium on the circadian distribution of breakthrough analgesia in advanced cancer patients

Most cancer patients will experience pain requiring opioid therapy during their illness. Standard opioid therapy includes fixed scheduled doses and so-called "rescue" doses for breakthrough pain. Circadian rhythms seem to influence the expression of pain and the responsiveness to analgesic medication. Delirium is a common complication in advanced cancer patients and it also may modify the expression of pain and the use of analgesic medication. We reviewed the circadian distribution of breakthrough analgesia (BTA) doses in 104 advanced cancer patients who were part of a prospective study of the occurrence of delirium. We found that the circadian distribution of BTA is significantly different from a random distribution in the case of patients with and without delirium. Patients without delirium tended to use more BTA (P < 0.001) in the morning, whereas patients with delirium tended to use more BTA in the evening and at night (P = 0.02). We conclude that delirium is associated with changes in the circadian distribution of BTA, which is possibly related to reversal of the normal circadian rhythm.

A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients

The issue of symptom management at the end of life and the need to use sedation has become a controversial topic. This debate has been intensified by the suggestion that sedation may correlate with 'slow euthanasia'. The need to have more facts and less anecdote was a motivating factor in this multicentre study. Four palliative care programmes in Israel, South Africa, and Spain agreed to participate. The target population was palliative care patients in an inpatient setting. Information was collected on demographics, major symptom distress, and intent and need to use sedatives in the last week of life. Further data on level of consciousness, adequacy of symptom control, and opioids and psychotropic agents used during the final week of life was recorded. As the final week of life can be difficult to predict, treating physicians were asked to complete the data at the time of death. The data available for analysis included 100 patients each from Israel and Madrid, 94 patients from Durban, and 93 patients from Cape Town. More than 90% of patients required medical management for pain, dyspnoea, delirium and/or nausea in the final week of life. The intent to sedate varied from 15% to 36%, with delirium being the most common problem requiring sedation. There were variations in the need to sedate patients for dyspnoea, and existential and family distress. Midazolam was the most common medication prescribed to achieve sedation. The diversity in symptom distress, intent to sedate and use of sedatives, provides further knowledge in characterizing and describing the use of deliberate pharmacological sedation for problematic symptoms at the end of life. The international nature of the patient population studied enhances our understanding of potential differences in definition of symptom issues, variation of clinical practice, and cultural and psychosocial influences.

Sedation for uncontrolled symptoms in a South African hospice

The need to sedate terminally ill patients for uncontrolled symptoms has been previously documented in a few reports. A retrospective consecutive chart review was undertaken at a hospice in Cape Town, South Africa, to develop an understanding of the local experience and assess the potential for improved patient management. Twenty-three of seventy-six (30%) patients received sedating therapies: twenty patients for delirium, two patients for delirium and dyspnea, and one patient for dyspnea alone. Fourteen patients were sedated with a continuous subcutaneous infusion of midazolam, seven patients with intermittent doses of benzodiazepines, and two patients with chlorpromazine and lorazepam. The mean midazolam dose was 29 mg per day (median 30 mg; range 15-60 mg per day). Patients were sedated on average 2.5 days before death (median 1 day; range 4 hours-12 days). The mean equivalent daily dose of parenteral morphine in the last week of life showed a significantly higher mean for the sedated group, as compared to the nonsedated group. There was minimal investigation of reversible causes for delirium, none of the patients underwent an opioid rotation, and the opioid dose was seldom decreased. None of the patients received parenteral hydration. The prevalence for the use of sedating treatment is consistent with the range of other literature reports. Nevertheless, the wide disparity in the reported prevalence of these problems, and the ethical concerns raised by the relative frequency of this sedative approach, cannot be ignored.