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Position Statements

Statement on Palliative Sedation

Approved by the Board of Directors
September 15, 2006
(replaces 2002 Statement on Sedation at the End-of-Life)

Background

Palliative care seeks to relieve suffering associated with disease. Unfortunately, not all symptoms associated with advanced illness can be controlled with pharmacologic or other interventions. Patients need and deserve assurance that suffering will be effectively addressed, as both the fear of severe suffering and the suffering itself add to the burden of terminal illness.

Statement

AAHPM believes that distinctions must be made among the following uses of sedatives in medical practice:

  • Ordinary sedation
    The ordinary use of sedative medications for the treatment of anxiety, agitated depression, insomnia, or related disorders, in which the goal of treatment is the relief of the symptom without reducing the patient’s level of consciousness.


  • Palliative sedation (PS)
    The use of sedative medication at least in part to reduce patient awareness of distressing symptoms that are insufficiently controlled by symptom-specific therapies. The level of sedation is proportionate to the patient’s level of distress, and alertness is preserved as much as possible.


  • Palliative sedation (PS) to unconsciousness
    The administration of sedatives to the point of unconsciousness, when less extreme sedation has not achieved sufficient relief of distressing symptoms. This practice is used only for the most severe, intractable suffering at the very end of life.

Health care providers serving patients near the end of life have a responsibility to offer sedatives in appropriate circumstances, usually targeted at specific symptoms (ordinary sedation). PS is occasionally necessary to relieve otherwise intractable suffering, with the degree of sedation proportionate to the severity of the target symptom. PS to unconsciousness should only be considered in the rare circumstance that thorough interdisciplinary assessment and treatment of a patient’s suffering has not resulted in sufficient relief (or is associated with unacceptable side effects), and when sedation to unconsciousness is needed to meet the patient’s goal of relief from suffering. As with all treatment, the use of PS requires informed consent. Treatment of pain and other symptoms should be continued with PS, as sedation may decrease the patient’s ability to communicate symptoms. PS should not be considered irreversible; reducing the sedation should be considered if clinical evaluation suggests that the symptom status may have changed.

Ethical principles and legal rulings support the use of palliative sedation even to the level of unconsciousness to relieve otherwise refractory suffering. With regard to PS, the key ethical features are:

  1. The clinicians’ intent is to relieve suffering,

  2. The degree of sedation must be proportionate to the severity of suffering, and

  3. The patient should give informed consent; if the patient is not capable of decision-making, the surrogate decision maker should give informed consent consistent with the goals of care and values previously stated by the patient.

In clinical practice, PS usually does not alter the timing or mechanism of a patient’s death, as refractory symptoms are most often associated with very advanced terminal illness. The possibility that PS might hasten death as an unintended consequence should be assessed by the health care team in its consideration of PS, and then addressed directly in the process of obtaining informed consent. Institutional bioethics committees may be consulted in cases where there is disagreement regarding the provision of PS.

References

Salacz M and Weissman DE. Fast Facts and Concepts #106 and #107. CONTROLLED SEDATION FOR REFRACTORY SUFFERING; PARTS I & II February 2004. End-of-Life Physician Education Resource Center www.eperc.mcw.edu

Lo B and Rubenfeld G. Palliative Sedation in Dying Patients. JAMA. 2005; 294;1810-1816.

Quill TE and Byock IR. Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids.

Ann Intern Med. 2000; 132:408-414.

Ramsay M, Savege TM, Simpson ER, Goodwin R. Controlled sedation with aphaxalone-alphadolone. BMJ. 1974;2:656-659.

Rousseau P. Palliative Sedation in the Management of Refractory Symptoms. J Supp Onc. 2004; 2:181-186.

Sykes N, Thorns A. Sedative use in the last week of life and the implications for end-of-life decision-making. Arch Intern Med. 2003; 163:341-344.

Vacco vs. Quill, 117 S.Ct. 2293 (1997).

Washington v. Glucksberg, 117 S.Ct. 2258 (1997).

 
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