Medical and ethical considerations in palliative sedation at the end of life

Abstract

Among patients with an advanced terminal illness whose primary goal is comfort, severe suffering occurs occasionally that is refractory even to intensive palliative care with standard medicines and techniques. Controlled deep sedation, sometimes to unconsciousness, may be the only effective means of protecting patients from end of life suffering in these unusual situations. Thus, it is ethically imperative that deep palliative sedation be accessible for these rare situations. Ethical provision of deep palliative sedation requires that the main goal of care agreed upon with the patient or the patient’s surrogate be comfort, that there be agreement to withhold or withdraw life-sustaining treatments, that informed consent be obtained from the patient or surrogate, that all staff members actively involved in caring for the patient be informed in advance of the plan, that the clinical intention be demonstrated by using the minimum doses of medicine needed to achieve an adequate degree of comfort, and that dose titration be based on close observation of the patient. Deep palliative sedation may be used to assure comfort during terminal discontinuation of mechanical ventilation. Deep palliative sedation is ethically fundamentally different from euthanasia and physician-assisted suicide and should not be confused with these practices.