Palliative sedation vs. terminal sedation: What’s in a name?

existential suffering and proposal of clinical guidelines for the sedation of patients with intractable physical, mental or spiritual distress1,2 are cogent, welcome contributions to the field of palliative medicine. His comments contain much to admire, including the emphasis on the patient’s symptoms, not the patient’s death, as the focus of care. His recommendation that the treatment (including drug dosages) be adjusted based on the patient’s symptoms gives this sometimes controversial practice a sensible clinical platform that withstands rigorous ethical investigation (for example, utilizing Jonsen’s four-box method3 of clinical ethical analysis). Content notwithstanding, however, I most admire Rousseau’s reviews for what they lack— the perpetuation of the linguistic quagmire, “terminal sedation.” Attributed to Robert E. Enck, MD,4 the phrase “terminal sedation” is commonly used for the clinical practice of utilizing therapeutic sedation in imminently dying patients, as a means of palliating symptoms which are not ameliorated by other, less aggressive measures. Debate concerning the ethical implications of the practice has been, at times, lively—ranging from case descriptions praising its efficacy and humaneness5 to editorials decrying it as “slow euthanasia.”6,7 For most clinicians, however, the practice seems to be an acceptable method of treating patients with otherwise intractable symptoms, provided that the focus of drug titration is symptom relief, not the patient’s death.8,9 This distinction appeals to the ethical principle of double effect: if the patient’s death is an undesired but anticipated secondary effect of the treatment, this is allowable, as the secondary effect was not intended.10 As this intervention grows in acceptance and in frequency, the use of the term “terminal sedation” to describe it should be abandoned. As Chater et. al. have pointed out,11 the phrase is confusing, in that the object of the adjective “terminal” is not explicit. Does it apply to the sedation (implying that the object of the practice is sedating someone to death) or to the patient (implying that the patient is in the final stage of illness)? Since this ambiguity is always present, the phrase is often interpreted to imply intent to kill. This interpretation has the potential to restrict patient access of state-of-the art palliative care, by leaving patients and families confused about their physicians’ intent, and by leaving physicians fearful that their palliative interventions will be wrongly prejudged as “mercy killing.”12,13 These considerations not withstanding, many authors8,9,14-20 (formerly including Rousseau himself21) have persisted in describing the clinical practice of sedating terminally ill patients with intractable physical, mental, or spiritual distress as terminal sedation. In explaining their position, Quill and Byock maintain that doing so is necessary to distinguish sedation in antemortem care from sedation in other settings (such as the treatment of burn victims), and to lend