Terminal sedation

Terminal sedation (also known as palliative sedation, or sedation for intractable distress in the dying/of a dying patient) is the practice of relieving distress in a terminally ill person in the last hours or days of a patient's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug.

Drugs used

A typical drug is midazolam, a short acting benzodiazepine. Opioids such as morphine are not used as the primary medicine since they are not effective sedative medications compared to benzodiazepines. However, if a patient was already on an opioid for pain relief, this is continued so pain relief while sedated is achieved. Other medications to be considered include haloperidol, chlorpromazine, pentobarbital or phenobarbital.

Nutrition and fluids

As patients undergoing terminal sedation are typically in the last hours or days of their lives, they are not usually eating or drinking significant amounts. There has not been any conclusive studies to demonstrate benefit to initiating artificial nutrition (TPN, tube feedings, etc.) or artificial hydration (subcutaneous or intravenous fluids). Before initiating terminal sedation, a discussion about the risks, benefits and goals of nutrition and fluids is encouraged.

Risk assessment

There is no evidence that titrated sedation causes the death of the patient and sedation does not equate with euthanasia. At the end of life sedation is only used if the patient perceives their distress to be unbearable, and there are no other means of relieving that distress. In palliative care the doses of sedatives are titrated to keep the patient comfortable without compromising respiration or hastening death. For more information on the palliative care use of sedatives and the safe use of opioids see Opioids.

Patients (or their legal representatives) do have the right to refuse life-sustaining treatment (such as with a living will), which is legally considered as passive euthanasia. However, once unconsciousness begins, the patient is no longer able to decide to stop the sedation or to request food or water and the clinical team needs to act in the patient's best interests.

Sedation at the end of life should be a treatment response to the symptom distress of terminal restlessness and agitation. There can be a problem for the nurse or doctor in deciding "who" is distressed: the patient themselves, the family, or the professional. Sedation is "not" routine in palliative and most patients die comfortably without the need for sedation.

Legal position

Terminal sedation is legal in the United States of America. In 2008, the American Medical Association Council on Ethical and Judicial Affairs approved an ethical policy regarding the practice of palliative sedation. [ [http://www.ama-assn.org/amednews/2008/07/07/prsi0707.htm American Medical News article on palliative sedation] ] [ [http://www.ama-assn.org/ama1/pub/upload/mm/369/ceja_5a08.pdf American Medical Association Palliative Sedation Position] ] According to the principle of double effect such treatment is ethically justified if a doctor administers the drug with the intention to alleviate pain/suffering. The defence of double effect is only open to medical practitioner.

ee also

* Uniform Rights of the Terminally Ill Act
* Double Effect
* Opioids

External links

* [http://www.acponline.org/ethics/quill.htm "Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids"] , American College of Physicians
* [http://www.worldrtd.net/faqs/factsheets/?id=39 "Terminal Sedation"] , The World Federation of Right to Die Societies
* [http://www.eapcnet.org/forum Discussion Forum] , European Association for Palliative Care

References