Terminal sedation
Encyclopedia
In medicine
, specifically in end-of-life care, palliative sedation (also known as terminal sedation, continuous deep sedation, or sedation for intractable distress in the dying/of a dying patient) is the palliative practice of relieving distress in a terminally ill
person in the last hours or days of a dying patient's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative
drug
. This is an option of last resort for patients whose symptoms cannot be controlled by any other means. This should be differentiated from euthanasia
as the goal of palliative sedation is to control symptoms through sedation but not shorten the patient's life, while in euthanasia
the goal is to shorten life to cease suffering.
According to 2009 research, 16.5% of all deaths in the United Kingdom during 2007-2008 took place after continuous deep sedation. On the other hand, a 2009 survey of almost 4000 U.K. patients whose care had followed the Liverpool Care Pathway for the dying patient found that while 31% had received low doses of medication to control distress from agitation or restlessness, only 4% had required higher doses.
or a tracheostomy, so that eventually symptom control is impossible. Instead of experiencing death by suffocation, once symptoms are intolerable some patients will request palliative sedation to ease their symptoms as death approaches.
, a short acting benzodiazepine
. Opioid
s 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 for pain relief while sedation is achieved. Other medications to be considered include haloperidol
, chlorpromazine
, pentobarbital
, propofol or phenobarbital
.
, or nausea", suffering that is commonly unknown to providers or families.
(1). 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 (i.e. varied) to keep the patient comfortable without compromising respiration or hastening death. Death results from the underlying medical condition. For more information on the palliative care use of sedatives and the safe use of opioids see Opioids.
Patients (or their legal representatives) only have the right to refuse treatments in living wills, they cannot demand life saving treatments, or any treatments at all. However, once unconsciousness begins, as the patient is no longer able to decide to stop the sedation or to request food or water, the clinical team can act in the patient's best interests. A Living Will, made when competent, can under UK law, give a directive that they refuse 'Palliative Care' or 'Terminal Sedation', or 'any drug likely to suppress my respiration'.
Council on Ethical and Judicial Affairs approved an ethical policy regarding the practice of palliative sedation. According to the principle of double effect
such treatment may be ethically justified if a doctor administers the drug with the intention to alleviate pain/suffering. The defense of double effect is only open to medical practitioners.
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
, specifically in end-of-life care, palliative sedation (also known as terminal sedation, continuous deep sedation, or sedation for intractable distress in the dying/of a dying patient) is the palliative practice of relieving distress in a terminally ill
Terminal illness
Terminal illness is a medical term popularized in the 20th century to describe a disease that cannot be cured or adequately treated and that is reasonably expected to result in the death of the patient within a short period of time. This term is more commonly used for progressive diseases such as...
person in the last hours or days of a dying patient's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative
Sedative
A sedative or tranquilizer is a substance that induces sedation by reducing irritability or excitement....
drug
Drug
A drug, broadly speaking, is any substance that, when absorbed into the body of a living organism, alters normal bodily function. There is no single, precise definition, as there are different meanings in drug control law, government regulations, medicine, and colloquial usage.In pharmacology, a...
. This is an option of last resort for patients whose symptoms cannot be controlled by any other means. This should be differentiated from euthanasia
Euthanasia
Euthanasia refers to the practice of intentionally ending a life in order to relieve pain and suffering....
as the goal of palliative sedation is to control symptoms through sedation but not shorten the patient's life, while in euthanasia
Euthanasia
Euthanasia refers to the practice of intentionally ending a life in order to relieve pain and suffering....
the goal is to shorten life to cease suffering.
According to 2009 research, 16.5% of all deaths in the United Kingdom during 2007-2008 took place after continuous deep sedation. On the other hand, a 2009 survey of almost 4000 U.K. patients whose care had followed the Liverpool Care Pathway for the dying patient found that while 31% had received low doses of medication to control distress from agitation or restlessness, only 4% had required higher doses.
General practice
Palliative sedation is often initiated at the patient's request. It can also be initiated by the physician who would discuss the option with the patient and family. Palliative sedation can be used for short periods with the plan to awaken the patient after a given time period, making terminal sedation a less correct term. The patient is sedated while symptom control is attempted, then the patient is awakened to see if symptom control is achieved. In some cases, palliative sedation is begun with the plan to not attempt to reawaken the patient. One such common example is a patient with an enlarging cancer in the throat that compresses the trachea in a patient who does not want intubationIntubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...
or a tracheostomy, so that eventually symptom control is impossible. Instead of experiencing death by suffocation, once symptoms are intolerable some patients will request palliative sedation to ease their symptoms as death approaches.
Drugs used
A typical drug is midazolamMidazolam
Midazolam is a short-acting drug in the benzodiazepine class developed by Hoffmann-La Roche in the 1970s. The drug is used for treatment of acute seizures, moderate to severe insomnia, and for inducing sedation and amnesia before medical procedures. It possesses profoundly potent anxiolytic,...
, a short acting benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
. Opioid
Opioid
An opioid is a psychoactive chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract...
s such as morphine
Morphine
Morphine is a potent opiate analgesic medication and is considered to be the prototypical opioid. It was first isolated in 1804 by Friedrich Sertürner, first distributed by same in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists' shop. It was more...
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 for pain relief while sedation is achieved. Other medications to be considered include haloperidol
Haloperidol
Haloperidol is a typical antipsychotic. It is in the butyrophenone class of antipsychotic medications and has pharmacological effects similar to the phenothiazines....
, chlorpromazine
Chlorpromazine
Chlorpromazine is a typical antipsychotic...
, pentobarbital
Pentobarbital
Pentobarbital is a short-acting barbiturate that was first synthesized in 1928. Pentobarbital is available as both a free acid and a sodium salt, the former of which is only slightly soluble in water and ethanol....
, propofol or phenobarbital
Phenobarbital
Phenobarbital or phenobarbitone is a barbiturate, first marketed as Luminal by Friedr. Bayer et comp. It is the most widely used anticonvulsant worldwide, and the oldest still commonly used. It also has sedative and hypnotic properties but, as with other barbiturates, has been superseded by the...
.
Discomfort
While the intent of palliative sedation is to eliminate pain and suffering, a significant minority of patients "continue to experience pain, dysphoriaDysphoria
Dysphoria is medically recognized as a mental and emotional condition in which a person experiences intense feelings of depression, discontent and indifference to the world around them.Mood disorders can induce dysphoria, often with a heightened risk of suicide, especially in...
, or nausea", suffering that is commonly unknown to providers or families.
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). There is also the risk that IV fluids or feedings can worsen symptoms, especially respiratory secretions and pulmonary congestion. If the goal of palliative sedation is comfort, IV fluids and feedings are often not consistent with this goal (1). Before initiating terminal sedation, a discussion about the risks, benefits and goals of nutrition and fluids is encouraged, and is mandatory in the United Kingdom.Sedation vs. Euthanasia
There is no evidence that titrated sedation causes the death of the patient and sedation does not equate with euthanasiaEuthanasia
Euthanasia refers to the practice of intentionally ending a life in order to relieve pain and suffering....
(1). 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
Palliative care
Palliative care is a specialized area of healthcare that focuses on relieving and preventing the suffering of patients...
the doses of sedatives are titrated (i.e. varied) to keep the patient comfortable without compromising respiration or hastening death. Death results from the underlying medical condition. For more information on the palliative care use of sedatives and the safe use of opioids see Opioids.
Patients (or their legal representatives) only have the right to refuse treatments in living wills, they cannot demand life saving treatments, or any treatments at all. However, once unconsciousness begins, as the patient is no longer able to decide to stop the sedation or to request food or water, the clinical team can act in the patient's best interests. A Living Will, made when competent, can under UK law, give a directive that they refuse 'Palliative Care' or 'Terminal Sedation', or 'any drug likely to suppress my respiration'.
United States of America
In 2008, the American Medical AssociationAmerican Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...
Council on Ethical and Judicial Affairs approved an ethical policy regarding the practice of palliative sedation. According to the principle of double effect
Principle of double effect
The principle of double effect; also known as the rule of double effect; the doctrine of double effect, often abbreviated as DDE or PDE; double-effect reasoning; or simply double effect, is a set of ethical criteria for evaluating the permissibility of acting when one's otherwise legitimate act...
such treatment may be ethically justified if a doctor administers the drug with the intention to alleviate pain/suffering. The defense of double effect is only open to medical practitioners.
Sweden
In October 2010 Svenska Läkaresällskapets, an association of physicians in Sweden, published guidelines which allowed for palliative sedation to be administered even with the intent of the patient not to reawaken.See also
- Uniform Rights of the Terminally Ill ActUniform Rights of the Terminally Ill ActThe Uniform Rights of the Terminally Ill Act , has been recommended as a Uniform Act in the United States, and subsequently been passed by many states. The law allows a person to declare a living will specifying that, if the situation arises, he or she does not wish to be kept alive through life...
(USA) - Principle of double effectPrinciple of double effectThe principle of double effect; also known as the rule of double effect; the doctrine of double effect, often abbreviated as DDE or PDE; double-effect reasoning; or simply double effect, is a set of ethical criteria for evaluating the permissibility of acting when one's otherwise legitimate act...
- OpioidOpioidAn opioid is a psychoactive chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract...
- Liverpool Care Pathway - Standard UK NHS care guidance for dying terminal patients
External links
- "Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids", American College of Physicians
- "Terminal Sedation", The World Federation of Right to Die Societies
- Discussion Forum, European Association for Palliative Care
- "Hard Choice for a Comfortable Death: Sedation", New York Times, December 27, 2009