Palliative Sedation or Slow Euthanasia, Coursework Example

Abstract

Palliative care is one of the most debated areas of health care. Apart from debates about euthanasia, many authors examine the validity of applying sedative care for patients who are unable to deal with the pain, discomfort, and other negative effects of their illness. Sedation is often used to relieve pain, improve the quality of life, and its increased utilization is bringing up questions related to the validity of this approach in palliative care. It seems like many health care professionals are choosing this option, and – according to Raho (2014), statistics show that the frequency of CDS (continuous deep sedation) has increased in recent years. The author of the current study would like to review the reasons why health care staff is more prone to utilizing this approach instead of using other pain relief options? Do they make a decision based on the availability of options, the life expectancy of patients, or the severity of pain? And how confident are physicians making ethical decisions related to palliative care? Can CDS really be called “slow euthanasia”, as some authors suggest (Beland, 2012), or is it simply designed to improve the quality of life in the last few weeks? Are the official health care guidelines in line with ethical recommendations of palliative care professionals? What are the currently accepted guidelines inn America related to terminally ill patients’ pain relief? Do policies specify the requirement that alternative methods of pain relief should be tried and proven ineffective before applying CDS?

Through reviewing the related literature, research, and findings, the author of the current study would like to determine the ethical and legislative guidelines related to applying continuous deep sedation in a way that it causes the least harm and delivers the most benefits for patients who are nearing the end of their lives. Based on Raho’s (2014) review and recommendation, the author would like to examine alternative approaches and the application of the “proportionality” principle.

Palliative Sedation or Slow Euthanasia?

Raho (2014) provides clear ethical guidelines for practitioners in palliative care. The author, specializing on researching palliative sedation reviewed related literature related the ethical and medical questions surrounding continuous, deep palliative sedation. The author of the current review would like to examine the implications of the principle that Raho (2014, p. 19): proportionality. What Raho implies in his article is that every case should be assessed based on the severity of pain, life outcomes, and level of consciousness. The below review and analysis will address some of the points of the principle and examine its validity in palliative care of patients who can benefit from intensive or mild sedation, maybe continuous sedation in extreme cases.

Raho (2014) states that “physicians should aim exclusively at the relief of suffering, not the hastening of death (even though the latter may result as a foreseen, unintended result)” (p. 18). That statement alone indicates that – in normal and morally right cases – continuous deep sedation should never be used as a tool to speed up death, therefore, it is not a form of euthanasia. Indeed, the author also concludes that patients who are being administered CDS are often in more advanced stage of a terminal or critical illness than those who request euthanasia. In this context, it is evident that – while in some cases CDS speeds up dying, – sedation is not a tool to relieve suffering and make people die faster. It is there to make sure that people’s dignity is preserved, and they do not have to suffer unnecessarily.

Still, Raho (2014) argues that the loss of consciousness is not a form of euthanasia, but the loss of consciousness can indeed reduce the patient’s ability to communicate with loved ones in the last days of their lives. In this term, using continuous deep sedation results in a trade-off, and – as the author suggests -every case should be assessed individually. In Raho’s (2014, p. 19) definition, “palliative sedation refers to a spectrum of therapeutic interventions aimed at reducing the severity of a refractory symptoms”. It is clear from the definition that the main aim of sedation is to relieve suffering.

Further, Raho (2014, p. 19) argues that “the potential life-shortening effects of palliative sedation have not been confirmed”. If the above statement is true, the question is no longer whether or not CDS is considered as a slow euthanasia, but the timing of the intervention. The author lists a few guidelines from around the world regarding the decision-making process. Summarizing Raho’s literature review, it is clear that physicians should only use the intervention if:

• refractory, difficult to manage symptoms need to be present
• signs of imminent death
• when symptoms cannot be relieved by other interventions
• within an acceptable time frame

The above guidelines, suggested by several authors are problematic in many ways. First of all – as Raho highlights – the patient is the only person who can adequately assess the severity of the symptoms and pain. In ideal circumstances, they should be able to make the decision related to the trade-off. Would they rather bear the symptoms and stay conscious in the knowledge that their family is around, or would they trade their consciousness for the lack of suffering? Raho (2014) suggests that decisions should be made on an individual basis. This makes the work of physicians and palliative care professionals even harder, and it is important that they are aware not only of health care guidelines, but ethical recommendations as well. Making the decision is left to physicians most of the time, as patients are not in the condition to think rationally about the trade-off. Next, the question of how to ensure that death is imminent arises. It has been noted by several authors covering the ethical background of euthanasia that it is almost impossible to be a hundred percent sure that death is imminent. While some recommendations say that imminent death should be described as a life expectancy of less than two weeks, many cases have proven predictions wrong. Therefore, CDS might be simply taking away the one percent chance of patients for recovery.

Finally, Raho mentions the question of other therapies being ineffective to relieve refractory symptoms. The availability of tools and therapies change from one health care provider to the other. Therefore, patients in a better equipped hospital’s palliative care unit will have a “greater chance of avoiding” CDS than those who are looked after by a “less advanced” provider.  Similarly, the lack of physicians’ knowledge about alternative therapies for pain relief and symptom reduction will create health disparities, and this means that patients will not have equal chances of getting the least intrusive treatment.

Taking into consideration all the above mentioned reasons and ethical arguments, it can be agreed that CDS should be used in palliative care as a “last resort” solution, just like Raho (2014) suggests. Beland (2012) seems to agree with the above statement, too. He states: “CDS represents an indispensable last resort option for patients suffering unbearably as they near death”. The author covers one issue that Raho (2014) briefly mentions in his article: the question of artificial hydration. It is commonly known that patients who are under continuous deep sedation would suffer from dehydration. Raho (2014, p. 16) reveals, reviewing related research that “CDS was performed without ANH in 35 to 64 percent of cases”. The author states that withholding ANH should be a decision separate from the one related to applying deep sedation. There are several ethical aspects of ANH as well. Artificial hydration, according to Beland’s study (2012), can cause pain and discomfort in the gastrointestinal area. Other, confronting studies, quoted by the same author found that artificial hydration has little or no benefit for dying patients, while others stated that additional fluids can cause “bronchial and salivary secretions” (Beland, 2012, p. 24). In case of patients with water retention symptoms, for example, dehydration can cause severe symptoms and discomfort. Again, the logical approach regarding deciding on ANH is to assess each case individually.

Claessens, Menten,  Schotmans & Broeckaert (2008) created a comprehensive review of literature and research regarding palliative sedation. The research of the studies has revealed a high level of inconsistency related to reported prevalence of intermittent and continuous sedation.  The studies’ results examined reported 30-67 percent prevalence of intermittent sedation and 14-60 percent prevalence for continuous sedation. The results of different research studies related to deep and mild sedation varied at a similar manner. The above findings indicate that either the research studies created to assess the prevalence and application of sedation in palliative care had several limitations, or the utilization rate of the intervention varies from one country to another, and on health care provider to the next. If the latter is true, ethical guidelines across the health care profession are not clear enough to support professionals in their decisions. There is a third possibility, however, and it is that the knowledge of palliative care staff and the availability of alternative pain and symptom relief treatment options vary significantly.

Taking into consideration recent initiatives of governments to reduce health disparities, it is important to ensure that all patients are offered the most effective and less intrusive solution to relieve their suffering when they near the end of their lives. Physicians’ individual approach, ethical considerations, and preferences can also create a health disparity among populations. Does it really depend on the physician’s decision making process whether or not the patient will be offered alternative pain relief treatments before they are administered CDS?

Kimball (2012) lists three predominant decision-making models that physicians use to determine the best possible intervention. Informed choice seems to be the most ethical, as it is based on the patient’s choice, or the designated family member’s decision. Paternalism is based on the assumption that physicians are the most suitable persons for making the decision, based on their experience. There is, however, one problem with this approach: physicians are rarely able to feel the pain of the patient or the discomfort. Further, they would not have the same preferences, religious considerations as the patient. The third approach to making decisions about interventions that Kimball (2012) mentions is shared decision making. This, by far, seems to be the most promising method, as it involves the patient (or family member) who has existing knowledge about the preferences and severity of symptoms, their subjective level of discomfort, and the physician who has a relevant knowledge and experience to provide advice and outline the options available.

References

Beland, P. (2012) Ethical issues around continuous deep sedation without hydration. Nursing Times. 18.09.12. Vol 108 No 38

Claessens, P., Menten, J., Schotmans, P. & Broeckaert, B. (2008) Palliative sedation: A review of the research literature. Journal of Pain and Symptom Management Vol. 36 No. 3 September 2008

Kimball, C. (2012) End-of-life health care disparity: A case study. Dignity in Death Imperative. Nursing Economics. 2012.

Raho, J. (2014) Palliative sedation: a review of the ethical debate. Health Care Ethics USA.  Special Issue. 2014.