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Sedation and Expertise in Palliative Care

Instituto Português de Oncologia, Porto, Portugal

To the Editor:

Sedation intending to control pain related with a procedure is not an ethical problem, is used in many fields of medicine, and is widely accepted. Therefore, I will not address this particular context and I will only focus on sedation used to control the suffering that doctors cannot treat by any other means.

Among palliative care professionals there is a consensus that sedation is, in certain conditions, an acceptable method to control symptoms that cannot be controlled without affecting the consciousness level. However, this consensus does not exist among all health professionals, as this practice was thought by some of them to be related with euthanasia,¹ and sometimes is called slow euthanasia.²

Palliative care literature has produced important definitions and guidelines regarding this kind of sedation, trying to create an ethical framework and a common language, in order to reach comparability among data from diverse settings. I believe there is now a consensus that the level of sedation to be reached should be the one that relieves the symptom and not necessarily a deep sedation, as the definition of Chater et al implies.³ That is, the goal is symptom control, not a certain level of consciousness. Mild sedation (conscious sedation) if enough to make a patient comfortable is not an ethical problem, but deep sedation can make physicians and ethicists disagree about its legitimacy, namely if nutrition and hydration should be maintained and the implication of withholding or withdrawing them on survival.^1,4

I also believe that there is a consensus among palliative care physicians that the decision to initiate sedation is legitimate only if the symptom is refractory. And a refractory symptom, according to Cherny and Portenoy,⁵ can be defined as one that "cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness" and the physician should perceive that other intervention either invasive or noninvasive are: "(A) incapable of providing adequate relief, (B) associated with excessive and intolerable acute or chronic morbidity, or (C) unlikely to provide relief within a tolerable time frame."⁵ A different situation would be a symptom that is difficult to control, but that is potentially controllable within a tolerable time frame, and in this case, sedating the patient is not indicated.

Another consensus, implied by the definition of refractory symptom, is the expertise and experience required in palliative care and symptom control in order to ensure that sedation is used as a last resource, when nothing else effectively works.

Expertise and experience are, however, a relative concept and heterogeneous in a worldwide context and even within the countries. Although, trying to distinguish difficult from refractory symptoms is an important theoretic effort, the distinction will never be settled in a way that can be universally applied. There are countries where there are only a few palliative care teams, if there are any. The stage of development of the teams can be very different. Probably, in most countries, the majority of the patients with very advanced chronic diseases are treated by doctors and teams without any expertise in symptom control. What can we recommend in this situation? Should we say that, as they are not experts in palliative care, perhaps the problem could be controlled by someone else? However, someone else who might know what to do is probably not available. And, certainly, the most important concern is to relieve patients' suffering. To let them suffer is not an option. As Robert Twycross wrote about euthanasia "a doctor who leaves a patient to suffer intolerably is morally more reprehensible than the doctor who performs euthanasia."⁶ More reprehensible would be to leave a patient suffer without trying a method which is, in general, believed as morally much less problematic.

My point is that the rules that palliative care physicians establish for themselves in order to control the quality of their work and achieve the excellence of care which patients deserve are not universally applicable. Without expertise in palliative care, the priority should continue to be the control of suffering, certainly involving discussion in the team and all the knowledge available of colleagues, pain specialists, psychiatrists, and all others who can help, without forgetting that time can be an important variable. But, if after that, the problem is not satisfactorily solved and many doubts remain, I believe that if the patient agrees (if the patient is incompetent, the team should act according to the patient's best interests—this is another discussion), the sedation needed to control the problem should start. However, in those contexts of much uncertainty, sedation should proceed carefully (well, in all contexts it should) and if deep sedation is required, it should be intermittent with scheduled periods of relief and revaluation. At least hydration should be maintained in order to keep the reversibility of the process, unless the patient was not eating or drinking anymore or is obviously dying in a few hours.

Usually, sedation is morally justified by the principle of double effect,⁷ which distinguishes the intended from the foreseen consequences of an act. However, these intensions may be ambiguous and sometimes even the actor is not sure about their real intensions. It is, perhaps, more realistic to consider that the primary obligation of a doctor to a suffering patient, with an untreatable very advanced chronic disease, is to relieve him or her, and sometimes there is not a solution for it that does not compromise consciousness. The will of the patient, if can be expressed, is essential in the process of decision.

I believe that this topic deserves a broad discussion. Therefore, I hope to hear comments on this letter.

Author's Disclosures of Potential Conflicts of Interest

The author indicated no potential conflicts of interest.

REFERENCES

1. Orentlicher D: The Supreme court and physician-assisted suicide: Rejecting assisted suicide but embracing euthanasia. N Engl J Med 337:1236-1239, 1997[Free Full Text]

2. Billings JA, Block SD: Slow euthanasia. J Palliat Care 12:21-30, 1996[Medline]

3. Chater S, Viola R, Paterson J, et al: Sedation for intractable distress in the dying: A survey of experts. Palliat Med 12:255-269, 1998[Abstract/Free Full Text]

4. Craig GM: On withholding artificial hydration and nutrition from terminally ill sedated patients: The debate continues. J Med Ethics 22:147-153, 1996[Abstract/Free Full Text]

5. Cherny NI, Portenoy RK: Sedation in the management of refractory symptoms: Guidelines for evaluation and treatment. J Palliat Care 10:31-38, 1994[Medline]

6. Twycross RG: Euthanasia: Going Dutch? J R Soc Med 89:61-63, 1996[Abstract]

7. Rousseau P: The ethical validity and clinical experience of palliative sedation. Mayo Clin Proc 75:1064-1069, 2000[Abstract]

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