factors to be considered when considering whether or not palliative sedation is the appropriate approach for a particular client

factors to be considered when considering whether or not palliative sedation is the appropriate approach for a particular client

Palliative/terminal sedation, with palliative care being a new and  developing specialty, has been the subject of much ethical scrutiny.  However, at the center of this controversy the patient experience needs to be considered and a big part of the patient experience in the this setting is usually centered around pain. Alleviating suffering is the root motivation for the exploring and discussing  palliative/terminal sedation. So with this intention, and common goal, how does It happen that there can be so many conflicting points of view when it comes to palliative/terminal sedation?  Lowering a patients level of consicouness deliberately and with medications is not ethically benign.  Much discussion and disagreement has been made of various aspects surrounding  palliative/terminal sedation,  everything from the indication to the family experience needs to be taken into account when weighing the advantages and disadvantages of palliative/terminal sedation. Some of the key advantages being; the improvement of refractory symptoms (    )in palliative patients and the relief it can bring to families watching a loved one suffering. The difficult and not easily dismissible disadvantages of palliative sedation being; the controversy surrounding the practice potentially hastening death and the parallels many people draw to physician assisted suicide. Ultimately, many factors will be considered when considering whether or not palliative sedation is the appropriate approach for a particular client.

Pain in palliative care typically can be seen as one of the most important symptom the health care team will have to manage or tend to. However, other symptoms patients will potentially experience during their end of life experience that can be equally distressing and uncomfortable. Symptoms such as; delirium, dyspnea, agitation, vomiting can all progress to the point where they can be unmanageable and ‘… is considered refractory when all possible treatments available within a tolerable time frame and risk–benefit ratio have been tried, but have not been successful’. Whether multiple symptoms are present or only one,   Azoulay. D., et al., emphasizes their significance and goes on to list these symptoms as ‘[p]rimary indications for PS …’ (  ). In Europe,  “The European Association of Palliative Care (EAPC) recommendations consider sedation to be an important therapy in the care of selected palliative care patients with otherwise refractory distress. ” The American Academy of Hospice and Palliative Medicine (AAHPM) position statement is in alignment with this view and goes on to specify it is done to “to reduce patient awareness of a severe and refractory symptom (or symptoms)” (217)  Lux et al goes on to refer to palliative sedation  as “…a tool in the management of refractory symptoms at the end of life.” (221) Although the monitoring of palliative sedated patients for comfort is not standardized, few key points can be evaluated, such as; no adverse effects from the sedation, the level of sedation and level of consciousness  (       ).  As per the scope of comfort and relief palliative sedation can provide, one study concluded ” [f]ollowing PS, there was documentation of a global symptomatic improvement in 73.7% of the patients …” (pg 37 Azoulay.D. ).  Included in actual documentation was  the occurrence of  which specific refractory symptoms and their relief, providing a more tangible manner for health care workers to quantify the effectiveness of this treatment modality.

Another advantage of palliative/terminal sedation is the relief it can provide for families. As Vayne-Bossert and Zulian point out, ” [they] have usually found that family members were relieved after administration of PS, once control of the refractory symptom is well established” (786) To achieve this outcome, however, requires some organization on behalf of the institution.  Information about the delivery of palliative sedation should be given prior to the initiation of sedation and specific expectations needs to be set regarding the process .  (         )  Information and timing of the delivery of this information are key to achieving a positive outcome for the family.  The importance of this communication cannot be understated as setting these expectations maybe the best way to prevent any concerns or discord later on. (Dutch Paper 242) “Therefore, relatives should be taken into account in the information-sharing and the decision-making processes. In all, 80% of the relatives in [the] study confirmed having been informed about the PS at the beginning of the hospitalization.” (Vayne-Bossert and Zulian  pp 789) Part of the information sharing process includes also making sure the “reason for the palliative sedation was well understood by all the [families]” (Vayne-Bossert and Zulian  pp 789)   Van Tol, D.,G., Kouwenhoven, P., van, d. V., and Weyers, H. also concurs “the possibility of continuous sedation as a means to end the patient’s suffering is mostly embraced as a relief by the patient and the family.” (   ) In fact, patient suffering to the family is such a concern and plays such a role for the families’ experience in the palliative care setting that, as Van Tol, D.,G., Kouwenhoven, P., van, d. V., and Weyers, H. points out many physcians’ would increase the doses of medication administered for palliative sedation and “explain their act by pointing at the high pressure put on them by family members. ” (Deutch article 242)  The pressure these doctors feel to increase the dosages of medication would suggest the families of these patients find relief in the administration of  palliative sedation.

Part of the disadvantages of this practice includes the perception and controversy that terminal/palliative sedation actually hastens death.  As ten Have and Welie  point out “… many health care providers likewise experience palliative sedation as an ethically problematic practice.  Of those surveyed, 77% thought that continuous deep sedation (CDS) was partly or explicitly intended to hasten death. Only 4% believed that it had no life-shortening effect. ” Although exposure and experience in palliative care seems to play a role in this perception, many GPs, physicans who work in acute care, rehabilitation milieus believe the hastening of death is an inherent part of palliative sedation. ( 477   ) While inpatient palliative care consult teams and home care palliative consult teams offered up varying views on the matter. R.-A. Foley et al goes on to point out how significant these viewpoints can be as it impacts certain a milieus proclivity toward using palliative/terminal sedation.  In summary, practitioners on palliative care units had a tendency not to view the terminal/palliative as death hastening (although admitted there maybe issues of hydration withdrawl should the sedation continue for an extended period of time) and would favor the use of palliative sedation. GPs viewed palliative sedation as death hastening  and did not use terminal/palliative sedation, physicans in acute care settings were more likely to view palliative sedation as death hastening and preferred physician assisted suicide or euthanisia. (    ) Physicians in rehabilitative centers viewed the terminal/palliative sedation as death hastening, but were more likely to use palliative sedation, viewing as an acceptable risk on the part of the physician. (          ) In patient consult teams were in favor of using palliative sedation and emphasized the distinction of  terminal/palliative sedation from physician assisted suicide and / or euthanasia. The outpatient consult teams tended to view death hastening as a major risk of terminal/palliative sedation, however no clear tendency was determined regarding whether terminal/palliative sedation was favoured. (         ) Families can also carry the belief that these measures may hasten death in their loved one and cannot have their experiences discounted throughout this process.

Another disadvantage to palliative sedation is the emotional impact it can have on nurses. Nurses are very involved in the terminal/palliative sedation experience,