PALLIATIVE SEDATION
In the field of medicine, palliative sedation is generally the end-of-life care. All treatment options are advanced in order to save life and improve the quality of health of patients. However, there are certain terminal stages where patients might have to endure a lot of pain when the signs and symptoms of the infection they are suffering has proven to the futile, when it comes to offering treatment.
Palliative sedation can also be associated with other medical terms such as continuous deep sedation, sedation for intractable distress of dying patient, or terminal sedation. It is a general medical practice of relieving pain distress in patients who are terminally ill in their last hours or days of their life. Medical practitioners can perform this procedure by means of subcutaneous infusion of a sedative drug, continuous intravenous, or by using a specialized charter that is specifically designed to provide comfort through a system of discrete administration through the rectal route.
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 this setting is usually centered on pain. Alleviating suffering is the root motivation for the exploring and discussing palliative/terminal sedation (Bodnar, 2017). 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 patient’s level of consciousness deliberately and with medications is not ethically benign. Don't use plagiarised sources.Get your custom essay just from $11/page
The health industry is always sensitive of the fact that palliative care is an option administered only as the last resort. In this case, they have to confirm that the symptoms displayed by the patient cannot in any way be controlled by any other means. It is specifically designed to shorten the patient’s life and not to control symptoms as a form of euthanasia. A research conducted in 2009 indicates that 16.5% of the total deaths recorded in the UK between 2007 and 2008 came as a result of continuous deep sedation (“Caregivers Perception of Palliative Sedation: A French Opinion and Survey,” 2015). Therefore, it is a form of practice that at some point must be considered in order to save a dying patient from further pain.
Policies:
In order to understand the various pros and cons of palliative sedation as a legal medical practice, it is important to know some of the policies that control the procedure. Even though it is known as a legal practice, there must be policies and regulations in order to control the nature of activities that take place concerning palliative sedation in medical facilities.
Some of the countries that have made it public through enacting policies that govern this medical procedure are the United States and Sweden. The American Medical Association Council on Ethical and Judicial Affairs converged and approved a policy of ethics that relates to palliative sedation, in 2008 (Chai, Meier, Morris, & Goldhirsch, 2014). In October 2010, the same move was witnessed by Sweden when Svenska Läkaresällskapets, a group of physicians who came together to form an association in the country, published a list of guidelines that approved the administering of palliative sedation. Some of the policies that govern the procedure in the two countries are;
- The principle of Double Effect
- The Uniform Rights of the Terminally Ill Act in the US
The Uniform Rights of the Terminally Ill Act in the US
The Act was enacted in 1985 and revised in 1989. The law in this case allows an individual to declare a living will that clearly specifies that in the event of a critical medical illness, they may not wish to be kept alive through the life support machine. Terminal illness and coma are the two major conditions that are outlined in the Act. The Act offers a provision for the patient to obtain a healthcare power of attorney (In Booker, 2015). The power obtained in this case allows the chosen attorney to appoint and agent who can make a medical decision on behalf of the patient for situations where the patient becomes incompetent.
Most people in different states of the country make this decision because they may not wish to endure a lot of pain and suffering when they are weakened by fatal diseases. At this stage, they may not also be in a position to make the decision on their own. For this reason, the chosen attorney may consider working with a close family member in order to make the decision on behalf of the patient (In Booker, 2015). Due to the critical nature of the decision, it is always advisable to have a close family member to make the final decision before the patient is subjected to palliative sedation.
Another major reason for people using this Act is to protect their families from going through too much suffering after they have been weakened by a fatal disease. Most patients would wish to die with a certain level of dignity and give their families enough time to recover. In the medical field, this form of death is known as passive euthanasia.
The Principle of Double Effect
The Act is also referred to as the rune of double effect. It offers a set of ethical guidelines that have been advocated mainly by Christian philosophers. The ethical standards advocate for the evaluation of permissibility of initiating an action when the legitimate act of an individual may result to an incidence that one would rather avoid (In Taboada, 2015). The doubt effect in this case may even be from the medical practitioners who are involved in the treatment process of the patient.
The pros and cons of palliative sedation
The topic of palliative sedation has generated a lot of controversial debates in the society. Different angles of approaching the issue from different fields such as philosophy, religion, medicine, and many other entities that make up the society have generated different ideas concerning the Act (Nelson, 2017). For instance, in religion, it has been clearly outlined that it is only God who can give and take away the life of a human being. For this reason, they believe that no human being should do anything that may affect the life of another individual. On the other hand, a controversial argument arises on whether one should do nothing about another human suffering when it is clear they cannot be saved from their medical condition. The issue of logic from the field of philosophy then arises to challenge the view of religion, that we have a choice of shortening the life of a human being when they are in great pain and cannot be helped from the medical state they are in.
Looking at the nature of the act, one has to be sensitive of the fact that very many people are involved in these decisions. Even though the patient might have made an early arrangement to end their life in cases where their medical conditions cannot be assured, their family members and other close parties may not agree with the same opinion (Nelson, 2017). It may be permitted by the law but due to the fact that some people do not agree, it leaves a mark of pain and anguish that may never be healed and forgotten by some family members.
An adequate comparison of the controversy that surrounds this ethical dilemma in healthcare should bear the total consequences that come with it. The issues that must be addressed at this point are;
- The procedures involved for the dying process
- The physicians involved
- The relatives of the patient
- All the caregivers involved
- The society at large
All the mentioned parties are involved in the dying process in one way. Considering the nature of the society that the affected patient resides from, they would wish to understand the main reason that led to the decision. Some societies have religious standards that do not permit certain activities. In this case, such standards might have an effect on the way the society chooses to react towards the action.
The society which makes up the public domain may also have a different perception of the medical industry. People will always need to develop a certain level of trust from their caregivers in order for them to visit the various medical centers for treatment (Nelson, 2017). For cases where an ethical issue of ending the life of an individual may not agree with their standards, they may develop a stereotypic perception or fear towards the medical facility in question. The intention of health industry is to ensure that they constantly provide quality care to their customers without any controversies.
The ethical issue of shortening the life of an individual, however, might develop misconceptions among the healthcare receivers even after confirming that the process has observed all the ethical and legal demands. In such situations, the medical fraternity might be torn between two sides of the divide on whether relieving a patient from pain by shortening their lives would be the best thing to do.
There are physicians and other care givers who are involved in the process of treatment. They are involved in the actual process of ending one’s life in order to ease pain. Different people might react in different ways. However, there are situations where doctors might have to endure long term psychological effects due to the tough choices they have to make. Dealing with patients who are under palliative care in itself might have an effect on physicians and other care givers (Van Norman, 2014). The encounter may not be an easy task especially for doctors who are at the beginning stage of their career.
Due to the emotional distress that comes along, some doctors may end up engaging in risky activities such as the use of drugs and heavy drinking during their free time. In order to ease their minds, they might have different thoughts on what they think could relieve them. The end result is addiction and other risky ventures. In addition, care givers may even develop habits that may affect their families (Van Norman, 2014). For instance, the use of drugs and engaging in heavy drinking may completely affect the peace of their family members. Therefore, one can imagine how a simple action of palliative sedation aimed at relieving the pain of an individual might affect many other people who are not involved in the first place. The various issues that may arise due to emotional distress include;
- Violent activities to families and friends
- Heavy drinking habits
- Self denial where one might start avoiding crowds
- Break ups in families that may even lead to divorce, etc
As illustrated above, someone might decide to sign with their attorney and have their life taken even before their days are over. However, the family members might not be convinced that this would be the right way to go. Not everyone would be comfortable with having their loved ones life taken away. In most cases, when someone falls sick, family members would do anything to ensure that the person gets proper medication. Family members for this reason might totally violate (Victoria, 2015). The situation may lead to potential conflicts between members of a family after some are in total agreement whereas others may not agree. The level of grief on the other hand may also amount for some members. Knowing that someone’s life has to be cut short due to pain is a wound that most of the family members may carry without getting healed.
As we reflect on the major setbacks and challenges that are associated with palliative sedation to patients as the last resort, it is important to look at some of the bright sides of the divide. First, there are critical stages where a patient may not survive certain diseases. With the human nature, it may create more damage to the emotional well being of all the people involved including family members and care givers. Therefore, palliative care has a positive side of having to do away with the issue of pain by offering a sooner death (Victoria, 2015). There are critical conditions where patients might have to endure a lot of unimaginable pain in order for them to survive. Cancer critical stages is among the conditions that one has to endure a lot of pain especially if the treatment options available have proven futile. In this case, it would be argued that administering of palliative care should be justified and patient’s life put to an end in order to have them get relief at a personal level.
Another disadvantage to palliative sedation is the emotional impact it can have on nurses. Nurses are very involved in the terminal/palliative sedation experience, and for that reason, they may have to endure all the memories and emotional distress that comes along. Such emotional distress may not only affect them on an individual basis, might spread and affect the nature in which they interact with people socially, the way they relate with their families back at home, and their overall lifestyle (Victoria, 2015). In more critical conditions, the psychological trauma that comes along after performing the procedure by nurses might even affect performance and cost their career.
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 (Victoria, 2015). 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]primary 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 “following 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. 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, physicians 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 favored. 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.
The greatest controversy that exists at some level is that the procedure of palliative care entirely involves the patient who is suffering. Even though other parties might have an interest due to the love they bear for their loved ones who are ailing, it is the patient alone who has to go through all the conditions. Therefore, it all the attention is awarded to the individual who is the victim in this context, one may openly agree that we should justify the act of life shortening due to critical illness condition. No one would want to endure suffering that is too much when it is clear that there is no chance of getting healed. In this case, the human part of every human being who can imagine the kind of pain one would have to go through to the time a natural death point is achieved, it would be much more reasonable to justify the medical procedure.
References
Bodnar, J. (2017). A Review of Agents for Palliative Sedation/Continuous Deep Sedation: Pharmacology and Practical Applications. Journal of Pain & Palliative Care Pharmacotherapy, 31(1), 16-37. doi:10.1080/15360288.2017.1279502
Caregivers Perception of Palliative Sedation: A French Opinion and Survey. (2015). Journal of Palliative Care & Medicine, 05(05). doi:10.4172/2165-7386.1000233
Chai, E., Meier, D., Morris, J., & Goldhirsch, S. (2014). Palliative Sedation. Geriatric Palliative Care, 116-121. doi:10.1093/med/9780195389319.003.0022
In Booker, K. J. (2015). Critical care nursing: Monitoring and treatment for advanced nursing practice.
In Taboada, P. (2015). Sedation at the end-of-life: An interdisciplinary approach.
Nelson, P. (2017). Palliative Sedation. Oxford Medicine Online. doi:10.1093/med/9780190204709.003.0013
Van Norman, G. A. (2014). Ethics and Clinical Aspects of Palliative Sedation in the Terminally Ill Child. Pediatric Sedation Outside of the Operating Room, 699-710. doi:10.1007/978-1-4939-1390-9_37
Victoria. (2015). Palliative care.