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Definition and Epidemiology

Palliative sedation remains somewhat contentious, due to:

  • lack of a consistent and universal definition,
  • disparity in clinical use,
  • ethical and moral apprehensions,
  • confusion regarding sedative medications,
  • and a paucity of well-controlled research.

Palliative sedation has not been universally and definitively defined (Beel 2002, Cowan 2002), making interpretation, comparison, and extrapolation of many studies and case analyses problematic.

Many clinicians argue that palliative sedation does not necessarily mandate sedation to total unconsciousness and, instead, suggest there are variable degrees of sedation as well as duration of sedation.

Working definition of palliative sedation:

Palliative sedation may be more clearly defined and clinically characterized as the primary intention of deliberately inducing a temporary or permanent light-to-deep sleep, but not deliberately causing death, in patients with terminal illness and specific refractory symptoms.

  • The primary intent is to sedate the dying patient so that s/he may not experience and suffer due to specific refractory and intractable symptoms.
  • The intent is NOT to deliberately hasten the dying process.
  • Be aware that palliative sedation can be considered if and ONLY if :
    • The patient is dying (as documented in the medical records by the attending physician based on supportive documentation).
    • The patient is experiencing unendurable suffering that is not amenable to any standard palliative treatment measures.

Other common definitions of palliative sedation:

Definition 1 Palliative sedation is the intentional administration of sedative drugs in dosages and combinations required to reduce the consciousness of a terminal patient as much as necessary to adequately relieve one or more refractory symptoms.
Definition 2 The Hospice and Palliative Nurses Association(http://www.hpna.org/position_PalliativeSedation.asp.) defines palliative sedation as the monitored use of medications intended to induce varying degrees of unconsciousness, but not death, for relief of refractory and unendurable symptoms in imminently dying patients.
Definition 3 The American Academy of Hospice and Palliative Medicine forgoes a formal definition but suggests the use of sedating medications is intended to decrease a patient’s level of consciousness to mitigate the experience of suffering, but not to hasten the end of life.

Intent v. Outcome

The intent of Palliative Sedation is the relief of intractable suffering caused by refractory symptom(s) and not to deliberately end the life of the terminally ill patient.

The specific outcome of palliative sedation is to intentionally sedate the patient to a point where the patient is unaware of the problematic symptom that was causing the intractable suffering.

In writing about this topic, U.S. Supreme Court Justice Sandra Day O’Connor, have endorsed the practice, arguing that “a patient who is suffering from a terminal illness and who is experiencing great pain has no legal barrier to obtaining medication, from qualified physicians, to alleviate that suffering, even to the point of causing unconsciousness and hastening death.”

Differentiating Palliative Sedation from Physician Assisted Suicide

Palliative sedation

Physician assisted suicide (PAS)

Intent

 Alleviating intractable suffering of a terminally ill patient primarily by sedation. Hastening death is not a primary or intended outcome. Alleviating intractable suffering of a terminally ill patient by providing them with medication that the patient may then take to hasten their own deaths.

Hastening death is a primary and intended outcome.

Informed consent

 Required Required

Where is it legal currently

British Medical Association. Physician assisted suicide: the law.

 All the states in USA Currently only in Oregon.

Available to a select subset of terminally ill patients who can request for PAS.

Under consideration in California.

Although palliative sedation is unquestionably a valuable and efficacious palliative intervention and was fundamentally sanctioned by the United States Supreme Court decision opposing a constitutional right to physician-assisted suicide (Rousseau 2001, Orentlicher 1997, Vacco v Quill 1997 Washington v Glucksberg 1997), its use remains somewhat nebulous, with a reported incidence ranging from 2% to 52% (Rousseau 2000, Quill 1997, Ventafridda 1990).

The wide variance in the use of palliative sedation is probably due to:

  • lack of a universal definition of palliative sedation,
  • the retrospective nature of many studies,
  • lack of consensus on the definition of a refractory symptom (particularly refractory existential suffering),
  • ethical and moral concerns, and
  • cultural and ethnic diversity (Rousseau 1999, 2000, 2001)
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