The Problem of Psychological Suffering

The term “symptom” conventionally connotes a physical malady, such as pain or dyspnea. However, it is acknowledged (Cherny 1994) that psychological symptoms like anxiety, panic and existential issues can also result in intractable suffering. Clinicians must be cognizant that suffering from existential anguish can be just as significant and distressful as refractory physical symptoms, thus endorsing consideration of palliative sedation in refractory cases (Rousseau 2000).

Palliative sedation for psychological or existential suffering is ethically and morally more problematic than is sedation for physical suffering.

Reasons for this is as follows:

• The lack of standardized clinical and psychological assessments for existential distress, particularly during the dying process, when overwhelming and demoralizing losses are exceedingly prevalent.
• Patients with existential distress may also be awake, alert, and without obvious physical symptoms, further confounding and complicating the decision to utilize palliative sedation.
• If palliative sedation is considered for existential suffering, untreated depression, delirium, anxiety, and familial discord must be distinguished from tangible refractory existential distress, and ethics and psychiatric consultations should be considered.
• Different health care systems may have different rules governing the sensitive issue of palliative sedation for psychological or existential suffering.

Department of Veterans Affairs position on palliative sedation for intractable psychological and existential suffering: Permitted Palliative sedation is permitted in terminally ill patients for alleviation of refractory physical symptoms.   Instituting palliative sedation for alleviation non-physical refractory symptoms is contraindicated in all VA facilities. Click here for a 2006 document detailing the Department of Veterans Affairs position on palliative sedation