Rethinking: Guidelines for the Use of Palliative Sedation

By Berger, Jeffrey T. | The Hastings Center Report, May-June 2010 | Go to article overview

Rethinking: Guidelines for the Use of Palliative Sedation


Berger, Jeffrey T., The Hastings Center Report


Current guidelines treat palliative sedation to unconsciousness as an effective medical treatment for terminally ill patients who need relief from severe symptoms, yet also restrict its use in ways that are extraordinary for medical treatments. A closer look at the kinds of cases in which palliative sedation is used suggests a way of adjusting the guidelines to resolve this seeming contradiction.

Imagine a seventy-three-year-old man admitted to the hospital for abdominal pain and vomiting. He has a history of colon cancer; three years ago, doctors removed a portion of his bowel. Now, a CT scan shows that his bowel is obstructed. It also shows that the cancer has returned--he has evidence of tumors in his liver, throughout his abdomen, and even in his bones. His doctors predict that he will survive only a month or so. They start him on high doses of narcotics to control his pain, but the side effects--primarily nausea and muscle twitching--are intense and distressing. The drugs also keep his bowel obstruction from resolving.

After a week of hospitalization, the bowel obstruction has not improved much, and neither has his pain. His physicians recommend a spinal catheter to deliver the narcotics, hoping that the medications will cause fewer side effects if they are administered this way. But the man is horrified by the thought of a tube sticking out of his spine. He begs his doctors to sedate him in order to relieve his pain. His doctors tell him that sedation will almost certainly shorten his survival to mere days, but he doesn't care. He doesn't see why he should have to go through all this just to live a few more horrible weeks.

Sedation is used to provide relief in a variety of medical contexts. It can be used concurrently with life-sustaining and curative treatments for patients who are not terminally ill, such as burn victims; it can be continuous or not, and it can vary in degree from light sedation to full unconsciousness. (1) Continuous palliative sedation to unconsciousness, or PSU, is a special case, limited to terminally ill patients and even then reserved for cases in which severe symptoms persist despite intensive interdisciplinary efforts to find a tolerable palliative treatment that does not affect the patient's level of consciousness. (2) It is a last resort. For some patients, however, PSU may be the only effective means of symptom palliation. (3)

The use of PSU rests on a consensus that leads quickly to controversy. For example, although there is consensus on the criteria of a terminal state and symptom refractoriness, authorities disagree about whether PSU is appropriate for existential suffering and about how close to death the patient should be before PSU is introduced. Some authorities stipulate that PSU should be withheld until the patient is within hours to days from death, while others specify no particular time frame for its use once the patient has a terminal prognosis. (4) (Table 1 summarizes the key points of current guidelines and other authoritative statements on PSU.) A patient sedated to unconsciousness is unable to eat or drink, and terminally ill patients under palliative sedation generally receive neither enteral nor parenteral fluids. These patients die from dehydration in two weeks or less unless--as in fact typically happens--they die first from the underlying disease. (5)

There is also a consensus within medicine that PSU is a medical treatment and is therefore not tantamount to active euthanasia. However, the consensus also holds that PSU should be subject to restrictions that do not otherwise apply to medical treatments. In short, PSU is both a medical treatment and subject to restrictions that are extraordinary in medicine. Medical authorities have not articulated a cogent medical and ethical rationale for this seeming contradiction. This article delves into this problem, along with some others associated with PSU, and offers revised guidelines for its use. …

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