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  • Dispelling Myths, New and Old, Surrounding the Practice of Continuous Sedation until Death
  • Lalit K.R. Krishna (bio)

I. Introduction

The practice of applying sedation at the end of life for the treatment of intractable suffering is fraught with concerns (Billings and Block 1996; Battin 2008; Krishna 2010). These worries have revolved around four prime areas of concern. First, the potential for hastening death through the application of sedation and potentially opioids to a frail and vulnerable patient group who are particularly susceptible to the life abbreviating side effects of these interventions (Sykes and Thorns 2001; Wilcock and Chauhan 2007; Krishna 2010, 2012). Next, the continued practice of routine cessation of Clinically Assisted Hydration and Nutrition (CANH) for these sedated terminally ill patients, propagating fears of death through starvation and dehydration (Battin 2008). Additionally the lack of a clear definition and scope of this practice which opens the practice of sedating patients at the end of life for the amelioration of suffering to threats of misuse and more worryingly the practice of “slow euthanasia” (Billings and Block 1996). Finally, the fear that suppression of consciousness through the application of deep continuous sedation will rob patients of their personhood (Juth et al. 2010; Materstvedt 2012; LiPuma 2013).

The coadunation of these concerns has led to Rietjens et al.’s (2007) finding that there is consternation amongst healthcare professionals when considering employment of this treatment of last resort and potentially perpetuating the suffering of between 5–50% of all terminally ill patients (Cherny 2006: 977; Cowan et al. 2007: 983; Rousseau 2007: 629). This situation is confounded [End Page 259] further when any form of sedative use at the end of life for the treatment of symptoms of lesser severity becomes embroiled in this debate (Krishna 2012). Urgent clarification of these concerns is necessary for appropriate patient-centred palliative care to be delivered effectively.

II. LiPuma’s Position on Continuous Sedation until Death (CSD)

In his recent article in the Journal of Medical Philosophy, Samuel LiPuma brings to the fore two critical areas of concern with regard to the practice of Continuous Sedation until Death (CSD) (LiPuma 2013).

The first area of concern revolves around the clinical and ethical considerations concerning the scope, indications and goals of this specific intervention within the spectrum of practices described by Morita et al. (2001). Based on the works of Erich Loewy (2001), John Cowan and Declan Walsh (2001), Margaret Battin (2008), Hasselaar et al. (2008), Raus, Sterckx and Mortier (2011) and Rys et al. (2012), the focus of LiPuma’s attention is the specific category of Terminal Sedation (TS), which he refers to as Continuous Sedation until Death (CSD) for the treatment of intractable suffering at the end of life.

LiPuma describes CSD as being “where the patient is rendered permanently unconscious until complete biological death” (Lipuma 2013: 3). CSD is characterised by seven key facets. To begin the indication for the application of CSD must be the presence of intractable symptoms or symptoms not remediable through any other means but deep continuous sedation to unconsciousness. Second, CSD is applied to patients with a limited prognosis. In LiPuma’s case study of Mrs B, her prognosis appeared to be a matter of hours. Third, the primary means of inducing sedation is through the application of barbiturates which are evidenced to meet the primary goal of reducing pain by “eliminating consciousness” (Lipuma 2013: 3). Next, CSD refers solely to deep continuous sedation and not lesser forms of sedation that Morita et al. describe as being associated with sedation at the end of life (2003: 358) (Lipuma 2013: 3). Fifth, this form of deep sedation is applied to continuously sedate patients to unconsciousness till their demise. LiPuma does not employ the term CSD as a euphemism for Terminal Sedation (TS) but merely specifies that his attention is focused upon this particular subtype of TS (LiPuma 2013: 3). Sixth, the application of CSD typically “means that nutrition and hydration are no longer provided once sedation begins” (Lipuma 2013: 3). Finally, the intention underpinning the application of this intervention is one focused on providing relief for intractable suffering through the proportional, monitored and appropriate [End Page 260] application of...

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