The use of terminal sedation to control theintense discomfort of dying patients appearsboth to be an established practice inpalliative care and to run counter to the moraland legal norm that forbids health careprofessionals from intentionally killingpatients. This raises the worry that therequirements of established palliative care areincompatible with moral and legal opposition toeuthanasia. This paper explains how thedoctrine of double effect can be relied on todistinguish terminal sedation from euthanasia. The doctrine of double effect is rooted inCatholic moral casuistry, but (...) its applicationin law and morality need not depend on theparticular framework in which it was developed. The paper further explains how the moral weightof the distinction between intended harms andmerely foreseen harms in the doctrine of doubleeffect can be justified by appeal to alimitation on the human capacity to pursue good. (shrink)
There has been much discussion regarding the acceptable use of sedation for palliation. A particularly contentious practice concerns deep, continuous sedation given to patients who are not imminently dying and given without provision of hydration or nutrition, with the end result that death is hastened. This has been called ‘early terminal sedation’. Early terminal sedation is a practice composed of two legally and ethically accepted treatment options. Under certain conditions, patients have the right to reject hydration and nutrition, even if (...) these are life-sustaining. Patients are also entitled to sedation as palliation for intolerable, intractable suffering. Though early terminal sedation is thought to be rare at present, the changing nature of palliative medicine suggests its use will increase.Arguments regarding early terminal sedation have failed to recognize early terminal sedation as a distinct legal and ethical entity. It can be seen as both the simple sum of treatment refusal and sedation for palliation, analogous to terminal sedation. It can also be seen as an indivisible palliative treatment, more analogous to assisted suicide or euthanasia. But ultimately, it is wholly analogous neither to terminal sedation given when death is imminent, nor to assisted suicide or euthanasia. This paper contends that early terminal sedation should be considered as a distinct entity. Such a reconception promises to provide a way forward in the debate, practice and policy regarding this contentious area of palliative medicine. (shrink)
Abstract Continuous sedation until death (CSD), the act of reducing or removing the consciousness of an incurably ill patient until death, often provokes medical–ethical discussions in the opinion sections of medical and nursing journals. Some argue that CSD is morally equivalent to physician-assisted death (PAD), that it is a form of “slow euthanasia.” A qualitative thematic content analysis of opinion pieces was conducted to describe and classify arguments that support or reject a moral difference between CSD and PAD. Arguments pro (...) and contra a moral difference refer basically to the same ambiguous themes, namely intention, proportionality, withholding artificial nutrition and hydration, and removing consciousness. This demonstrates that the debate is first and foremost a semantic rather than a factual dispute, focusing on the normative framework of CSD. Given the prevalent ambiguity, the debate on CSD appears to be a classical symbolic struggle for moral authority. Content Type Journal Article Category Original Research Pages 1-13 DOI 10.1007/s11673-012-9369-8 Authors Sam Rys, Department of Public Health, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussel, Belgium Reginald Deschepper, Department of Public Health, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussel, Belgium Freddy Mortier, End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Brussels, Belgium Luc Deliens, End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Brussels, Belgium Douglas Atkinson, Interfacultair Departement voor Taalonderwijs (ITO), Vrije Universiteit Brussel, Brussels, Belgium Johan Bilsen, Department of Public Health, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussel, Belgium Journal Journal of Bioethical Inquiry Online ISSN 1872-4353 Print ISSN 1176-7529. (shrink)
The relatively new practice of continuous sedation at the end of life (CS) is increasingly being debated in the clinical and ethical literature. This practice received much attention when a U.S. Supreme Court ruling noted that the availability of CS made legalization of physician-assisted suicide (PAS) unnecessary, as CS could alleviate even the most severe suffering. This view has been widely adopted. In this article, we perform an in-depth analysis of four versions of this ?argument of preferable alternative.? Our goal (...) is to determine the extent to which CS can be considered to be an alternative to PAS and to identify the grounds, if any, on which CS may be ethically preferable to PAS. (shrink)
Surveys in different countries (e.g. the UK, Belgium and The Netherlands) show a marked recent increase in the incidence of continuous deep sedation at the end of life (CDS). Several hypotheses can be formulated to explain the increasing performance of this practice. In this paper we focus on what we call the ‘natural death’ hypothesis, i.e. the hypothesis that acceptance of CDS has spread rapidly because death after CDS can be perceived as a ‘natural’ death by medical practitioners, patients' relatives (...) and patients.We attempt to show that the label ‘natural’ cannot be unproblematically applied to the nature of this end-of-life practice. We argue that the labeling of death following CDS as ‘natural’ death is related to a complex set of mechanisms which facilitate the use of this practice. However, our criticism does not preclude the view that CDS may be clinically and ethically justified in many cases. (shrink)
This paper is concerned with the moral justification for palliative sedation until death. Palliative sedation involves the intentional lowering of consciousness for the relief of untreatable symptoms. The paper focuses on the moral problems surrounding the intentional lowering of consciousness until death itself, rather than possible adjacent life-shortening effects. Starting from a Kantian perspective on virtue, it is shown that continuous deep sedation until death (CDS) does not conflict with the perfect duty of moral self-preservation because CDS does not destroy (...) capacities for agency. In addition, it is argued that CDS can frustrate the imperfect duty of self-cultivation by reducing consciousness permanently. Nevertheless, there are cases where CDS is morally acceptable, namely, cases where the agent has already permanently lost the possibility for free action in advance of sedation—for example, due to excruciating and ongoing pain. Because the latter can be difficult to diagnose properly, safeguards may be needed in order to prevent the application of CDS for the wrong reasons. (shrink)
Background Intensivists must provide enough analgesia and sedation to ensure dying patients receive good palliative care. However, if it is perceived that too much is given, they risk prosecution for committing euthanasia. The goal of this study is to develop consensus guidelines on analgesia and sedation in dying intensive care unit patients that help distinguish palliative care from euthanasia. Methods Using the Delphi technique, panelists rated levels of agreement with statements describing how analgesics and sedatives should be given to dying (...) ICU patients and how palliative care should be distinguished from euthanasia. Participants were drawn from 3 panels: 1) Canadian Academic Adult Intensive Care Fellowship program directors and Intensive Care division chiefs (N = 9); 2) Deputy chief provincial coroners (N = 5); 3) Validation panel of Intensivists attending the Canadian Critical Care Trials Group meeting (N = 12). Results After three Delphi rounds, consensus was achieved on 16 statements encompassing the role of palliative care in the intensive care unit, the management of pain and suffering, current areas of controversy, and ways of improving palliative care in the ICU. Conclusion Consensus guidelines were developed to guide the administration of analgesics and sedatives to dying ICU patients and to help distinguish palliative care from euthanasia. (shrink)
To fulfill their crucial duty of relieving suffering in their patients, physicians may have to administer palliative sedation when they implement treatment-limitation decisions such as the withdrawal of life-supporting interventions in patients with poor prognosis chronic severe brain injury. The issue of palliative sedation deserves particular attention in adults with serious brain injuries and in neonates with severe and irreversible brain lesions, who are unable to express pain or to state their wishes. In France, treatment limitation decisions for these patients (...) are left to the physicians. Treatment-limitation decisions are made collegially, based on the presence of irreversible brain lesions responsible for chronic severe disorders of consciousness. Before these decisions are implemented, they are communicated to the relatives. Because the presence and severity of pain cannot be assessed in these patients, palliative analgesia and/or sedation should be administered. However, palliative sedation is a complex strategy that requires safeguards to prevent a drift toward hastening death or performing covert euthanasia. In addition to the law on patients' rights at the end of life passed in France on April 22, 2005, a recent revision of Article 37 of the French code of medical ethics both acknowledges that treatment-limitation decisions and palliative sedation may be required in patients with severe brain injuries and provides legal and ethical safeguards against a shift towards euthanasia. This legislation may hold value as a model for other countries where euthanasia is illegal and for countries such as Belgium and Netherlands where euthanasia is legal but not allowed in patients incapable of asking for euthanasia but in whom a treatment limitation decision has been made. (shrink)
The moral importance of the ‘intention–foresight’ distinction has long been a matter of philosophical controversy, particularly in the context of end-of-life care. Previous empirical research in Australia has suggested that general physicians and surgeons may use analgesic or sedative infusions with ambiguous intentions, their actions sometimes approximating ‘slow euthanasia’. In this paper, we report findings from a qualitative study of 18 Australian palliative care medical specialists, using in-depth interviews to address the use of sedation at the end of life. The (...) majority of subjects were agnostic or atheistic. In contrast to their colleagues in acute medical practice, these Australian palliative care specialists were almost unanimously committed to distinguishing their actions from euthanasia. This commitment appeared to arise principally from the need to maintain a clear professional role, and not obviously from an ideological opposition to euthanasia. While some respondents acknowledged that there are difficult cases that require considered reflection upon one's intention, and where there may be some ‘mental gymnastics,’ the nearly unanimous view was that it is important, even in these difficult cases, to cultivate an intention that focuses exclusively on the relief of symptoms. We present four narratives of ‘terminal’ sedation – cases where sedation was administered in significant doses just before death, and may well have hastened death. Considerable ambiguities of intention were evident in some instances, but the discussion around these clearly exceptional cases illustrates the importance of intention to palliative care specialists in maintaining their professional roles. (shrink)
A distinction is commonly drawn between continuous sedation until death and physician-assisted suicide/euthanasia. Only the latter is found to involve killing, whereas the former eludes such characterization. I argue that continuous sedation until death is equivalent to physician-assisted suicide/euthanasia in that both involve killing. This is established by first defining and clarifying palliative sedation therapies in general and continuous sedation until death in particular. A case study analysis and a look at current practices are provided. This is followed by a (...) defense of arguments in favor of definitions of death centering on higher brain (neocortical) functioning rather than on whole brain or cardiopulmonary functioning. It is then shown that continuous sedation until death simulates higher brain definitions of death by eliminating consciousness. Appeals to reversibility and double effect fail to establish any distinguishing characteristics between the simulation of death that occurs in continuous sedation until death and the death that occurs as a result of physician-assisted suicide/euthanasia. Concluding remarks clarify the moral ramifications of these findings. (shrink)
The Rule of Double Effect (RDE) holds that it may be permissible to harm an individual while acting for the sake of a proportionate good, given that the harm is not an intended means to the good but merely a foreseen side-effect. Although frequently used in medical ethical reasoning, the rule has been repeatedly questioned in the past few decades. However, Daniel Sulmasy, a proponent who has done a lot of work lately defending the RDE, has recently presented a reformulated (...) and more detailed version of the rule. Thanks to its greater precision, this reinvented RDE avoids several problems thought to plague the traditional RDE. Although an improvement compared with the traditional version, we argue that Sulmasy's reinvented RDE will not stand closer scrutiny. Not only has the range of proper applicability narrowed significantly, but, more importantly, Sulmasy fails to establish that there is a morally relevant distinction between intended and foreseen effects. In particular, he fails to establish that there is any distinction that can account for the alleged moral difference between sedation therapy and euthanasia. (shrink)
In this Critical Notice of Emily Jackson and John Keown’s Debating Euthanasia , the respective lines of argument put forward by each contributor are set out and the key debating points identified. Particular consideration is given to the points each contributor makes concerning the sanctity of human life and whether slippery slopes leading from voluntary medically assisted dying to non-voluntary euthanasia would be established if voluntary medically assisted dying were to be legalised. Finally, consideration is given to the positions adopted (...) by the contributors in relation to the legalisation of voluntary medically assisted dying. (shrink)
Is a painful experience less bad for you if you will not remember it? Do you have less reason to fear it? These questions bear on how we think about medical procedures and surgeries that use an anesthesia regimen that leaves patients conscious – and potentially in pain – but results in complete ‘drug-induced amnesia’ after the fact. I argue that drug-induced amnesia does not render a painful medical procedure a less fitting object of fear, and thus the prospect of (...) amnesia does not give patients a reason not to fear it. I expose three mistakes in reasoning that might explain our tendency to view pain or discomfort as less fearful in virtue of expected amnesia: a mistaken view of personal identity; a mistaken view of the target of anticipation; and a mistaken method of incorporating past evidence into calculations about future experiences. Ultimately my argument has implications for whether particular procedures are justified and how medical professionals should speak with anxious patients about the prospect of drug-induced amnesia. (shrink)
The U.S. Supreme Court's majorityopinion in Vacco v. Quill assumes thatthe principle of double effect explains thepermissibility of hastening death in thecontext of ordinary palliative care and inextraordinary cases in which painkilling drugshave failed to relieve especially intractablesuffering and terminal sedation has beenadopted as a last resort. The traditionaldoctrine of double effect, understood asproviding a prohibition on instrumental harmingas opposed to incidental harming or harming asa side effect, must be distinguished from otherways in which the claim that a result is (...) notintended might be offered as part of ajustification for it. Although double effectmight appropriately be invoked as a constrainton ordinary palliative care, it is not clearthat it can be coherently extended to justifysuch practices as terminal sedation. A betterapproach would reconsider double effect'straditional prohibition on hastening death as ameans to relieve suffering in the context ofacute palliative care. (shrink)
Palliative care and hospice should be the standards of care for all terminally ill patients. The first place for clinicians to go when responding to a request for assisted death is to ensure the adequacy of palliative interventions. Although such interventions are generally effective, a small percentage of patients will suffer intolerably despite receiving state-of-the-art palliative care, and a few of these patients will request a physician-assisted death. Five potential “last resort” interventions are available under these circumstances: (1) accelerating opioids (...) for pain or dyspnea; (2) stopping potentially life-prolonging therapies; (3) voluntarily stopping eating and drinking; (4) palliative sedation (potentially to unconsciousness); and (5) physician-assisted death. Patient, family, and clinicians should search for the least harmful way to respond to intolerable end-of-life suffering in ways that are effective and also respect the values of the major participants. A system that allows an open response to such cases ultimately protects patients by ensuring a full clinical evaluation and search for alternative responses, while reinforcing the need to be responsive and to not abandon. (shrink)
To the Editor: It was with great interest that our Canadian Palliative Sedation Therapy Guideline working group read Jeffrey Berger's recent article ("Rethinking Guidelines for the Use of Palliative Sedation," May-June 2010). Given our own group's efforts to develop national guidelines, we have rethought the issue of palliative sedation therapy several times over the past year.The use of clear and concise definitions is fundamental to the development of any consensus guidelines on this topic. In the article, the term "palliative sedation (...) to unconsciousness," or PSU, implies the concerning assumption that sedation will knowingly be to unconsciousness in the palliative case under consideration. This conflicts with .. (shrink)
The Liverpool Care Pathway is intended as a palliative care regime at the end of life. Even its critics agree that certain of its recommendations may be useful and appropriate. Additionally, critics are aware that there are occasions when death may be a foreseen side effect of perfectly licit palliation whose primary ends are not homicidal at all. It is evident that treatment may be over-expensive, over-burdensome or simply futile. There is no suggestion that critics of the Pathway adhere irrationally (...) to what is known in medical ethics as the error of vitalism, the commitment to excessive, extraordinary or futile treatment, or over-burdensome care at the end of life. However, to ask whether treatment is futile, over-burdensome or over-expensive is very different to the discriminatory question about the futility, burden or expense of a frail and vulnerable patient. The sedation-dehydration aspect of the Pathway attracts much proper opposition. Doctors and families have found that those on the Pathway recovered when they intervened to take the patient off it. Senior medics have stepped forward, in the face of managerial opposition to argue that it is often impossible to know with certainty whether a person is imminently dying. One problem with the Pathway is that where a patient is misdiagnosed as terminal, the combination of morphine and dehydration has a self-fulfilling character and is likely to undermine a patient’s capacity. Persistent dehydration of even fit and healthy sedated patients will kill them. This was the difficulty highlighted by concerned medical professionals many years ago. The independent inquiry ordered in response to Freedom of Information Act requests performed in 2012 demonstrating a staggering increase in the number of people dying on the Pathway once it was financially incentivised needs to ensure certain investigations take place. What is needed, however, is not a whitewash but an independent inquiry with all interests declared and data sets interrogated and collated. These will cover a time-series medical history of each anonymised patient on the Pathway, duration until death, information about interventions provided during the period, monthly raw data from each trust, hospice or care home, medical histories, removals from the Pathway, information about journals that were corrected once a patient recovered, demographic data, location information and an audit trail of all data management. (shrink)
This paper explores how using a domains of ethics analysis approach might constructively contribute to an enhanced understanding (among those without specialized ethics training) of ethically-complex health care practices through the consideration of one such sample practice, i.e., deep and continuous palliative sedation (DCPS). For this purpose, I select four sample ethics domains (from a variety of possible relevant domains) for use in the consideration of this practice, i.e., autonomous choice, motives, actions and consequences. These particular domains were choosen because (...) of their relevance to the analysis of DCPS and their relative ease of access to those without ethics training. The analysis demonstrates that such an approach could facilitate the emergence of accessible arguments and discussion points that could enhance the understanding and appreciation of this and other health care practices with strong ethics dimensions. (shrink)
The recent revelation that the rolling out of the Liverpool Care Pathway as the NHS National End of Life Care strategy in 2008 had been financially incentivised and implemented with astonishing compliance emerged as a thought-provoking development. Many of us have been warning for years of the financial, political and research interests that there are in institutionalising sedation-and-dehydration regimes, and then, inevitably, medical homicide. Freedom of Information Act requests exposed the millions of pounds that have been paid for the implementation (...) of this national end-of-life care strategy. Much more interestingly, it showed that some hospital trusts had been paid these funds for ensuring that up to two thirds of all deaths were Pathway deaths. Given that the very livelihood of health professionals was being judged against the new Commissioning for Quality Innovation (CQUIN) ’Gold Standards Framework’, professional observance of the pathway was predictable. The revelation of management targets, despite the best efforts of the regime’s proponents to play them down, radically alters the debate. Unlike education or housing targets, these ones are potentially homicidal. (shrink)
BACKGROUND: Through their action on the locus coeruleus, ␣ 2-adrenoceptor agonists induce rapidly reversible sedation while partially preserving cognitive brain functions. Our goal in this observational study was to map brain regions whose activity is modified by clonidine infusion so as to better understand its loci of action, especially in relation to sedation. METHODS: Six ASA I–II right-handed volunteers were recruited. Electroencephalogram (EEG) was monitored continuously. After a baseline H215O activation scan, clonidine infusion was started at a rate ranging from (...) 6 to 10 g ⅐ kgϪ1 ⅐ h Ϫ1. A sequence of 11 similar scans was then performed at 8 min intervals. Plasma clonidine concentration was measured. Using statistical parametric mapping, we sought linear correlations between normalized regional cerebral blood flow (rCBF), an indicator of regional brain activity, and plasma clonidine concentration or spindle EEG activity. RESULTS: Clonidine induced clinical sedation and EEG patterns (spindles) comparable to early stage nonrapid eye movement sleep. A significant negative linear correlation between clonidine concentration and rCBF or spindle activity was observed in the thalamus, prefrontal, orbital and parietal association cortex, posterior cingulate cortex, and precuneus. CONCLUSIONS: The EEG patterns and decreases in rCBF of specific brain regions observed during clonidine-induced sedation are similar to those of early stage nonrapid eye movement sleep. Patterns of deactivated brain regions are also comparable to those observed during general anesthesia or vegetative state, reinforcing the hypothesis that alterations in the activity of a common network occur during these modified conscious states. (shrink)
A book for nurses, doctors and all who provide end of life care, this essential volume guides readers through the ethical complexities of such care, including current policy initiatives, and encourages debate and discussion on their controversial aspects. dived into two parts, it introduces and explains clinical decision making-processes about which there is broad consensus, in line with guidance documents issued by WHO, BMA, GMC, and similar bodies. The changing political and social context where 'patient choice' has become a central (...) idea, and the broadened scope of potients' best interests, have added to the complexity of decision-making in end of life care. The authors discuss issues widely encountered by GPs, nurses, and hospital clinicians. These include patient choice, consent, life-prolonging treatment, and symptom relief including sedation. Part rwo explores the more controversial current end of life care initiatives, such as advance care planning preferred place of care and death, euthanais and assited suicide, extended ideas of 'best interests', and the view that there are therapeutic duties to the relatives of Throughout their discussion the authors draw attention to loose ends and contradictions in some of the proposals. Examining the current policy of comsumerist choice, they reject its place in the health service, proposing a a realistic, fair, humane and widely adoptable system of end of life care. -/- As knowledge of ethical theories is required in training courses, and the vocabulary of ethical theory is widespread in current discussions a substantial appendix on ethical theories and terms is available online. -/- Written by the same authors as The Philosophy of Palliative Care: Critique and Reconstruction, which won the Medical Journalists' Association Specialits Book Award 2007, this new book for non-specialists is essential reading for all health care professionals involved in providing end of life care. (shrink)
Objective: To review the principles and practice of the use of conscious sedation for IVF.Design: The pertinent literature was reviewed and recommendations are provided.Result(s): Conscious sedation appears to be the most commonly used method of pain relief for transvaginal retrieval of oocytes. Conscious sedation does not require the presence of an anesthesiologist and can be done in freestanding clinics. Agents commonly used include opioids in combination with benzodiazepines. This combination minimizes pain, decreases anxiety, and provides sedation and some amnesia Adjuvants (...) such as promethazine and hydroxyzine can also be used but often are not needed. Conscious sedation is well tolerated by patients and does not require highly specialized equipment. However, there are specific safeguards that should be followed. Only a few toxicity studies have been performed, but they are reassuring because they have not found significant effects on fertilization or cleavage.Conclusion(s): Conscious sedation appears to be a safe and cost-effective method of providing analgesia and anesthesia for transvaginal retrieval of oocytes. (shrink)
As palliative care develops across many of the countries of Europe, we find that it continues to raise important ethical challenges. Palliative care practice requires ethical sensitivity and understanding. At the same time the very existence of palliative care calls for ethical explanation. Ethics and palliative care meet over some vital issues: 'the good death', sedation at the end of life, requests for euthanasia, futile treatment, and the role of research. Yet palliative care appears uncertain about its goals and there (...) is evidence that its ethical underpinnings are changing. Likewise, the moral problems of palliative care are only partly served by the four 'principles' of modern bioethics. This innovative book, with contributions by clinicians, ethicists, philosophers and social scientists, provides the first ever picture of palliative care ethics in the European context. It will be of interest to those involved in the delivery and management of palliative care services, as well as to students and researchers. (shrink)
