Last week I spent 4 days at a conference on palliative sedation. It was a fascinating and I learned many important facts concerning palliative sedation techniques, and the current practice of sedation.
I have been wanting to learn more about palliative sedation since the Quebec College of Physicians and Surgeons (Quebec College) stated in February 2010, that Canada needs to legalize euthanasia because doctors are “doing it already.” The Quebec College stated that everyday people are sedated (palliative sedation) and everyday people are given large doses of analgesics, which the Quebec College stated was the same as euthanasia.
Link to an article on the position of the Quebec College of Physicians on Euthanasia:
Euthanasia is an action or an omission of an action that directly and intentionally causes the death of a person to relieve suffering. If an action or omission of an action is not the direct and intentional cause of death, then it is not euthanasia. Euthanasia is a form of homicide and is prosecuted as homicide.
The Euthanasia Prevention Coalition (EPC) responded to the Quebec College by stating that the proper use of sedation techniques and the proper use of large doses of analgesics (pain killers) is not euthanasia. Since the proper use of sedation techniques and the proper use of large doses of analgesics is not euthanasia, therefore the Quebec College must be suggesting that everyday Quebec physicians abuse the proper use of palliative sedation and abuse the proper use of analgesics. If this is true, then how does the Quebec College expect that euthanasia, if legalized, would not be abused?
The proper use of palliative sedation
The Canadian Palliative Sedation Therapy Guideline working group was particularly bothered by the statement of Quebec College comparing palliative sedation to euthanasia. They stated:
“Palliative sedation therapy, correctly practiced, neither aims at death nor shortens life. Palliative sedation therapy is the use of a sedative medication to control severe and untreatable suffering at the end of life when other measures have been exhausted. It does not shorten life.”Link to an article from the Palliative Sedation Therapy Guideline working group:
The Palliative Sedation Therapy Guideline working group is working on “national guidelines” to ensure the proper use of palliative sedation.
What would constitute an abuse of palliative sedation making it an act of euthanasia?
Since palliative sedation neither aims at death nor shortens life, and since euthanasia constitutes the direct and intentional cause of death, therefore when sedation is abused by directly and intentionally causing the death of the person then the act is euthanasia.
The act of deep continuous sedation of a person, who is not yet nearing death, combined with the withdrawal of hydration and nutrition, when death by dehydration occurs, this is an act of euthanasia. In this circumstance, the death was not caused by the person’s condition but rather the intentional decision to dehydrate the person to death. This is often referred to as “slow euthanasia” because the death is intentionally caused by dehydration and yet it takes longer to complete the act of euthanasia than giving a person a lethal injection. People who question that this act is euthanasia need to consider that by employing deep continuous sedation the person has been denied the opportunity to take fluids by mouth.
It is important to note that when a person is deeply and continuously sedated and hydration and nutrition is withdrawn, that the outcome is clear. This person will die of dehydration.
When a person is terminally ill and actually nearing death, the withdrawal of hydration and nutrition is not euthanasia because the person dies of their medical condition.
In the Netherlands, the abuse of palliative sedation appears to be a common practice. The recent, five year report from the Netherlands (2005), indicates that number of euthanasia deaths had declined possibly due to: “the increased application of other end-of-life interventions, such as palliative sedation.” The report stated that deep continuous sedation represented approximately 8.2% of all deaths in the Netherlands. Recent reports have indicated that the use of deep continuous sedation is increasing.
Link to the Netherlands study.
EPC welcomes the work of the Palliative Sedation Therapy Guideline working group and we encourage the proper use of palliative care. Many people have falsely stated that euthanasia needs to be legalized in order to control pain and manage symptoms at the end-of-life. It has been suggested that traditional palliative care practices can effectively control 95% of painful symptoms. When the proper use of sedation is included in the palliative care arsenal it becomes possible effectively control all pain and symptoms.
Some believe that sedation causes people to sleep through their final days of life. The suggestion is that this is no different than causing a persons death by euthanasia.
The fact is that sedation guidelines should encourage the use of light or moderate sedation and the practice of intermittent sedation. The proper use of sedation does not necessitate that the person be permanently or completely unable to interact with others.
1. Before deep continuous sedation is done, the person must be actually dying. Since the practice of deep continuous sedation usually includes the withdrawal of hydration and nutrition, therefore the method cannot be done on a person who has a terminal or significant condition, but who is not otherwise dying.
2. The decision to withdraw hydration and nutrition must remain separate from the decision to apply deep continuous sedation. Death by dehydration is “slow euthanasia” especially since the person who has been sedated is also denied the opportunity to sip or request fluids. The direct and intentional action or omission must not be to cause death, but rather to relieve suffering.
3. To ensure the proper use of sedation, palliative sedation must be considered a last resort. It is important that other techniques of controlling pain are given a reasonable chance of success before the medical team resorts to sedation.
4. The person must be experiencing refractory symptoms. It is not ethical to sedate a person who can experience effective pain relief without losing consciousness. To deny a person consciousness also means that we are denying a person the option of changing their mind, of saying goodbye to others or even indicating that their pain has been relieved.
5. The intention of the palliative sedation therapy is centrally important. The intention must be to relieve the refractory symptom. There is a concern that sedation is being used for people who are experiencing existential pain that may be effectively treated without denying the person consciousness.
6. The use of sedation must be proportional to the symptoms that the physician is trying to relieve. If a person can be comfortable through the use of light sedation then it is an abuse of the use of sedation to immediately employ deep sedation. Once again, deep continuous sedation denies a person consciousness, which should be always treated as a serious decision.
EPC encourages the proper use of palliative care and we encourage the use of sedation when it is necessary and not abused. Palliative care concerns the care of the “whole person.” EPC encourages the continued development of patient centered care.
More research needs to be done on the alleviation of refractory symptoms. We recognize the need for compassionate community care that is oriented to the psychological, social and spiritual needs of the person who is nearing death, to be with the other.
We recognize that human suffering may lead someone to request euthanasia or assisted suicide, but we also recognize that these requests most often represent a “cry for help”. We need to care for the person, even when caring is difficult, and not kill the person who is difficult to care for.