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Sedation at the end-of-life : an interdisciplinary approach
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Taboada / Paulina
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Springer Netherlands, Dordrecht
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2015
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The books main contribution is its interdisciplinary approach to the issue of sedation at the end-of-life. Because it occurs at the end of life, palliative sedation raises a number of important ethical and legal questions, including whether it is a covert form of euthanasia and for what purposes it may legally be used. Many of the book chapters address the first question and almost all deal with a specific form of the second: whether palliative sedation should be used for those experiencing existential suffering? This raises the question of what existential suffering is, a topic that is also discussed in the book. The different chapters address these issues from the perspectives of the relevant disciplines: Palliative Medicine, Bioethics, Law and Theology. Hence, helpful accounts of the clinical and historical background for this issue are provided and the importance of drawing accurate ethical and legal distinctions is stressed throughout the whole book. So the volume represents a valuable contribution to the emerging literature on this topic and should be helpful across a broad spectrum of readers: philosophers, theologians and physicians.

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Springer Science+Business Media Dordrecht 2015

Paulina Taboada (ed.) Sedation at the End-of-life: An Interdisciplinary Approach Philosophy and Medicine 10.1007/978-94-017-9106-9_1

1. Sedation at the End of Life. Clinical Realities, Trends and Current Debate

Paulina Taboada 1

(1)

Center for Bioethics and Department of Internal Medicine, Faculty of Medicine, Pontificia Universidad Catlica de Chile, Alameda 340, Santiago, Chile

Paulina Taboada

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1.1 Introduction

The use of sedation is not new in medicine. In fact, sedation is widely used to alleviate pain and discomfort associated with both invasive procedures such as surgery, as well as severe burns (Claessens et al. ).

During the last decade, medical knowledge about PS has significantly increased. Several clinical studies (Ventafridda et al. ); etc. However, the most debated issues are connected with the ethical foundations of PS and its conceptual difference with euthanasia and physician-assisted-suicide.

In the following, I shall start with the description of two real clinical cases, to introduce some aspects of the current debate on the concepts and definitions of palliative sedation, as well as the controversies related to its clinical applications. A critical analysis of the content of some of the guidelines for the use of PS that have been proposed in different parts of the world suggests a current need for re-thinking the clinical, ethical and theological foundations of this therapeutic intervention at the end-of-life. Although I will refer to some of the ethically relevant questions connected to the use of PS, I will not enter into a deep analysis of these issues here, as this will be the task of the following chapters.

1.2 Clinical Settings: Examples of Real Cases

Case 1

29 years-old woman with an end-stage brain tumor (glioblastoma). She has had a very low intake of fluids and nourishment for several months and is currently cachectic and bed-bounded. The tumors mass effect has been causing her mild headache and confusion over the past weeks, for which she is currently under treatment with steroids and opioids, with a partial response.

Due to tumor involvement at the level of the brain stem, she developed shortness of breath and was admitted to an Acute Symptom Management Unit. Attempts to relieve her dyspnoea with oxygen and with increasing doses of opioids has failed.

As the patient did not have the capacity to participate actively in medical decision-making (due to her mental confusion), the use of sedation was proposed to the parents and fianc as a last resort therapy to relieve her respiratory distress. They hesitated, as they understood that inducing a state of unconsciousness would prevent them from the possibility to communicate with her during her last days of life. But after witnessing her increasing respiratory distress, they ended up accepting the treatment. Before starting sedation, they requested a priest to come and give her Holy Communion and the Blessing of the Sick, as they were all practicing Catholics.

Sedation was efficiently induced with low doses of Midazolam i.v. and the moderately sedated patient did not look distressed anymore. She died peaceful 4 days later, in the company of her parents and fianc.

In such a case, one can assume that death was caused by respiratory arrest due to tumour compression at the level of the brain stem and not by the use of sedatives.

Case 2

59 years-old lady with an invasive ductal breast carcinoma and a scamous carcinoma of the vagina. In spite of the intense radio- and chemotherapy, the disease is now widely disseminated. In fact, she has multiple lung, pleural, hiliar, brain and subcutaneous metastases. Her symptom assessment reveals an appropriate control of physical symptoms, but a persistent state of enormous anguish.

She is married to a supportive husband, who visits her daily at the Acute Symptom Management Unit were she has been recently admitted. They never had children, as they got married rather late. The source of her current anguish seems to be related to a deep questioning of some important life-decisions and the overall meaning of her existence. Her emotional state might be labeled as existential suffering.

The patient requests her attending Palliative Care Physician to be put asleep, as she cannot bare this horrible anguish anymore. The husband agrees with the patients request. The attending physician hesitates whether this is a case for palliative sedation and decides to consult with other colleagues.

In the mean time, each time the doctor enters the patients room, she inquires: Why am I not asleep yet? I have already told you that I cannot stand this anguish anymore! The patients strong insistence provokes a distress reaction in the doctor, who decides to initiate a continuous i.v. infusion of Midazolam.

Nevertheless, mild sedation does not seem to work well for the patient. In fact, every time the doctor enters the patients room, she keeps asking why she is not asleep yet. Hence, the doctor decides to increase the doses of Midazolam after each visit. Since this strategy does not work, the physician decides to add Phenobarbital. After 3 days, a state of unconsciousness is finally reached and the patient dies.

According to the advanced stage of her cancer, the estimated prognosis of this patient was less than 2 month. Nevertheless, she actually died in a few days, probably due to respiratory arrest caused by the rapid increase of sedatives, combining the use of benzodiazepines and barbiturates.

These two cases confront us with questions related to the distinction between palliative sedation and euthanasia. In order to draw this distinction, we first need to clarify the concepts.

1.3 The Debate on Terms, Concepts and Definitions

A review of the medical and bioethical literature reveals that not all the authors understand the same thing when referring to sedation as a useful therapeutic tool in Palliative Medicine. In fact, several definitions have been proposed in the literature (Claessens et al. ). Strictly speaking, definitions come in various sorts: operational, descriptive and conceptual definitions. Therefore, when liming a concept, one tries to give an conceptual definitions of it (e.g. knowledge is justified true belief). Thus, grasping the essential elements of the subject under study is a first necessary step to provide a good conceptual definition.

In regard to specific conceptual definitions, one has to be careful to define the term taking into account what it actually is. And PS is fundamentally an action type. Hence, it should be defined in a way apropos for action types, for example, it should note the object, the intention of the agent and the circumstances. From this perspective, palliative sedation could be defined as the medical act of administering sedatives with the deliberate intention of reducing the level of consciousness of a terminally ill patient as much as needed to achieve a proportionate good therapeutic goal, as is the relieve of severe and refractory symptoms at the end of life. Boyle (Chap. ) provide good examples of this sort of action-type definition of PS when undertaking an accurate analysis of the problem as to whether the administration of drugs that have the effect of deprivation of consciousness in the patient, is or is not an action that could (or should) be justified by the application of the so called principle of the double effect (PDE).

Indeed, the common idea underlying the various definitions of PS used in the current bioethical and medical literature is that it is the intentional administration of sedative drugs in dosages and combinations required to reduce the consciousness of a terminal patient as much as necessary to adequately relieve one or more refractory symptoms. (Claessens et al. )

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