Palliative sedation

In medicine, specifically in end-of-life care, palliative sedation (also known as terminal sedation, continuous deep sedation, or sedation for intractable distress in the dying/of a dying patient) is the palliative practice of relieving distress in a terminally ill person in the last hours or days of a dying patient's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug. This is an option of last resort for patients whose symptoms cannot be controlled by any other means. This should be differentiated from euthanasia as the goal of palliative sedation is to control symptoms through sedation but not shorten the patient's life, while in euthanasia the goal is to shorten life to cease suffering.

According to 2009 research, 16.5% of all deaths in the United Kingdom during 2007-2008 took place after continuous deep sedation. On the other hand, a 2009 survey of almost 4000 U.K. patients whose care had followed the Liverpool Care Pathway for the dying patient found that while 31% had received low doses of medication to control distress from agitation or restlessness, only 4% had required higher doses.

General Practice
Palliative sedation is often initiated at the patient's request. It can also be inititated by the physician who would discuss the option with the patient and family. Palliative sedation can be used for short periods with the plan to awaken the patient after a given time period, making terminal sedation a less correct term. The patient is sedated while symptom control is attempted, then the patient is awakened to see if symptom control is achieved. In some cases, palliative sedation is begun with the plan to not attempt to reawaken the patient. One such common example is a patient with an enlarging cancer in the throat that compresses the trachea in a patient who does not want intubation or a tracheostomy, so that eventually symptom control is impossible. Rather than death by suffication the patient is aware of, once symptoms are intolerable some patients will request palliative sedation to ease their symptoms while the disease progresses to eventually be fatal.

Drugs used
A typical drug is midazolam, a short acting benzodiazepine. Opioids such as morphine are not used as the primary medicine since they are not effective sedative medications compared to benzodiazepines. However, if a patient was already on an opioid for pain relief, this is continued for pain relief while sedation is achieved. Other medications to be considered include haloperidol, chlorpromazine, pentobarbital, propofol or phenobarbital.

Nutrition and fluids
As patients undergoing terminal sedation are typically in the last hours or days of their lives, they are not usually eating or drinking significant amounts. There has not been any conclusive studies to demonstrate benefit to initiating artificial nutrition (TPN, tube feedings, etc.) or artificial hydration (subcutaneous or intravenous fluids). There is also the risk that IV fluids or feedings can worsen symptoms, especially respiratory secretions and pulmonary congestion. If the goal of palliative sedation is comfort, IV fluids and feedings are often not consistent with this goal (1). Before initiating terminal sedation, a discussion about the risks, benefits and goals of nutrition and fluids is encouraged, and is mandatory in the United Kingdom.

Sedation vs. Euthanasia
There is no evidence that titrated sedation causes the death of the patient and sedation does not equate with euthanasia(1). At the end of life sedation is only used if the patient perceives their distress to be unbearable, and there are no other means of relieving that distress. In palliative care the doses of sedatives are titrated (i.e. varied) to keep the patient comfortable without compromising respiration or hastening death. Death results from the underlying medical condition. For more information on the palliative care use of sedatives and the safe use of opioids see Opioids.

Patients (or their legal representatives) only have the right to refuse treatments in living wills, they cannot demand life saving treatments, or any treatments at all. However, once unconsciousness begins, as the patient is no longer able to decide to stop the sedation or to request food or water, the clinical team can  act in the patient's  best interests. A Living Will, made when competent, can under UK law, give a directive that they refuse 'Palliative Care' or 'Terminal Sedation', or 'any drug likely to suppress my respiration'.

United States of America
In 2008, the American Medical Association Council on Ethical and Judicial Affairs approved an ethical policy regarding the practice of palliative sedation. According to the principle of double effect such treatment may be ethically justified if a doctor administers the drug with the intention to alleviate pain/suffering. The defense of double effect is only open to medical practitioners.

Sweden
In October 2010 Svenska Läkaresällskapets, an association of physicians in Sweden, published guidelines which allowed for palliative sedation to be administered even with the intent of the patient not to reawaken.