Palliative Sedation in End-of-Life Care

Susan D. Bruce, RN, BSN, OCN; Cristina C. Hendrix, DNS, APRN-BC, GNP, FNP; Jennifer H. Gentry, RN, MSN, ANP, APRN-BC, PCM

Disclosures

Journal of Hospice and Palliative Nursing. 2006;8(6):320-327. 

In This Article

Legal and Moral Issues in Palliative Sedation

In 1997, the United States Supreme Court ruled against physician-assisted suicide but maintained support for aggressive palliative care. The Supreme Court rulings Vacco v Quill 521 US 793 (1997) and Washington v Glucksberg 521 US 702 (1997) supported the concept of sedation when used to relieve intractable suffering. These decisions sanctioned the use of sedation, even to the point of rendering a patient unconscious or hastening death. It is felt that in palliative sedation, unconsciousness relieves suffering.[17] Palliative sedation is the use of carefully titrated medications and is distinct from assisted suicide. In Supreme Court briefs opposing physician-assisted suicide, proponents for hospice and palliative care found palliative sedation to be a morally and clinically preferable last resort alternative to the relief of intractable symptoms.

The traditional approach to providing care (use of sedatives and analgesics for symptom management) for a dying patient is ethically and morally acceptable in our society. Palliative sedation in which the patient is kept unconscious as a means of relieving intractable symptoms is a different matter. One of the moral issues is that palliative sedation has many of the same risks associated with physician-assisted suicide and voluntary active euthanasia. There is concern about where the boundaries are, and there are more gray areas than not. It is clear in the literature that practitioners cannot decide on a universal definition of palliative sedation, making it more difficult to make the distinction. Opponents of palliative sedation have recommended a variety of safeguards to prevent abuse or improper use of sedation to reduce the risk among vulnerable patients. Quill et al[18] proposed safeguards for any medical action that may hasten death. These safeguards include determining that palliative care is ineffective, obtaining informed consent, ensuring diagnostic and prognostic clarity, obtaining an independent second opinion, and documenting and reviewing the processes to ensure accountability.

The patient's family experiences moral dilemmas and is often left with the guilt and consequences of their decision or support of palliative sedation. It is frightening to think that their loved one will never wake up again. It is certainly anguishing to watch the patient die. The family may struggle with whether their loved one has already died and is just the body or shell of a person. Families may even stop visiting their loved ones after sedation is started. On the other hand, it is agonizing to watch a loved one suffer from unrelenting pain and other uncontrolled symptoms. Then there is the question of existential suffering. It would seem that the family is caught between the proverbial "rock and a hard place."

Healthcare providers are not exempt from the moral challenges of providing palliative sedation. There can be much confusion about their moral responsibility. Some of the confusion arises from previous training, the ethical tenets of doing no harm, and the desire to help provide a dignified death for the patient and family. This does not even to begin to incorporate the personal, religious, or spiritual beliefs of the healthcare provider. It is important for the care team to hold periodic conferences to help alleviate some of the emotional burden that is associated with caring for these patients at the end of life.

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