Managing Profound Suffering at the End-of-Life: Should expanding access to continuous deep sedation be the priority?

Jeffrey Kirby

doi:10.7202/1035489ar

Abstract

This paper argues that in addressing and managing profound suffering at the end-of-life, the priority should not be the legalization of physician-assisted suicide or voluntary active euthanasia in jurisdictions where these practices are not currently available. Rather, concerted efforts should be made by society and the healthcare provider community to expand patient access to proportionate distress-relieving sedation and continuous deep sedation.

Highlights

The recent passing of Bill 52 in the Canadian province of Quebec, which provides a legislative framework for the practice of voluntary active euthanasia (VAE), has added some fresh kindling to the provocative fires of debate and controversy about three assisted death practices: continuous deep sedation (CDS), physician-assisted suicide (PAS) and voluntary active euthanasia [1]
The doctrine of double effect is thought by most palliative medicine specialists and other physicians to extend to CDS, i.e., it is morally permissible for doctors to provide CDS in near-death paradigm circumstances if the physician’s sole intention is to relieve suffering, even though the theoretically ‘bad effects’ of unconsciousness and minimal hastening of death are definitely foreseen in the former and possible in the latter [4,5]
In terms of financial considerations related to direct bedside care in near-death paradigm circumstances, there is likely ‘to be a wash’ between the costs associated with caring for patients at home for several-day periods of CDS and the expenses associated with delays in obtaining formal second opinions and in completing documentation that is required by PAS and VAE regulatory systems

Summary

Introduction

The recent passing of Bill 52 in the Canadian province of Quebec, which provides a legislative framework for the practice of voluntary active euthanasia (VAE), has added some fresh kindling to the provocative fires of debate and controversy about three assisted death practices: continuous deep sedation (CDS), physician-assisted suicide (PAS) and voluntary active euthanasia [1]. The doctrine of double effect is thought by most palliative medicine specialists and other physicians to extend to CDS (as opposed to PAS/VAE), i.e., it is morally permissible for doctors to provide CDS in near-death paradigm circumstances if the physician’s sole intention is to relieve suffering, even though the theoretically ‘bad effects’ of unconsciousness and minimal hastening of death are definitely foreseen in the former and possible in the latter (in the absence of matched cohort date, there remains no definitive answer to the question of whether CDS minimally hastens death, it’s fair to claim that the use of CDS does not knowingly hasten death) [4,5] This doctrine, derived from Roman Catholic moral theology and influenced by Kantian ethics, is usually cited as the primary theoretical justification for CDS by its proponents, despite recent academic/analytic work that has demonstrated the conceptual and psychological complexity of human intentions in this context, where motivations are ambiguous in nature and difficult to evaluate [4,18,21]. Another ‘buy-in’ advantage of CDS over VAE is that only the former practice allows for some perceived diffusion of professional responsibility for the actions taken; the sedative agent used in CDS is ordered by the attending physician and typically administered by a cohort of nurses (and/or family members in the home setting) while, in VAE, the participating physician orders (decides to administer) and, in most cases, subsequently directly injects a ‘lethal cocktail’ [19]

A Key Difference in Consent Procedures

A Potential Distinction in the Obligations to Meet Healthcare Needs

Conclusion

National Assembly of the Province of Quebec: Bill 52

Findings

Royal Dutch Medical Society