Mandatory consultation for palliative sedation? Reflections on Koper et al.

Abstract

To the Editor: Patients nearing death often experience distressing symptoms that cannot be alleviated by conventional treatments. In these situations palliative sedation, i.e. the use of sedative drugs to relieve intolerable and refractory distress by reducing the patient’s consciousness, can be an option of last resort [1]. In their recent publication, Koper et al. [2] provided an important contribution to the palliative sedation literature uncovering a variety of arguments in favour of and against expert consultation before resorting to palliative sedation. Although consultation with specialist palliative care services can be regarded as supportive and helpful when physicians lack expertise, the authors found that Dutch physicians had both practical and theoretical objections against the European Association for Palliative Care (EAPC) recommendations on obligatory consultation [3]. We do not wish to dispute here whether expert consultation should be mandatory or not. Instead, we would like to focus on two aspects that we believe are underexposed in the study of Koper et al. and where some caution is required when interpreting results. First of all, a number of physicians in the study emphasised that palliative sedation, as opposed to euthanasia, is a normal medical treatment. The aim of palliative sedation is not to shorten life and therefore, societal control mechanisms like mandatory expert consultation were said to be redundant. Moreover, mandatory consultation might make palliative sedation look procedurally similar to euthanasia or at least morally equivalent to it [4]. However, palliative sedation is a broad concept that covers many forms of sedation which can range frommild sedation to the more controversial continuous deep sedation. Some commentators argue that continuous sedation undeniably can be a far-reaching procedure which may not only reduce the experience of suffering, but can completely remove a patient’s ability to have any experiences at all [5, 6], leading to the view that palliative sedation at the end of life is not always a normal end-of-life practice. Obviously, only grave, proportionate reasons can justify such a far-reaching intervention and palliative sedation should therefore always be used only as a ‘last’ resort option [7]. Recent data from the UK [8], The Netherlands [9] and Belgium [10], however, clearly show that the incidence of palliative sedation in all three countries is remarkably high and one might wonder whether frequencies up to 12.3 % (of all patients who died) in the Netherlands are compatible with a last resort option. Research from de Graeff [11] reveals that in 41 % (47 out of 113) of the cases where the palliative consultation team was consulted on palliative sedation, a negative advice was given, mostly due to the availability of alternative treatments. These results suggest that sedation may sometimes be performed unwarrantedly and may thus be questionable both on ethical grounds and in relation to the many guidelines, including the Royal Dutch Medical Association (RDMA) guideline [12]. In short, palliative sedation certainly cannot generally be labelled as an ordinary medical act and should be decided upon with the necessary caution. There is a need for revision of the concept of palliative sedation as normal medical practice [4]. Second, although Koper et al. suggests there is little support amongst Dutch physicians for the EAPC recommendations on L. Robijn (*) :K. Raus : L. Deliens : S. Sterckx :K. Chambaere End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium e-mail: Lenzo.Robijn@vub.ac.be