Abstract
BackgroundThe administration of sedatives in terminally ill patients becomes an increasingly feasible medical option in end-of-life care. However, sedation for intractable distress has raised considerable medical and ethical concerns. In our study we provide a critical analysis of seven years experience with the application of sedation in the final phase of life in our palliative care unit.MethodsMedical records of 548 patients, who died in the Palliative Care Unit of GK Havelhoehe between 1995–2002, were retrospectively analysed with regard to sedation in the last 48 hrs of life. The parameters of investigation included indication, choice and kind of sedation, prevalence of intolerable symptoms, patients' requests for sedation, state of consciousness and communication abilities during sedation. Critical evaluation included a comparison of the period between 1995–1999 and 2000–2002.Results14.6% (n = 80) of the patients in palliative care had sedation given by the intravenous route in the last 48 hrs of their life according to internal guidelines. The annual frequency to apply sedation increased continuously from 7% in 1995 to 19% in 2002. Main indications shifted from refractory control of physical symptoms (dyspnoea, gastrointestinal, pain, bleeding and agitated delirium) to more psychological distress (panic-stricken fear, severe depression, refractory insomnia and other forms of affective decompensation). Patients' and relatives' requests for sedation in the final phase were significantly more frequent during the period 2000–2002.ConclusionSedation in the terminal or final phase of life plays an increasing role in the management of intractable physical and psychological distress. Ethical concerns are raised by patients' requests and needs on the one hand, and the physicians' self-understanding on the other hand. Hence, ethically acceptable criteria and guidelines for the decision making are needed with special regard to the nature of refractory and intolerable symptoms, patients' informed consent and personal needs, the goals and aims of medical sedation in end-of-life care.
Highlights
The administration of sedatives in terminally ill patients becomes an increasingly feasible medical option in end-of-life care
The problems associated with sedation in end-of-life care and the different attitudes among clinicians and palliative care experts are reflected in inconsistent terminology [5], variation in techniques used to induce, maintain and monitor sedation [6], duration of and frequency of application, different concepts on the time of administering sedation and on intentions [7]
The results of our study indicate that sedation in end-oflife care seems to become an increasing ethical problem with attention to patients' wishes and needs and physicians' integrity
Summary
The administration of sedatives in terminally ill patients becomes an increasingly feasible medical option in end-of-life care. Sedation in the final stage of life is a controversial issue in palliative care with regard to medical and non-medical indications, decision-making and ethical implications. It is widely agreed, even though this is controversial too, that in patients with advanced cancer and other terminal (page number not for citation purposes). Some think that sedation leading to unconsciousness should be an option, or an alternative, for terminally ill patients with intolerable suffering if they request euthanasia or physician assisted suicide [2,3,4] or for those who just want "to die in sleep". While the ambiguous term "terminal sedation (TS)" [8,9] is used most often, other terms more clearly reflect the different viewpoints: "sedation for intractable distress in the imminently dying [10,11];", end-of-life sedation [12] "slow-euthanasia" [13], "palliative sedation" [14], "total sedation" [15], "sedation in the final phase", "palliative sedation therapy" [16]
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