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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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56. Terminal/Palliative Sedation
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Death is a friend that alone can bring the peace that treasures cannot purchase and remove the pain that medical practitioners cannot cure.
~ Mortimer Collins
Sedation Secrets
Terminal/Palliative Sedation in End-of-Life Care
It was a typical day on the palliative care unit at the hospital. Dr. Smith, a seasoned palliative care specialist, was reviewing the charts of her patients when she noticed something unusual. One of her patients, Mr. Johnson, had been showing signs of increasing distress and discomfort despite the high doses of pain medication he was receiving. Dr. Smith knew that Mr. Johnson was in the final stages of his illness, and she was concerned that his symptoms were becoming refractory, meaning that they could not be adequately controlled with the current medications.
Dr. Smith decided to consult with the hospital’s ethics committee to discuss the possibility of terminal sedation for Mr. Johnson. She knew that this was a delicate issue, and she wanted to make sure that all ethical and legal considerations were taken into account.
The ethics committee met to discuss the case. They reviewed the medical records and consulted with Mr. Johnson’s family and caregivers. They concluded that terminal sedation was a reasonable option to consider given Mr. Johnson’s deteriorating condition.
Dr. Smith sat down with Mr. Johnson’s daughter, who was acting as his surrogate, to discuss the possibility of terminal sedation. She explained that the goal of terminal sedation was to improve Mr. Johnson’s quality of life by relieving his refractory symptoms, not to hasten his death. She also explained that continuous sedation to unconsciousness (CSU) was a permanent and irrevocable decision, and that Mr. Johnson would no longer be able to interact with others or experience lucidity of mind.
After careful consideration, Mr. Johnson’s daughter decided that terminal sedation was the best option for her father. She understood that the decision was permanent, but she felt that it was the most compassionate choice given her father’s suffering.
Dr. Smith and the palliative care team began administering medication to Mr. Johnson to decrease his consciousness and relieve his symptoms. They monitored him closely to ensure that he remained comfortable and free from pain.
Mr. Johnson’s condition continued to decline, and he eventually slipped into unconsciousness. He passed away peacefully a few days later, surrounded by his family.
Dr. Smith used Mr. Johnson’s case as a teachable moment for her medical students and healthcare providers. She emphasized the importance of informed consent and the responsibility of medical practitioners and surrogates to act in the patient’s best interests while following the principles of beneficence and nonmaleficence. She also highlighted the evolving consensus around the use of the term “palliative sedation” to avoid confusion with euthanasia.
Through this case, Dr. Smith and her team were able to provide compassionate care to Mr. Johnson in his final days while also educating others about the important role of terminal/palliative sedation in end-of-life care.
Abstract
Terminal sedation, also referred to as palliative sedation, is a medical practice where medication is used to relieve refractory symptoms and decrease a patient’s consciousness in the final stages of life. The aim of terminal sedation is to improve the quality of life by reducing suffering and not hastening death. It is considered morally acceptable by many professional associations, including the American Medical Association (AMA) and American College of Physicians (ACP). Informed consent is essential for the practice of terminal sedation, and the decision to undergo continuous sedation to unconsciousness (CSU) is considered permanent and irrevocable. The medical practitioner and surrogate’s responsibility is to act in the patient’s best interests, in accordance with the patient’s reasonable goals, values, and priorities, while following the principles of beneficence and nonmaleficence. The decision to undergo CSU will result in the ending of the patient’s ability to interact with others and experience lucidity of mind.
**
Think
[56:1] Terminal sedation, also known as palliative sedation, is morally accepted by the American Medical Association (AMA), American College of Physicians (ACP), Veterans Administration (VA), and many other professional associations. It is agreed that terminal sedation is not a form of “slow” euthanasia.
[56:2] Terminal sedation is the use of medication to decrease a patient’s consciousness to relieve refractory symptoms making the final stages of dying more tolerable. The goal is to increase the quality and quantity of life by decreasing suffering and not to hasten death. 96% of all terminal sedation are for patients who have less than seven days to live, and 40% of that group have less than 24 hours to live.
[56:3] In comparison with Topic 5. Assisted Suicide, Topic 14. The Doctrine of Double Effect, and Topic 17. Euthanasia, terminal sedation is a relatively new concept first appearing in medical literature in 1991. The word terminal refers to end-of-life care, not that the sedation is terminal in its effect. However, because of such misunderstandings, there is an evolving consensus for the term “palliative sedation therapy” or simply “palliative sedation” should be the new preferred terminology.
Assess
Patient: 1) Autonomy
[56:4] Patient autonomy requires that the patient or surrogate provide informed consent authorizing the practitioner to provide palliative sedation. This means that the practitioner has instructed the patient or the patient’s surrogate about the diagnosis, prognosis, treatment options, risk of harm and benefits of sedation, answered all their questions, and is assured that the patient or surrogate is freely making their decision without coercion or manipulation.
[56:5] If a patient decides for intermittent sedation to unconsciousness, then a designated duration of sedation will be established, after which the patient, or surrogate, will be able to reassess autonomously what to do next.
[56:6] If a patient decides for continuous sedation to unconsciousness (CSU), then the designated duration will be until death, meaning that the patient will have made an autonomous decision never to be autonomous again. The decision for continuous sedation to unconsciousness (CSU) is permanent and irrevocable.
[56:7] However, in reality, by the time the patient has reached the stage in which the symptoms are medically refractory and intolerable by any other means other than by sedation, most patients will already be in a state of diminished decisional capacity and will be at most days if not just hours away from death. Under these conditions, the surrogate will need to make a medical decision in accordance with the patient’s reasonable goals, values, and priorities. If death is imminent, then the possibility of shortening the patient’s quantity of life will at most be minimal, making it much easier for the surrogate to focus on the patient’s quality of life rather than quantity of life.
[56:8] The patient or surrogate must understand that when deciding for continuous sedation to unconsciousness (CSU), the patient will no longer be able to drink or eat. Without medically administered nutrition and hydration (MANH), the patient will die within two weeks. 96% of patients who have continuous sedation to unconsciousness (CSU) die within seven days. Therefore, most patients and surrogates refuse medically administered nutrition and hydration (MANH). If the patient dies in less than two weeks, then the disease is the proximate cause of death. If the patient dies after two weeks, then the absence of medically administered nutrition and hydration (MANH) was the proximate cause of death.
[56:9] Autonomy, or self-rule, is essential for defining the human condition. The consequence of continuous sedation to unconsciousness (CSU) is the ending of the ability to ever again experience; one’s goals, values, and priorities; interact with family, friends, and others; and most importantly, to have lucidity of mind. Once continuous sedation to unconsciousness (CSU) has commenced, for the patient there is no mental or sociological difference between continuous sedation to unconsciousness (CSU) and death. Patients, therefore, need to be clear to their practitioner and surrogate(s) the extent to which they are willing to sacrifice their ability to interact with family and friends and sacrifice lucidity of mind for the relief of pain and suffering. If the patient has already lost their decisional capacity, lucidity of mind, and the ability to interact with family and friends, then such considerations become irrelevant.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[56:10] The medical practitioner’s professional responsibility and the surrogate’s role for the patient are to maximize the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities using the principles of beneficence (do good) and nonmaleficence (do no harm). The best way to determine the patient’s best interests is by the patient providing informed consent, a living will, or a surrogate through the use of a durable power of attorney for medical care (POA). Ideally, a living will had been created while the patient was in good health and able to express their wishes. If the patient’s reasonable goals, values, and priorities are not known or available, then the practitioner and surrogate must promote the patient’s best interests in accordance with medical standards of care.
[56:11] If medical practitioners have a moral obligation to reduce suffering, then there is a moral obligation to provide proportionate sedation if other treatment methods are failing. With continuous sedation to unconsciousness (CSU), because 96% of continuous sedation to unconsciousness (CSU) patients die within seven days, and 40% of that group die within 24 hours, it logically follows that continuous sedation to unconsciousness (CSU) is not a type of slow euthanasia. Every medical profession considers euthanasia incompatible with the medical profession’s mission, purpose, and vision. Continuous sedation to unconsciousness (CSU) for imminently terminal patients is within the medical standards of care for the American Medical Association (AMA), American College of Physicians (ACP), Veterans Administration (VA), and a host of other medical associations.
Public Policy: 4) Justice
[56:12] Terminal sedation, or palliative sedation, is legal everywhere, meaning that it is legal in every country in the world and every state in the United States. Any moral opposition to palliative sedation is personal, not religious, institutional, or governmental. Those opposed to palliative sedation usually do so because of the mistaken “fuzzy, gray and conflated” boundary between terminal sedation and “slow” euthanasia or aid-in-dying.
Conclude
[56:13] Terminal sedation is the use of medication to decrease a patient’s consciousness to relieve refractory symptoms making the final stages of dying more tolerable. Terminal sedation is not a form of “slow” euthanasia because most patients will be at most days if not just hours away from death.
[56:14] In summary, terminal sedation is a valuable medical practice that can make the final stages of dying more tolerable for patients experiencing refractory symptoms. This approach is not considered a form of “slow” euthanasia, as it aims to improve the quality of life without hastening death. With informed consent and a focus on the principles of beneficence and nonmaleficence, terminal sedation can be an ethical and compassionate option for patients nearing the end of life.
**
56. Review Questions
1. Terminal sedation, also known as palliative sedation, is morally accepted by the American Medical Association (AMA), American College of Physicians (ACP), Veterans Administration (VA), and a host of other professional associations.
2. Terminal sedation is a form of “slow” euthanasia.
3. Terminal sedation is the use of medication to decrease a patient’s consciousness to relieve refractory symptoms making the final stages of life more tolerable.
4. The word terminal, in terminal sedation, refers to end-of-life care, not that the sedation is terminal in its effect. Because of such misunderstandings, there is an evolving consensus for the term “palliative sedation therapy” or simply “palliative sedation” as the new preferred terminology.
5. If a patient decides for continuous sedation to unconsciousness (CSU), then the designated duration will be until death, meaning that the patient will have made an autonomous decision never to be autonomous again.
6. 96% of patients who have continuous sedation to unconsciousness (CSU) die within seven days. Therefore, most patients and surrogates request to have medically administered nutrition and hydration (MANH).
7. Because 96% of continuous sedation to unconsciousness (CSU) patients die within seven days, and 40% of that group die within 24 hours, it logically follows that continuous sedation to unconsciousness (CSU) is a type of slow euthanasia.
8. Moral opposition to palliative sedation is generally religious, institutional, or governmental.
**
Wrong 😕
[56:1] Terminal sedation, also known as palliative sedation, is morally accepted by the American Medical Association (AMA), American College of Physicians (ACP), Veterans Administration (VA), and many other hospice and palliative care professional associations. It is agreed that terminal sedation is not a form of “slow” euthanasia.
CORRECT! 🙂
[56:1] Terminal sedation, also known as palliative sedation, is morally accepted by the American Medical Association (AMA), American College of Physicians (ACP), Veterans Administration (VA), and many other hospice and palliative care professional associations. It is agreed that terminal sedation is not a form of “slow” euthanasia.
CORRECT! 🙂
[56:1] Terminal sedation, also known as palliative sedation, is morally accepted by the American Medical Association (AMA), American College of Physicians (ACP), Veterans Administration (VA), and many other hospice and palliative care professional associations. It is agreed that terminal sedation is not a form of “slow” euthanasia.
Wrong 😕
[56:1] Terminal sedation, also known as palliative sedation, is morally accepted by the American Medical Association (AMA), American College of Physicians (ACP), Veterans Administration (VA), and many other hospice and palliative care professional associations. It is agreed that terminal sedation is not a form of “slow” euthanasia.
CORRECT! 🙂
[56:2] Terminal sedation is the use of medication to decrease a patient’s consciousness to relieve refractory symptoms making the final stages of life more tolerable. The goal is to increase the quality and quantity of life by decreasing suffering and not hastening death. 96% of all terminal sedation are for patients who have less than seven days to live, and 40% of that group have less than 24 hours to live.
Wrong 😕
[56:2] Terminal sedation is the use of medication to decrease a patient’s consciousness to relieve refractory symptoms making the final stages of life more tolerable. The goal is to increase the quality and quantity of life by decreasing suffering and not hastening death. 96% of all terminal sedation are for patients who have less than seven days to live, and 40% of that group have less than 24 hours to live.
CORRECT! 🙂
[56:6] If a patient decides for continuous sedation to unconsciousness (CSU), then the designated duration will be until death, meaning that the patient will have made an autonomous decision never to be autonomous again. The decision for continuous sedation to unconsciousness (CSU) is permanent and irrevocable.
CORRECT! 🙂
[56:3] In comparison with 5. Assisted Suicide, 14. The Doctrine of Double Effect, and 17. Euthanasia, terminal sedation is a relatively new concept first appearing in medical literature in 1991. The word terminal refers to end-of-life care, not that the sedation is terminal in its effect. However, because of such misunderstandings, there is an evolving consensus for the term “palliative sedation therapy” or simply “palliative sedation” as the new preferred terminology.
Wrong 😕
[56:3] In comparison with 5. Assisted Suicide, 14. The Doctrine of Double Effect, and 17. Euthanasia, terminal sedation is a relatively new concept first appearing in medical literature in 1991. The word terminal refers to end-of-life care, not that the sedation is terminal in its effect. However, because of such misunderstandings, there is an evolving consensus for the term “palliative sedation therapy” or simply “palliative sedation” as the new preferred terminology.
Wrong 😕
[56:6] If a patient decides for continuous sedation to unconsciousness (CSU), then the designated duration will be until death, meaning that the patient will have made an autonomous decision never to be autonomous again. The decision for continuous sedation to unconsciousness (CSU) is permanent and irrevocable.
Wrong 😕
[56:8] The patient or surrogate must understand that when deciding for continuous sedation to unconsciousness (CSU), the patient will no longer be able to drink or eat. Without medically administered nutrition and hydration (MANH), the patient will die within two weeks. 96% of patients who have continuous sedation to unconsciousness (CSU) die within seven days. Therefore, most patients and surrogates refuse medically administered nutrition and hydration (MANH). If the patient dies in less than two weeks, then the disease is the proximate cause of death. If the patient dies after two weeks, then the the absence of medically administered nutrition and hydration (MANH) was the proximate cause of death.
CORRECT! 🙂
[56:8] The patient or surrogate must understand that when deciding for continuous sedation to unconsciousness (CSU), the patient will no longer be able to drink or eat. Without medically administered nutrition and hydration (MANH), the patient will die within two weeks. 96% of patients who have continuous sedation to unconsciousness (CSU) die within seven days. Therefore, most patients and surrogates refuse medically administered nutrition and hydration (MANH). If the patient dies in less than two weeks, then the disease is the proximate cause of death. If the patient dies after two weeks, then the the absence of medically administered nutrition and hydration (MANH) was the proximate cause of death.
Wrong 😕
[56:11] If practitioners have a moral obligation to reduce suffering, then there is a moral obligation to provide proportionate sedation if other treatment methods are failing. With continuous sedation to unconsciousness (CSU), because 96% of continuous sedation to unconsciousness (CSU) patients die within seven days, and 40% of that group die within 24 hours, it logically follows that continuous sedation to unconsciousness (CSU) is not a type of slow euthanasia. Every medical profession considers euthanasia incompatible with the medical profession’s mission, purpose, and vision. Continuous sedation to unconsciousness (CSU) for imminently terminal patients is within the medical standards of care for the American Medical Association (AMA), American College of Physicians (ACP), Veterans Administration (VA), and a host of other medical associations.
CORRECT! 🙂
[56:11] If practitioners have a moral obligation to reduce suffering, then there is a moral obligation to provide proportionate sedation if other treatment methods are failing. With continuous sedation to unconsciousness (CSU), because 96% of continuous sedation to unconsciousness (CSU) patients die within seven days, and 40% of that group die within 24 hours, it logically follows that continuous sedation to unconsciousness (CSU) is not a type of slow euthanasia. Every medical profession considers euthanasia incompatible with the medical profession’s mission, purpose, and vision. Continuous sedation to unconsciousness (CSU) for imminently terminal patients is within the medical standards of care for the American Medical Association (AMA), American College of Physicians (ACP), Veterans Administration (VA), and a host of other medical associations.
Wrong 😕
[56:12] Terminal sedation, or palliative sedation, is legal everywhere, meaning that it is legal in every country in the world and every state in the United States. Any moral opposition to palliative sedation is personal, not religious, institutional, or governmental. Those opposed to palliative sedation usually do so because of the mistaken “fuzzy, gray and conflated” boundary between terminal sedation and “slow” euthanasia or aid-in-dying.
CORRECT! 🙂
[56:12] Terminal sedation, or palliative sedation, is legal everywhere, meaning that it is legal in every country in the world and every state in the United States. Any moral opposition to palliative sedation is personal, not religious, institutional, or governmental. Those opposed to palliative sedation usually do so because of the mistaken “fuzzy, gray and conflated” boundary between terminal sedation and “slow” euthanasia or aid-in-dying.
56. Clinical Vignettes
1. Mr. Robert Edwards is a 75-year-old retired engineer who was diagnosed with pancreatic cancer that has metastasized to his liver. Despite receiving chemotherapy, Mr. Edwards has developed severe abdominal pain and nausea that has become intolerable. He is unable to eat or drink and is losing weight rapidly. His medical team has tried various medications to alleviate his symptoms, but they have been unsuccessful. Mr. Edwards and the medical team are considering terminal sedation to relieve his pain and suffering. What is the ethical question in this case?
2. Mr. James Johnson is a 75-year-old retired construction worker who has been battling pancreatic cancer for the past year. He is currently under hospice care and experiencing excruciating pain, nausea, and difficulty breathing despite aggressive symptom management. His medical team recommends continuous sedation to unconsciousness (CSU) to provide him with relief. Mr. Johnson's daughter, who is his healthcare surrogate, is struggling to make the decision as she fears that the CSU will hasten his death. What ethical question arises in this scenario?
3. Ms. Isabella Hunter is a 68-year-old woman with advanced pancreatic cancer that has metastasized to her liver. She has been receiving hospice care for several weeks and her symptoms, including pain, nausea, and shortness of breath, have been managed with medications. However, in the past few days, her pain has become increasingly difficult to control, even with the highest doses of opioids. Ms. Hunter is feeling very distressed and requests to be sedated until she passes away. What is the most appropriate action for the medical team to take?
4. Mr. Robert Martin is a 72-year-old retired electrician who has been recently diagnosed with stage IV pancreatic cancer. He has been experiencing severe abdominal pain, nausea, and vomiting, despite multiple rounds of chemotherapy. He is now bedridden and has lost significant weight. His medical team has recommended terminal sedation to relieve his symptoms, but Mr. Martin is hesitant to undergo the procedure as he fears losing control over his decision-making. What ethical principle is involved in this scenario?
5. Mrs. Ryan Cooper is an 80-year-old woman with advanced cancer who is being treated in the hospital for severe pain and other symptoms. She is no longer able to communicate effectively due to her illness, and her family members have been involved in her care decisions. The medical team has informed the family that Mrs. Cooper's pain and suffering can be effectively managed with continuous sedation to unconsciousness (CSU). The family is hesitant to agree to CSU because they feel that it is a form of euthanasia and goes against their religious beliefs. They also worry that Mrs. Cooper may not be able to communicate her wishes if she were to regain consciousness while under sedation.
CORRECT! 🙂
Explanation: The ethical question in this case is whether Mr. Edwards should be given terminal sedation to unconsciousness for relieving his pain and suffering. Terminal sedation is a medical practice used to relieve refractory symptoms in the final stages of life. It is considered morally acceptable by many professional associations and is aimed at reducing suffering and improving the quality of life without hastening death [56:1]. In this case, Mr. Edwards is experiencing severe pain and nausea that is not responding to other treatments, and terminal sedation is being considered as an option to alleviate his suffering. The other options are incorrect, because most patients who undergo continuous sedation to unconsciousness (CSU) will refuse medically administered nutrition and hydration (MANH) and will die within two weeks without it [56:8], because the decision to undergo terminal sedation is a personal one that should be made by the patient or surrogate with informed consent from the medical practitioner [56:4], and because the decision for CSU is permanent and irrevocable [56:6]. In conclusion, Mr. Edwards's medical team should consider the use of terminal sedation to relieve his pain and suffering, which is in line with the principles of beneficence and nonmaleficence [56:10], and the decision to undergo terminal sedation should be made with informed consent from Mr. Edwards or his surrogate, and the medical team should ensure that they are acting in his best interests in accordance with his reasonable goals, values, and priorities [56:4, 56:10].
Wrong 😕
Explanation: The ethical question in this case is whether Mr. Edwards should be given terminal sedation to unconsciousness for relieving his pain and suffering. Terminal sedation is a medical practice used to relieve refractory symptoms in the final stages of life. It is considered morally acceptable by many professional associations and is aimed at reducing suffering and improving the quality of life without hastening death [56:1]. In this case, Mr. Edwards is experiencing severe pain and nausea that is not responding to other treatments, and terminal sedation is being considered as an option to alleviate his suffering. The other options are incorrect, because most patients who undergo continuous sedation to unconsciousness (CSU) will refuse medically administered nutrition and hydration (MANH) and will die within two weeks without it [56:8], because the decision to undergo terminal sedation is a personal one that should be made by the patient or surrogate with informed consent from the medical practitioner [56:4], and because the decision for CSU is permanent and irrevocable [56:6]. In conclusion, Mr. Edwards's medical team should consider the use of terminal sedation to relieve his pain and suffering, which is in line with the principles of beneficence and nonmaleficence [56:10], and the decision to undergo terminal sedation should be made with informed consent from Mr. Edwards or his surrogate, and the medical team should ensure that they are acting in his best interests in accordance with his reasonable goals, values, and priorities [56:4, 56:10].
CORRECT! 🙂
Explanation: The ethical question that arises in this scenario is whether it is ethical to offer continuous sedation to unconsciousness (CSU) if it may hasten the patient's death [56:2]. Continuous sedation to unconsciousness (CSU) is a medical practice aimed at relieving refractory symptoms in terminally ill patients and improving their quality of life by reducing suffering. However, there is a concern that it may hasten death, and this raises ethical issues around the balance between providing comfort to the patient and ensuring that the treatment does not cause harm [56:1]. The other options are incorrect, because continuous sedation to unconsciousness (CSU) is considered necessary in some cases to relieve refractory symptoms in terminally ill patients [56:4], because in cases where the patient has lost decision-making capacity, the surrogate is responsible for making decisions that align with the patient's reasonable goals, values, and priorities [56:7], and because there is no evidence to suggest that patients receiving palliative sedation are at risk of addiction [56:1].
Wrong 😕
Explanation: The ethical question that arises in this scenario is whether it is ethical to offer continuous sedation to unconsciousness (CSU) if it may hasten the patient's death [56:2]. Continuous sedation to unconsciousness (CSU) is a medical practice aimed at relieving refractory symptoms in terminally ill patients and improving their quality of life by reducing suffering. However, there is a concern that it may hasten death, and this raises ethical issues around the balance between providing comfort to the patient and ensuring that the treatment does not cause harm [56:1]. The other options are incorrect, because continuous sedation to unconsciousness (CSU) is considered necessary in some cases to relieve refractory symptoms in terminally ill patients [56:4], because in cases where the patient has lost decision-making capacity, the surrogate is responsible for making decisions that align with the patient's reasonable goals, values, and priorities [56:7], and because there is no evidence to suggest that patients receiving palliative sedation are at risk of addiction [56:1].
Wrong 😕
Explanation: In this scenario, Ms. Hunter is experiencing refractory pain, which is defined as pain that is not adequately controlled despite optimal doses of analgesics and other interventions. The aim of palliative sedation, or CSU, is to relieve her refractory symptoms and improve her quality of life by reducing her suffering, rather than hastening her death [56:1]. Ms. Hunter has the right to make her own medical decisions and has requested sedation, so respecting her autonomy is crucial. Informed consent must be obtained, meaning the medical team must provide information about the risks and benefits of the procedure, as well as alternative options. Once Ms. Hunter has provided informed consent, the medical team can proceed with CSU to relieve her refractory symptoms [56:4]. The other options are not correct, because since Ms. Hunter's pain is refractory, alternative options have already been attempted and proven to be ineffective, because consulting with a palliative care specialist, which may be helpful is not necessary before proceeding with sedation, and because administering sedation intermittently may not adequately relieve Ms. Hunter's refractory symptoms and may not respect her autonomy in choosing to be sedated continuously. Overall, respecting Ms. Hunter's autonomy and providing informed consent, with what is considered to be medical standard of care, before proceeding with CSU is the most appropriate action for the medical team to take in this scenario [56:4].
CORRECT! 🙂
Explanation: In this scenario, Ms. Hunter is experiencing refractory pain, which is defined as pain that is not adequately controlled despite optimal doses of analgesics and other interventions. The aim of palliative sedation, or CSU, is to relieve her refractory symptoms and improve her quality of life by reducing her suffering, rather than hastening her death [56:1]. Ms. Hunter has the right to make her own medical decisions and has requested sedation, so respecting her autonomy is crucial. Informed consent must be obtained, meaning the medical team must provide information about the risks and benefits of the procedure, as well as alternative options. Once Ms. Hunter has provided informed consent, the medical team can proceed with CSU to relieve her refractory symptoms [56:4]. The other options are not correct, because since Ms. Hunter's pain is refractory, alternative options have already been attempted and proven to be ineffective, because consulting with a palliative care specialist, which may be helpful is not necessary before proceeding with sedation, and because administering sedation intermittently may not adequately relieve Ms. Hunter's refractory symptoms and may not respect her autonomy in choosing to be sedated continuously. Overall, respecting Ms. Hunter's autonomy and providing informed consent, with what is considered to be medical standard of care, before proceeding with CSU is the most appropriate action for the medical team to take in this scenario [56:4].
CORRECT! 🙂
Explanation: In this scenario, the ethical principle involved is autonomy. Patient autonomy requires that the patient or surrogate provide informed consent authorizing the practitioner to provide palliative sedation [56:4]. However, Mr. Martin is hesitant to undergo the procedure as he fears losing control over his decision-making. It is essential for the medical practitioner to ensure that Mr. Martin is making an informed decision without coercion or manipulation [56:4]. The decision to undergo continuous sedation to unconsciousness (CSU) is permanent and irrevocable [56:6]. The patient or surrogate must understand that when deciding for continuous sedation to unconsciousness (CSU), the patient will no longer be able to drink or eat, resulting in death within two weeks without medically administered nutrition and hydration (MANH) [56:8]. Therefore, patients need to be clear to their practitioner and surrogate(s) the extent to which they are willing to sacrifice their ability to interact with family and friends and sacrifice lucidity of mind for the relief of pain and suffering [56:9].
Wrong 😕
Explanation: In this scenario, the ethical principle involved is autonomy. Patient autonomy requires that the patient or surrogate provide informed consent authorizing the practitioner to provide palliative sedation [56:4]. However, Mr. Martin is hesitant to undergo the procedure as he fears losing control over his decision-making. It is essential for the medical practitioner to ensure that Mr. Martin is making an informed decision without coercion or manipulation [56:4]. The decision to undergo continuous sedation to unconsciousness (CSU) is permanent and irrevocable [56:6]. The patient or surrogate must understand that when deciding for continuous sedation to unconsciousness (CSU), the patient will no longer be able to drink or eat, resulting in death within two weeks without medically administered nutrition and hydration (MANH) [56:8]. Therefore, patients need to be clear to their practitioner and surrogate(s) the extent to which they are willing to sacrifice their ability to interact with family and friends and sacrifice lucidity of mind for the relief of pain and suffering [56:9].
CORRECT! 🙂
Explanation: From the perspective of the patient's family, there may be religious or cultural beliefs that conflict with the use of CSU [56:1], however, the medical team has a responsibility to provide information about the benefits and risks of all available treatment options, including CSU, to enable the family to make an informed decision [56:4]. The medical team should explain that CSU is not a form of euthanasia [56:2] and that the goal is to manage the patient's symptoms and improve quality of life [56:2]. The team should also reassure the family that if Mrs. Cooper were to regain consciousness, she would be free to reassess her treatment options. Ultimately, the medical team and the family should work together to reach a shared decision that is in Mrs. Cooper's best interests and respects her autonomy [56:10].
Wrong 😕
Explanation: From the perspective of the patient's family, there may be religious or cultural beliefs that conflict with the use of CSU [56:1], however, the medical team has a responsibility to provide information about the benefits and risks of all available treatment options, including CSU, to enable the family to make an informed decision [56:4]. The medical team should explain that CSU is not a form of euthanasia [56:2] and that the goal is to manage the patient's symptoms and improve quality of life [56:2]. The team should also reassure the family that if Mrs. Cooper were to regain consciousness, she would be free to reassess her treatment options. Ultimately, the medical team and the family should work together to reach a shared decision that is in Mrs. Cooper's best interests and respects her autonomy [56:10].
**
56. Reflection Vignettes
1. Dr. Olivia Lee is a 72-year-old internist who is seeing a 65-year-old patient named Mr. Johnson, who has end-stage cancer. During his visit, Mr. Johnson reports that his pain is becoming intolerable, despite previous attempts at pain management. Dr. Lee informs Mr. Johnson that his prognosis is poor, and that he may have only one or two weeks to live. She also mentions the possibility of continuous sedation to unconsciousness (CSU) to manage his refractory symptoms. Mr. Johnson expresses interest in the possibility of CSU, but is concerned about the effects it may have on his ability to interact with his family during his final days. Dr. Lee explains that CSU is a morally acceptable practice endorsed by many professional associations, including the American Medical Association (AMA) and American College of Physicians (ACP), and that informed consent is essential before administering the treatment. She also emphasizes the permanent and irrevocable nature of the decision, and that the patient or surrogate must act in the patient's best interests, in accordance with the patient's goals, values, and priorities, while following the principles of beneficence and nonmaleficence.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Dr. Lisa Rodriguez, a 45-year-old primary care physician, is infuriated with her colleague, Dr. James Thompson, for putting a patient in continuous sedation to unconsciousness (CSU). The patient is an 80-year-old man with end-stage cancer who is suffering from refractory symptoms despite maximal treatment. Dr. Rodriguez argues that CSU is no different than active euthanasia, which is illegal and unprofessional. She believes that the patient should have been provided with palliative care instead. Dr. Rodriguez's differential diagnosis includes a lack of understanding of the differences between CSU and euthanasia, as well as a lack of appreciation for the ethical and legal considerations surrounding end-of-life care.
The argument made by the medical practitioner is incorrect. Continuous sedation to unconsciousness (CSU) is a medically accepted practice that is distinct from active euthanasia. Terminal sedation, also known as palliative sedation, is a medical practice where medication is used to relieve refractory symptoms and decrease a patient’s consciousness in the final stages of life. The aim of terminal sedation is to improve the quality of life by reducing suffering and not hastening death. It is considered morally acceptable by many professional associations, including the American Medical Association (AMA) and American College of Physicians (ACP). In contrast, active euthanasia is the intentional act of ending a patient’s life, which is illegal and considered unethical by most professional medical organizations. Therefore, the practitioner's argument is not supported by the medical evidence and is not consistent with the professional standards of care. It is important for medical practitioners to have a clear understanding of the medical practices they are utilizing and to base their opinions on facts and professional standards, rather than personal biases or beliefs.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
