National Hospice and Palliative Care Organization (NHPCO) Position Statement and Commentary on the Use of Palliative Sedation in Imminently Dying Terminally Ill Patients

Palliative sedation: Why we should be more concerned about the risks that patients experience an uncomfortable death

“…However, in case of refractory symptoms leading to 20 unbearable suffering such as intolerable pain, dyspnea, and delir- 21 ium, a more drastic option may be chosen, known as palliative 22 sedation (Table 1). In these cases, comfort is sought by reducing 23 the patient's level of consciousness [12,23]. Although palliative 24 sedation is ethically controversial and some studies have ques- 25 tioned its efficacy and safety [29], this practice has substantially in- 26 creased.…”

“…Since the aim of palliative sedation is to give optimal comfort 117 but not to hasten death, the principle of proportionality is a pivotal 118 aspect of this treatment and hence, the guidelines state that seda-119 tion should be ''no deeper than necessary to avoid suffering'' 120 [9,11,15,16,23,24]. To meet this principle of proportionality, care-121 givers should carefully titrate the doses of the drugs so that they 122 are high enough to provide comfort but should not hasten death.…”

“…Paradoxically, the inability to report distress might also be 159 aggravated or even blocked by the use of drugs that might abolish 160 potential further communication and even facial expressions [9]. Palliative sedation is normal medical practice and must be clearly distinguished from the termination of life [35] Proportionality: the degree of sedation must not be deeper than necessary to relieve suffering [11,12,23,35] Palliative sedation will not (usually) hasten death (and that is certainly not the intention) [ [24] o ''Monitoring (observational) scales exist but the usefulness of these scales has not been proven'' [16] o ''Presently no particular scale can be recommended'' [16,24] ''Scales involving administration of painful stimuli are not acceptable'' [16] Frequency of monitoring: every 20 minutes until adequate sedation has been reached and then at least once a day [15,16] Nurses have the explicit task to observe, measure, and report [24] 161 Hence, some patients might have subjective phenomenological …”

Palliative Care and Hospice: A Paradigm for End-of-Life Care in Developing Nations

“…Many times all the family needs to hear is that the patient has accepted the diagnosis of the terminal condition and that it is his or her choice to accept hospice care. 19 Hospice treats the patient and the family as a unit and unless both parties understand the principles and the goal of hospice, the services offered will fail to be beneficial to all parties concerned.…”

Assessment of Patient Comfort During Palliative Sedation: Is it always Reliable?

“…However, in cases of severe pain caused by withdrawal of life-sustaining treatment, for example, or where refractory symptoms lead to unbearable suffering such as intolerable pain, dyspnea and delirium, a more drastic option may be chosen, known as palliative sedation (Box 1). In these cases, comfort is sought by reducing the patient's level of consciousness [2,3]. Palliative sedation is ethically controversial because it is viewed by some as a kind of 'slow euthanasia' and because patients are not always involved in the decision-making.…”