Palliative opioid use, palliative sedation and euthanasia: reaffirming the distinction

Abstract

We read with interest the extended essay published from Riisfeldt and are encouraged by an empirical ethics article which attempts to ground theory and its claims in the real world. However, such attempts also have real-world consequences. We are concerned to read the paper’s conclusion that clinical evidence weakens the distinction between euthanasia and normal palliative care prescribing. This is important. Globally, the most significant barrier to adequate symptom control in people with life-limiting illness is poor access to opioid analgesia. Opiophobia makes clinicians reluctant to prescribe and their patients reluctant to take opioids that might provide significant improvements in quality of life. We argue that the evidence base for the safety of opioid prescribing is broader than that presented, restricting the search to palliative care literature produces significant bias as safety experience and literature for opioids and sedatives exists in many fields. This is not acknowledged in the synthesis presented. By considering additional evidence, we reject the need for agnosticism and reaffirm that palliative opioid prescribing is safe. Second, palliative sedation in a clinical context is a poorly defined concept covering multiple interventions and treatment intentions. We detail these and show that continuous deep palliative sedation (CDPS) is a specific practice that remains controversial globally and is not considered routine practice. Rejecting agnosticism towards opioids and excluding CDPS from the definition of routine care allows the rejection of Riisfeldt’s headline conclusion. On these grounds, we reaffirm the important distinction between palliative care prescribing and euthanasia in practice.

A response to critics: weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation

“…Schofield et al 2 argue that my literature review excludes evidence regarding the safety of opioid and sedative use outside of the palliative care setting, and that this has introduced a cherry-picking bias and skewed the results. I agree with the authors that in other settings the safety of opioids and sedatives has been clearly established, for instance the large quoted range of daily oral morphine equivalent which is sometimes required and well tolerated (although note that the 21 600 mg was an outlier and the next highest dose in the study described was 720 mg) 6.…”

“…My recent essay ‘Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation’1 has generated some critique, notably from Schofield et al ,2 Materstvedt,3 Symons4 and Giebel,5 which together span most of the arguments originally presented. In this response I will explore these concerns.…”

While I breathe, I hope. Principles of palliative care in chronic breathlessness and advanced lung diseases

“…Palliative sedation has been shown not to shorten life and should be regarded for a form of symptom control for severe symptoms. It is not a treatment to hasten death nor as a kind of slow euthanasia [21]. Benzodiazepines are not intended as a routine medication for breathlessness but serve as a second-or third-line therapy, benefitting patients through their anxiolytic actions [22].…”

The concise argument

“…A sensitivity to the specific context is crucial, so that approvals do not impose a 'one-size-fits-all' template on research projects and, as has been often noted, this is something that ethical approval procedures have often struggled with. 11 Along with encouraging debate in the form of responses and commentaries on articles, see the responses to Riisfeldt's article, [12][13][14][15][16] Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation 17 and his reply, 18 we also encourage medical students and students of related disciplines to submit to the journal. In this issue we have a student essay by Conan, on frequently overlooked realistic moral bio-enhancement interventions.…”

“…Along with encouraging debate in the form of responses and commentaries on articles, see the responses to Riisfeldt’s article,12–16 Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation17 and his reply,18 we also encourage medical students and students of related disciplines to submit to the journal. In this issue we have a student essay by Conan, on frequently overlooked realistic moral bio-enhancement interventions 19.…”