Discussions often don’t occur on use of sedation at the end of life
U.S. patients rarely proactively informed on options
The justification for sedation, and the openness with which it is discussed, differed in the accounts of respondents from the United States and the Netherlands, according to a 2014 study.1 Researchers did qualitative interviews with 36 physicians in 2007 and 2008. Here are key findings:
• Most Dutch respondents justified the use of sedation by stating that it does not hasten death. Most American respondents indicated that it might hasten death, but that this was justifiable as long as that was not their primary intention.
• Many Dutch respondents indicated that they initiated open discussions about sedation proactively to inform patients about their options and to allow planning. American respondents reported fewer and less-open discussions, mostly occurring late in the dying process and with the patient’s relatives.
"The biggest issue for ethical consideration regarding terminal sedation is around dosing," says Nneka O. Mokwunye, PhD, director of the Center for Ethics and Spiritual Care Department at MedStar Washington Hospital Center in Washington, DC.
"The problems I hear the most from the clinical team are related to their discomfort in giving high doses of morphine and other medications that are known to have the double effect of respiratory suppression," says Mokwunye. "Although it takes a lot to have that side effect,’ oftentimes at the end of life a large continuous dose is needed."
Developing a comfort level with the appropriate dosing of pain medications so that the patient is kept comfortable, and so that the clinical staff feel comfortable, is the main reason for having palliative care clinicians, says Mokwunye.
"The typical ICU [intensive care unit] team benefits from assistance in making good terminal sedation decisions," she says. "A one size fits all’ approach to terminal sedation is not appropriate. Having trained palliative care physicians and nurses helps to improve care."
Bioethicists can help to address the discomfort of the staff, help with the family’s understanding of end-of-life practices, and address any conflict that may arise during this time.
"The bioethicist would also address educational needs to help improve understanding of terminal sedation and how it is a patient autonomy issue, as well as any hospital policies and practices around terminal sedation, including any potential conscientious objection issues," says Mokwunye.
- Rietjens JAC, Voorhees JR, van der Heide A, et al. Approaches to suffering at the end of life: The use of sedation in the USA and Netherlands. J Med Ethics. 2014;40:235-240.
- Nneka O. Mokwunye, PhD, Director, Center for Ethics, Spiritual Care Department, MedStar Washington Hospital Center, Washington, DC. Phone: (202) 877-6211. E-mail: Nneka.O.Mokwunye@Medstar.net.