|Year : 2018 | Volume
| Issue : 2 | Page : 87-90
Palliative sedation and ethical dilemma
Juri Salamah1, Sami Ayed Alshammary2, Stuart Brown3
1 Comprehensive Cancer Center, Palliative Care Unit, King Fahad Medical City, Riyadh, Saudi Arabia
2 Comprehensive Cancer Center, Palliative Care Unit, King Fahad Medical City; Centre for Postgraduate Studies in Family Medicine, Ministry of Health, Riyadh, Saudi Arabia
3 Department of Palliative Care, Two Worlds Cancer Collaboration Foundation, Abbotsford, Canada; International Network for Cancer Treatment and Research, Brussels, Belgium
|Date of Web Publication||2-Apr-2018|
Dr. Sami Ayed Alshammary
Comprehensive Cancer Center, Palliative Care Unit, King Fahad Medical City, Riyadh; Centre for Postgraduate Studies in Family Medicine, Ministry of Health, Riyadh
Palliative sedation is a unique concern for the patient as well as the family. It is a difficult serious ethical dilemma for the physicians to handle. The conflicting ethical principles of autonomy, beneficence and nonmaleficence in continuing versus discontinuing all supportive devices raise concerns among health professionals whether this is euthanasia (physician-assisted suicide) or is just prolonging the patient's unnecessary suffering.
Keywords: Ethical, palliative sedation, unnecessary suffering
|How to cite this article:|
Salamah J, Alshammary SA, Brown S. Palliative sedation and ethical dilemma. J Health Spec 2018;6:87-90
| Introduction|| |
A young adolescent male with metastatic osteosarcoma of pelvis, metastasis to lung and bone, was admitted and transferred to the oncology unit with a 'Do Not Resuscitate' (DNR) order. This was discussed by the oncologist with the patient and his family based on his progressive disease.
He was admitted with shortness of breath and was observed sitting in upright position all the time. His numerical scale of shortness of breath was 9/10. This complaint continued to progress despite escalation of morphine which was given regularly (and on an as-needed basis) through the subcutaneous route. Despite the high dose of morphine, his complaint continued to progress. He was shifted to morphine infusion with titration. He was also on an anxiolytic medication but continued to suffer and he experienced fatigue.
All other treatable causes of dyspnoea were excluded. The only cause for his symptom was his metastatic disease. He was fully supported by his family (mother, father, two sisters and two sons). He was the youngest in his family, and it was a great burden for the family to see him suffering.
His Karnofsky PPS was 20% and was given a prognosis that he was imminently dying. Mr. ABD was suffering a lot, so his palliative consultant who was directly attending to his care discussed his case with the members of the multidisciplinary team. They agreed on his plan of palliative sedation (PS) as last resort for him.
The following is a reflective case report on the knowledge and changes in practice attained from this case incident.
| Literature Review|| |
Palliative care is a relatively new medical specialty in Saudi Arabia, but it has shown tremendous growth in the last two decades. The Hospice and Palliative Nurses Association  defines PS as 'the monitored use of medications intended to induce varying degrees of unconsciousness, but not death, for the relief of refractory and unendurable symptoms in imminently dying patients'.
PS was discussed with Mr. ABD and his family, by the palliative consultant, senior registrar and the nurse. It included spiritual care with a background of the Islamic religion. The psychologist was also involved. The patient was mentally capable (was assessed by the team) of making decisions. His mother and father agreed as well with the decision made. On the same day, PS was initiated. He was assessed frequently by the nurse and the members of the multidisciplinary team for titration of the Midazolam infusion.
Mr. ABD's symptoms improved dramatically, but he was deeply on comatose (my concern as this point was is he really not suffering during this period?). After 2 days, his family was concerned when they saw him deeply on comatose. They were afraid that they will not be able to say goodbye to him again and that they were concerned that the patient cannot recite the syahadah, one of the important pillars in Islam, (It is a statement of belief in the presence of God and the Prophet Muhammad) before death. They requested to discontinue the sedation; however, it was against patient's autonomy. (ETHICAL DILEMMA).
Did we act on the patient's best interest? Is it morally acceptable?
Mr. ABD was fully assessed for treatable causes. His suffering was beyond the medication, he was imminently dying, and it was the last resort to relieve his suffering.
The role of PS was to relieve the suffering and to do this in amoral sensibilities to the patient and the people who are involve in his care. In this case, the situation done for the patient and the family and the action done by the multidisciplinary team who were involved in the act was morally justifiable.
The intention in this situation was to relieve the suffering of the terminally ill patient. In Islam, this type of argument is tested and legalised by the principle of intention (called Niyya). That is to say, that the action is judged by the intention behind it.
Did we respect patient autonomy?
Patient's autonomy should be respected (agreement to respect the patient's right to self-determination and contribute in the medical decision), if he is mentally capable. Suffering is a personal experience. The patient was suffering from extreme shortness of breath, and it is the duty of the health-care providers to relieve the patient's suffering without doing any harm. Thus, they should accept the limitation on autonomy if the harm is great.
Patient's autonomy was respected in the beginning, but the problem raised by family to discontinue the PS has led to a lot of ethical dilemma. Mr. ABD and his family consented, but there was no written consent. The documentation in the chart of the patient was very poor. It was written that the PS was accepted by the patient and family but the mental capacity of the patient, the side effect of the medication, and the people who were involved were not documented. The professional integrity of the health-care providers was not preserve because there was no written consent. In addition, the patient's hospital journey and wishes were not clearly documented. The patient's and family's sense of autonomy was not maintained.
The case was discussed with the multidisciplinary team. The agreement was that the patient was deprived from his rights by not having a written consent, and because of poor documentation and insufficient communication. As they did not follow the international guidelines, the decision was to taper the sedation and to see the response of the patient's symptoms. This was discussed with the family. The case was also raised to the ethical committee in the hospital.
In the Asian culture, the family acts as unit of autonomy. Thus, families' autonomy should be respected as well as the patients'. Although they agreed in the beginning, they saw their beloved son dying. They were frustrated that they were not able to say goodbye. The problem which can be seen here is probably poor delivery of communication since PS was discussed but may have not been very well reinforced. The team was supposed to discuss with them clearly that the patient may be unconscious until his death.
Sedation was tapered and discontinued for 2 days, but Mr. ABD was still deeply on comatose, and he did not wake up. His shortness of breath was settled. He looked comfortable, but after couple of days, he passed away without saying goodbye to the family.
Beneficence and non-maleficence
The meaning of beneficence is to promote the good to the patients  and non-maleficence is the guidance to do no harm to patients. Relief of suffering is a key and ethical value in palliative medicine. PS can be provided for Mr. ABD, but a controversy remained whether how can the health-care providers judge if the patients is still suffering if he was on an unconscious state. Some suggested that sedation is more beneficial for doctors and family than patients  and that some patients might get abused by others while he/she is unconscious.
In this case, the good effect was that his refractory symptoms were controlled and he died comfortably. However, the bad effect was that he lost his sense of autonomy (the patient was unconscious), but he autonomously chose to lose his mental capacity. Another issue was the conflict around PS whether it can hasten death.
The doctrine on double effect defines that the good effect must outweigh the bad effect, and the intent should be in good effect and should outweigh the harm. In this case, the bad effect will be allowable. This principle provides the ethical justification of using PS.
Comparative studies between a patient who received PS and those who did not, found that it does not hasten death., One study found that adding sedative in the last 48 h of life does not accelerate death. However, the patient might experience side effects of sedation which include respiratory depression.
The patient in this case study continued to be unconscious despite not being on sedation anymore. He was not in the assisted ventilator. He was only on room air. Probably, his death was result of his disease and not secondary to PS.
After few days of discontinuing sedation, Mr. ABD was actively dying. The discussion was done with his family to withhold the intravenous fluid as the process of end-of-life. This time, all the team was involved. Meeting and reinforcement was done with the family. They agreed and acted on the best interest of the patient.
There are also few studies concerned about the level of consciousness of the patient and nutritional issues, but it is considered morally acceptable if the physician thinks that it is for the benefit of the patients.,, Mr. ABD was off sedation. He was actively dying. Thu, keeping intravenous hydration will cause a lot of chest rattle. Hence, the action was justifiable.
Justice is the need to treat patients well and equally. Mr. ABD received the same treatment as any patient who may have suffered from refractory symptoms. When he was actively dying from cost-effective and for his benefit as any patients in the end of life hydration was withhold. One of the things which was not equally right to similar patients was the poor documentation, poor communication and the failure to follow the PS guidelines.
Legality in this case
The laws in Islam (shariah) allows PS if it seems to be the only feasible option. It was not intended to do euthanasia or assisted-physician suicidal as it is not legal in the religion corresponding to the Holy Book. The main source of regulations for Muslims state that: 'and do not take any human being's life-the (life) which Allah has willed to be sacred-other than in the (pursuit of) justice'.
What could they have done better?
PS is controversial due to the many adverse effect from sedation. The patient is usually unconscious and so is unable to speak with the family. For Muslims, it is important to allow till death, the worship rites or recall of God for the possible long period time before death., The most important role of palliative is to relieve suffering. It is known that physicians' actions are morally justifiable and crucial to respond to suffering.
Therefore, PS is morally acceptable if it conforms to what patients wants. It must be based on his personal intention  apart from the professional intention.
In this case, the physician was a junior, and his knowledge was insufficient about PS. His intention was morally acceptable but commenced a lot of ethical mistakes. This was a lesson to the physician involved in the care including the whole team. Lesson learned was to read a lot about any treatment before initiating it, and to follow the guidelines.
It was decided among the team that if PS will be used, consent must be obtained and multidisciplinary meeting must be conducted before and after the sedation to discuss their ethical points to address cultural sensitivity and emotions. Patients and families will be provided with good communication. Furthermore, educational material or leaflet regarding PS (including the medication, culture, ethical and religious point of view) to be provided to the patient and families will be of great value.
Meeting with family after death will allow them to grieve and ventilate about their feeling at the time of decision-making and after death. Orientation to people inside hospital regarding the use of PS will be useful.
With a framework for PS including life expectancy, quality, refractory symptoms, intention and level of sedation, and with formal consent and guideline to follow PS is considered morally acceptable. Hence, a decision was made to have in the hospital, a guideline with the formal written consent in the system for sedation through the hospital quality committee which is still not approved.
There was a conflict of value when the patient lost autonomy and his family requested to remove sedation. The patient was not suffering anymore. However, queries will now arise regarding other patients. There should be clear rules with respect to culture in this manner.
Some patients cannot express his free will if he is extremely suffering, so therefore, PS is acceptably moral and justifiable if done within framework and guidelines.
| Conclusion|| |
In PS, like all other medical treatments, patients have the right to refuse and withdraw at any time in the future if they decide to. PS would not be considered euthanasia or physician-assisted suicide. It should not be considered any different from withdrawing from a ventilator or total parenteral nutrition. Nevertheless, DNR patients should be offered the right to initiate or stop PS after knowing the risks and benefits from such decisions, although DNR and PS seem mutually exclusive. The patient and their appointed attorneys play a central role in this decision. Palliative care physician and the entire multidisciplinary team perform a vital role in starting patient and family education before initiating PS and at the time of the end of life. The knowledge attained through this reflective process was shared with the multidisciplinary team and the policy-makers in the hospital. The hospital policy will soon be drafted for approval.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Alshammary SA, Abdullah A, Duraisamy BP, Anbar M. Palliative care in Saudi Arabia: Two decades of progress and going strong. J Health Spec 2014;2:59-60. [Full text]
HPNA Position Statement on Palliative Sedation at End of Life. Hospice and Palliative Nurses Association; June, 2003.
Kasule OH. Medical ethics from Maqasid Al Shari'at. Arab J Psychiatry 2004;15:75-6.
Cherny NI, Portenoy RK. Sedation in the management of refractory symptoms: Guidelines for evaluation and treatment. J Palliat Care 1994;10:31-2.
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th
ed. New York: Oxford University Press; 2009. p. 38-9.
Hallenbeck JL. Terminal sedation: Ethical implications in different situations. J Palliat Med 2000;3:313-20.
LaVera C, Koffman J. Ethnic and cultural aspects of palliative care. Oxford Text Book of Palliative Medicine. 5th
ed. Oxford, United Kingdom: Oxford University Press; 2015. p. 84-6.
Gillon R. Medical ethics: Four principles plus attention to scope. Br Med J 1994;309:184-8.
Shaver WA, Rousseau PC. A Challenge to the Ethical Validity of Palliative Sedation. Program and Abstracts of the American Academy of Hospice and Palliative Medicine/Hospice and Palliative Nurses Association Annual Assembly; 2005; New Orleans, Louisiana, Abstract 318; 2005.
Enck RE. Drug-induced terminal sedation for symptomcontrol. Am J Hosp Palliat Care 1991;8:3-5.
Quill TE, Dresser R, Brock DW. The rule of double effect – A critique of its role in end-of-life decision making. N Engl J Med 1997;337:1768-71.
Sykes N, Thorns A. The use of opioids and sedatives at the end of life. Lancet Oncol 2003;4:312-8.
de Graeff A, Dean M. Palliative sedation therapy in the last weeks of life: A literature review and recommendations for standards. J Palliat Med 2007;10:67-85.
Morita T, Tsunoda J, Inoue S, Chihara S. Effects of high dose opioids and sedatives on survival in terminally ill cancer patients. J Pain Symptom Manage 2001;21:282-9.
Billings JA, Block SD. Slow euthanasia. J Palliat Care 1996;12:21-30.
Quill TE, Lo B, Brock DW. Palliative options of last resort: A comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. JAMA 1997;278:2099-104.
Quill TE, Lee BC, Nunn S. Palliative treatments of last resort: Choosing the least harmful alternative. University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel. Ann Intern Med 2000;132:488-93.
Al-Shahri M, Al-Khenaizan A. Palliative care for Muslim patients. J Support Oncol 2005;3:432-6.
van Delden JJ. Terminal sedation: Source of a restless ethical debate. J Med Ethics 2007;33:187-8.
Wanzer SH, Federman DD, Adelstein SJ, Cassel CK, Cassem EH, Cranford RE, et al.
The physician's responsibility toward hopelessly ill patients. A second look. N Engl J Med 1989;320:844-9.
Materstvedt LJ, Bosshard G. Deep and continuous palliative sedation (terminal sedation): Clinical-ethical and philosophical aspects. Lancet Oncol 2009;10:622-7.