Palliative Sedation: Myth vs. Fact
The belief that symptom management hastens death in the dying is a classic example of confusing an association with causation. It is a fact that many people have distressing symptoms while dying—for example, pain, shortness of breath, nausea, restlessness and agitation. Treatment of these symptoms is for the purpose of providing relief. The fact that dying people require symptom relief does not mean that symptom relief causes death. Studies demonstrate that symptom relief near death does not hasten death. To the contrary, untreated symptoms such as pain, stress and anxiety lead to worsening strain and exhaustion in patients and family members alike. Intractable pain itself, in fact, may hasten death.
Health care providers have a responsibility to do no harm and to relieve suffering. This is as true with palliative sedation as with any other aspect of medical treatment. In the United States, Supreme Court rulings (Vacco v. Quill, 1997 and Washington v. Glucksberg, 1997) supported the concept of sedation when used to relieve intractable suffering.
Myth: Palliative sedation hastens death.
Fact: It is disease progression that causes the body to gradually shut down and eventually die. Patients with poorly controlled pain, shortness of breath, and agitation actually die sooner because of the stress caused by this suffering. Studies clearly demonstrate that palliative sedation does not hasten death. Research showing that patients at the very end of life who receive palliative sedation do not die more quickly than patients who are not sedated has been published in such top tier peer reviewed professional journals as Annals of Oncology, Journal of Palliative Medicine, Journal of Pain and Symptom Management, Archives of Internal Medicine, and Palliative Medicine. (A bibliography of these articles is available from NHPCO.)
Myth: Palliative sedation is common and widely used.
Fact: Palliative sedation is a treatment of last resort when symptom distress cannot be relieved using standard methods. It is used extremely rarely because the vast majority of patients get acceptable relief without sedation.
Myth: There are no universally accepted protocols for treating people in the last weeks of life.
Fact: Much has happened in the last six years. Multiple protocols and guidelines for medical care during the last hours of living exist on the websites of major health and palliative care organizations and medical journals and textbooks have clear guidelines. The American Academy of Hospice and Palliative Medicine (AAHPM) has a specific position statement on palliative sedation, including a definition. The National Hospice and Palliative Care Organization also offers a statement on palliative sedation.
Myth: Patients in a coma feel pain.
Fact: People in a coma—medically induced or natural—do not feel pain.
Myth: Palliative sedation promotes dehydration and starvation.
Fact: When people are at the very end of life, their bodies are shutting down and unable to absorb and digest food and water. It is progression of disease, not sedation that causes the body to reject food and water.
Myth: Artificial nutrition and hydration prolongs life and reduces suffering.
Fact: Data have shown that artificial nutrition and hydration do not prolong life in the dying, and in fact, may hasten death by causing fluid overload in the skin, the lungs, and the GI tract, resulting in shortness of breath, total body swelling, diarrhea, and nausea and vomiting, among other symptoms.
References
- Cherny NI. The use of sedation in the management of refractory pain. Principles and practice of supportive oncology Updates. 2000; 3:1-11.
- Cherny NI, Portenoy RK. Sedation in the management of refractory symptoms: guidelines for evaluation and treatment. J Pal. Care. 1994; 10:31-38.
- Charter S, et al. Sedation for intractable distress in the dying-a survey of experts. Pall Med. 1998; 12:255-269.
- Braun TC, et al. Development of a clinical practice guideline for palliative sedation. J Pall Med. 2003; 6:345-350.
- Hallenbeck J. Terminal sedation for intractable distress. West J Med. 1999; 171(4):222-3.
- Muller-Busch H, et al. Sedation in palliative care - a critical analysis of 7 years experience. BMC Palliative Care. 2003; 2(1):2.
# # #
The Center to Advance Palliative Care (CAPC) provides health care professionals with the tools, training, and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings. Located at Mount Sinai School of Medicine, CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious illness. www.capc.org
Contact: Lisa Morgan, LDM Strategies, 212-924-6182 or [email protected].