Correspondence
Terminal Sedation
N Engl J Med 1998; 338:1230-1231April 23, 1998
- Article
To the Editor:
In attempting to equate the medical practice of terminal sedation with euthanasia, Orentlicher (Oct. 23 issue)1 argues from the premise that terminal sedation can be a form of euthanasia, but his conclusions follow only if terminal sedation is a form of euthanasia. He admits that terminal sedation may not be morally equivalent to euthanasia under certain circumstances, yet he insists on stating that “terminal sedation is often a type of euthanasia.” Such a claim is empirical and should be demonstrable, but the author offers no evidence in support of it.
Furthermore, the moral link between euthanasia and terminal sedation would not be made even if he could provide such evidence. Poorly done surgery may be morally equivalent to battery and bad psychotherapy may represent a form of abuse, yet it is erroneous to argue that surgery and psychotherapy are morally untenable practices as a consequence. If a medical practice is often carried out in an ethically indefensible manner, then practitioners are morally culpable and the profession is obligated to seek a remedy. If people are being subjected to euthanasia under the guise of terminal sedation, as the author implies, then we must bring such abuses to light and eliminate the practice. It is hard to see how legalizing physician-assisted suicide alone will have any serious effect on such behavior.
1 ReferencesMark R. Tonelli, M.D.
University of Washington, Seattle, WA 981951
Orentlicher D . The Supreme Court and physician-assisted suicide -- rejecting assisted suicide but embracing euthanasia. N Engl J Med 1997;337:1236-1239
Full Text | Web of Science | Medline
To the Editor:
In his analysis of the Supreme Court's ruling on assisted suicide, Dr. Orentlicher assumes, as did the Court, that terminal sedation shortens life. In most cases, this is probably not true. What little research has been done1-3 suggests that the use of sedation in someone who is dying is largely irrelevant to the timing of death, though it may prolong life slightly. Patients who now spend their last hours or days sedated are very sick. Even before they are sedated, these patients are not eating or drinking substantial amounts, and artificial hydration or nutrition is usually contraindicated because it would increase the risk of pulmonary edema and other adverse effects. Patients are also often restless, delirious, or anguished. Left alone, they would die in part from exhaustion.
Terminal sedation is not ordinarily the choice of an awake and thoughtful person. Rather, it is usually instituted after trials of reduced dosages, alternative medications, or adjuvant medications fail to provide adequate pain management. It is easy to distinguish euthanasia from the current practice of sedation near the time of death. The physician cannot know whether sedation slightly prolongs or shortens the life of a patient who is near death and who must be asleep to be comfortable. Furthermore, even if the patient were likely to survive in this manner for a few weeks, the physician would not be justified in stepping in to accelerate dying. In contrast, for euthanasia, the physician's goal would be to accelerate dying and a patient's failure to die would prompt further intervention.
Sedation in patients near death entails challenges that guarantee that it will not be lightly chosen. Physicians who are not experienced in managing sedation for those near death may not realize how difficult it is. The physician must stay closely involved, reassessing symptoms and medications, avoiding oversedation and complications while also avoiding a recurrence of suffering. The family and care-giving team need explanations, reassurance, support, and help planning for bereavement. In contrast, euthanasia seems likely to be technically easy and quite time-limited.
Furthermore, one must document that other courses of care are inadequate and that acceptance of sedation is proportionate to a serious need. This is a practical way to ensure the law, the public, and the family that the physician is accepting, but not seeking, the patient's death.
3 ReferencesJoanne Lynn, M.D.
Center to Improve Care of the Dying, Washington, DC 20037-18031
Brescia FJ ,Portenoy RK ,Ryan M ,Krasnoff L ,Gray G . Pain, opioid use, and survival in hospitalized patients with advanced cancer. J Clin Oncol 1992;10:149-155
Web of Science | Medline2
Partridge JC ,Wall SN . Analgesia for dying infants whose life support is withdrawn or withheld. Pediatrics 1997;99:76-79
CrossRef | Web of Science | Medline3
Forster LE ,Lynn J . Predicting life span for applicants to inpatient hospice. Arch Intern Med 1988;148:2540-2543
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Orentlicher replies:
To the Editor: As Dr. Lynn suggests, terminal sedation takes many forms. When it is administered to a patient who is in the last hours or days of life and for whom nutrition and hydration are contraindicated, terminal sedation is not euthanasia. In such cases, as Dr. Lynn observes, the sedation probably does not shorten the patient's life. Even if it did, the shortening of life would be permissible under the principle of double effect.
In other cases, however, terminal sedation is a form of euthanasia. In some cases, the patient clearly could live for several more days or even a few weeks, and the patient's life is shortened by the combination of the sedation and the withholding of food and water. The sedation renders the patient unable to eat or drink, and the withholding of food and water results in death by dehydration or starvation.1 In cases in which the inability to eat or drink is caused by the sedation rather than by the patient's illness, we cannot justify the patient's death in terms of the natural progression of disease. Rather, death results from the physician's intentional actions. When this is the case, terminal sedation is a form of euthanasia. Moreover, in these cases, terminal sedation is euthanasia, even though it is performed properly. Dr. Tonelli, then, misunderstands my argument when he characterizes it as being about poorly performed terminal sedation.
Dr. Lynn is confident that terminal sedation will be reserved for truly compelling cases, and she may be correct. However, there is nothing in the practice that ensures this outcome. Any patient can be sedated and have nutrition and hydration withheld, whether or not the patient is within hours or days of death and whether or not the patient has already stopped eating and drinking. If we can trust that physicians will use terminal sedation only in cases of serious need in which other care is inadequate, we should also be able to trust that physicians will reserve assisted suicide for such cases.
1 ReferencesDavid Orentlicher, M.D., J.D.
Princeton University, Princeton, NJ 08544-10131
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;278:2099-2104
CrossRef | Web of Science | Medline
- Citing Articles (4)
Citing Articles
1
Sonja Roth
rmel. (2004) Terminale Sedierung aus juristischer Sicht. Ethik in der Medizin 16:4, 349-357
CrossRef2
Ferdinando Cancelli, Marilène Filbet. (2002) La sédation en phase terminale: une expérience à domicile. InfoKara 17:3, 86
CrossRef3
Tai-Yuan Chiu, Wen-Yu Hu, Bee-Horng Lue, Shao-Yi Cheng, Ching-Yu Chen. (2001) Sedation for Refractory Symptoms of Terminal Cancer Patients in Taiwan. Journal of Pain and Symptom Management 21:6, 467-472
CrossRef4
James L. Hallenbeck. (2000) Terminal Sedation: Ethical Implications in Different Situations. Journal of Palliative Medicine 3:3, 313-320
CrossRef
