1. Jansen LA, Sulmasy DP. “Sedation, alimentation, hydration, and equivocation: careful conversation about care at the end of life” Ann Intern Med. 2002;136:845-9. [PMID: 12044133]. [abstract: http://www.annals.org/cgi/content/abstract/136/11/845 ]

 2. Response of P. Rousseau:

Ann Intern Med  17 December 2002 | Volume 137 Issue 12 | Pages 1009-1010

TO THE EDITOR:

When discussing terminal sedation (more palatably referred to as palliative sedation), Jansen and Sulmasy state that the rule of double effect is morally acceptable if “one does not aim at unconsciousness directly” and “unconsciousness is not the means by which one intends to relieve symptoms.” I contest this interpretation, since unconsciousness is certainly the means to relieve suffering in refractory situations. Consequently, I am perplexed by the authors’ assertions about the moral and therapeutic actions of sedation. If they believe that suffering is not directly relieved by sedation, why sedate?

Jansen and Sulmasy then state that patients should not be sedated for existential suffering, even after other therapeutic interventions have been unsuccessful, because it is tantamount to “physicians ... giving up.” Their realistic concern is that many patients who are initially unresponsive to counseling respond favorably over time and that the need to treat existential suffering with sedation is not sufficient given proportionate reasoning. I understand their argument but believe they trivialize the significance of existential distress. By restricting palliative sedation to physical suffering, they disregard the anguish of existential suffering and, more important, may precipitate further suffering. That said, I argue that anyone sedated for existential distress must be in the advanced stages of a terminal illness with a documented do-not-resuscitate order, should have undergone aggressive psychological or psychiatric intervention, and should first be considered for a trial of respite sedation. In respite sedation, the patient is sedated for a limited period to assess the effect of sedation on existential suffering and the need for further sedative pharmacotherapy. Respite sedation may allow sleep-deprived, anxious patients to regain the ability to deal with existential issues and may thereby preclude the need for continued sedation.

Finally, the authors offer that “sedation of the imminently dying” fulfills the moral approbation of double effect but define “sedation toward death” as “rendering the patient unconscious, not to serve future consciousness but to shorten life.” Such words distort the true character and purpose of palliative sedation. I hope that no physician would use sedation to knowingly and deliberately shorten life, but rather to relieve suffering. Physician intent is intimately bound to the rule of double effect. If sedation is used to shorten life and cause death, it is clearly no longer palliative sedation but euthanasia.  [http://www.annals.org/cgi/content/full/137/12/1009-a ]

3. “Palliative Sedation in the Management of Refractory Symptoms”. Paul Rousseau, MD, The Journal of Supportive Oncology, vol 2, no.2, March/April 2004
[PDF format: http://www.supportiveoncology.net/journal/articles/0202181.pdf ]

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