Off the Charts

By Judy Schwarz, PhD, RN*  

The NY Times article of 12/26/09 that described use of palliative sedation in hospice institutional settings provided helpful and clinically accurate informative—for the most part. These few notes are meant to address those issues raised by the article that may unduly alarm dying patients, their families, and their clinical caregivers.

1) There is a consensus among palliative care clinicians that “palliative sedation to unconsciousness” (a descriptive term that eliminates some of the visceral reaction elicited by use of the term “terminal sedation”) is an intervention used only when other therapies that do not compromise patient consciousness have failed and the patient continues to experience intolerable and intractable suffering that cannot otherwise be relieved.

2) Use of palliative sedation to unconsciousness has NOT been shown to cause a hastened 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 peer-reviewed journals as Annals of Oncology, Journal of Palliative Medicine, Journal of Pain and Symptom Management, Archives of Internal Medicine, and Palliative Medicine. (In response to the Times article, the National Hospice and Palliative Care Organization has made available a bibliography of these articles.)

This intervention is generally only provided when patients are “imminently” dying (a condition the recognition of which requires experience and clinical judgment) and is distinct from ”respite sedation,” which is used when clinicians plan to awaken a patient from the unconscious state to determine if their suffering has been relieved. It would be clinically inappropriate to awaken a dying patient whose suffering was deemed intractable and intolerable to them.

3) The Times article mentions an article published by Billings and Block in 1996 in the Journal of Palliative Care (vol 12, pp 21-30), an article intended to highlight the inappropriate use of morphine drips that were ordered by some physicians with the intention of causing a merciful death. These two very skilled and experienced palliative care clinicians were attempting to highlight the difference between the appropriate use of palliative sedation, in which the infusion of opiate and sedative is titrated and set to relieve suffering and cause unconsciousness, and “hanging a morphine drip,” in which the infusion rate is continuously increased in order to cause obtundation, respiratory depression, and death.

4) Finally, the one issue that was not addressed in this generally excellent article was the difficulties faced by dying, suffering patients whose symptoms merit use of palliative sedation to unconsciousness but who want to be able to die at home. In my experience, most hospices are unable or unwilling to provide this intervention to suffering patients who want to die comfortably and peacefully in their own homes.

*Schwarz, the author of “Stopping Eating and Drinking,” published in the September 2009 issue of AJN, is a regional clinical coordinator at Compassion and Choices, a nonprofit end-of-life advocacy and consultative organization.