palliative sedation: the last resort may not be the best

Gerard S Brungardt, MD, BeL, FACP, FAAHPM Harry Hynes Memorial Hospice; University of Kansas School of Medicine – Wichita, Wichita, KS 67202,
Daniel P. Sulmasy, OFM, MD, PhD, Farr A. Curlin, MD, University of Chicago, Chicago, Il, 60637

We are pleased that Quill et al. recognize a distinction between Proportionate Palliative Sedation (PPS)—vigorous treatment of physical symptoms recognizing that sedation might be a side-effect—and Palliative Sedation to Unconsciousness (PSU)—intending to sedate the patient to unconsciousness.(1) In drafting clinical policies, we encourage maintaining as bright a line as possible between these two types of palliative sedation. While there will always be grey areas, maintaining this distinction and not crossing the line into intentionally sedating patients to unconsciousness will better serve our patients, their families, and our profession.

The authors recognize that sedation for existential suffering is deeply morally controversial. Yet their broad and ambiguous description of the indications for “PSU” already opens the door for sedation for existential suffering. The authors state that “PSU” is “usually initiated” when “continuing consciousness under the circumstances is unacceptable.” Existential suffering is precisely the patient’s awareness (the “continuing consciousness”) of his or her existential situation as a finite, embodied person facing both physical symptoms and the suffering that results from the confrontation with questions of meaning, value, and relationship that dying inevitably occasions.

Over our decades of experience in accompanying dying patients and their families, we have found that it is often the very patient who has significant unaddressed and/or unresolved existential needs who experiences the most refractory physical symptoms. Under the proposal of Quill et al., it would be exactly the patients who most need to have their existential suffering addressed who will be sedated to unconsciousness instead.

A key practical concern is that unconscious patients cannot tell us what they are experiencing. Sedation alone does not always relieve physical symptoms, as data regarding awareness under anesthesia now demonstrate.(2) The patient in the case they describe might still have died in horrific nausea without the ability to complain about it. Using increasing doses of drugs that are active against the symptom, tolerating unconsciousness as a side-effect (PPS), is better suited to patient- centered care.

Proportionate palliative sedation is often a reasonable and morally acceptable approach to treating refractory symptoms at the end of life. Intentionally sedating patients to unconsciousness raises far too many questions to consider it the standard of care such that a clinician or institution should be obliged to explain why they do not offer it.

1. Quill TE, Lo B, Brock DW, Meisel A. Last-resort options for palliative sedation. Ann Intern Med. 2009 Sep 15;151(6):421-4.

2. Davis, MP. Does Palliative Sedation Always Relieve Symptoms? Journal of Palliative Medicine. -Not available-, ahead of print. doi:10.1089/jpm.2009.0148.