Terminal sedation (also known as palliative sedation, or sedation for intractable distress in the dying/of a dying patient) is the practice of relieving distress in a terminally ill person in the last hours or days of a patient's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug.

Contents 1 Drugs used 2 Nutrition and fluids 3 Risk assessment 4 Legal position 5 See also 6 External links 7 References

[edit] Drugs used

A typical drug is midazolam, a short acting benzodiazepine. Opioids such as morphine are not used as the primary medicine since they are not effective sedative medications compared to benzodiazepines. However, if a patient was already on an opioid for pain relief, this is continued so pain relief while sedation is achieved. Other medications to be considered include haloperidol, chlorpromazine, pentobarbital, propofol or phenobarbital.

[edit] Nutrition and fluids

As patients undergoing terminal sedation are typically in the last hours or days of their lives, they are not usually eating or drinking significant amounts. There has not been any conclusive studies to demonstrate benefit to initiating artificial nutrition (TPN, tube feedings, etc.) or artificial hydration (subcutaneous or intravenous fluids). Before initiating terminal sedation, a discussion about the risks, benefits and goals of nutrition and fluids is encouraged. In the United Kingdom, however, it is mandatory - not merely encouraged - to have this discussion before withdrawing food and fluids; in the UK not doing so is considered murder.

[edit] Risk assessment

The examples and perspective in this article may not represent a worldwide view of the subject. Please improve this article and discuss the issue on the talk page.

There is no evidence that titrated sedation causes the death of the patient and sedation does not equate with euthanasia. At the end of life sedation is only used if the patient perceives their distress to be unbearable, and there are no other means of relieving that distress. In palliative care the doses of sedatives are titrated (ie. varied) to keep the patient comfortable without compromising respiration or hastening death. For more information on the palliative care use of sedatives and the safe use of opioids see Opioids.

Patients (or their legal representatives) only have the right to refuse treatments in living wills, they cannot demand life saving treatments, or any treatments at all. However, once unconsciousness begins, as the patient is no longer able to decide to stop the sedation or to request food or water, the clinical team can act in the patient's best interests. A Living Will, made when competent, can under UK law, give a directive that they refuse 'Palliative Care' or 'Terminal Sedation', or 'any drug likely to suppress my respiration'.

[edit] Legal position

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Terminal sedation is legal in the United States of America. In 2008, the American Medical Association Council on Ethical and Judicial Affairs approved an ethical policy regarding the practice of palliative sedation.^[1][2] According to the principle of double effect such treatment is ethically justified if a doctor administers the drug with the intention to alleviate pain/suffering. The defense of double effect is only open to medical practitioners.

Terminal sedation is illegal in the UK.^{[citation needed]} Significant advances in analgesia made over the past 30 years may now mean there is no need whatsoever to administer any opiate or opioid drug in potentially life-threatening dosages to alleviate pain, as many alternatives with no lethal side effects are available; as a consequence, the pretense of the 'double effect' defense may be seen as invalidated by some.

[edit] See also

• Uniform Rights of the Terminally Ill Act (USA)
• Principle of double effect
• Opioid
• Liverpool Care Pathway - Standard UK NHS care guidance for dying terminal patients

[edit] External links

• "Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids", American College of Physicians
• "Terminal Sedation", The World Federation of Right to Die Societies
• Discussion Forum, European Association for Palliative Care

[edit] References