Palliative Sedation: Controversial Discussions and Appropriate Practice

Editorial accompanying the article: “Sedatives and Sedation at the End of Life in the Hospital— A Multicenter Retrospective Cohort Study ” by Dr. med. Eva Schildmann MSc. et al. on the following pages

Thirteen years have passed since publication of the “Framework for the Use of Sedation in Palliative Care” by the European Association for Palliative Care (EAPC) (1). The debate about the use of sedative medication to control the symptoms of patients in a palliative situation (so-called palliative sedation) still shows no signs of abating, however; the topic remains controversial and the discussion lively. Primarily (but very importantly) there is a problem of unclear terminology (2): When does the use of sedatives correspond to the concept of “palliative sedation”? Which clinical scenarios and indications are actually meant and which not?

Different premises and many questions

As a rule the therapeutic team has no problem with administering sedatives in situations characterized by agitation, anxiety, and other refractory symptoms in the context of impending death. Perceptions are different, however, if for example a patient who is still completely mobile and far from close to death demands sedation, whether because of bothersome symptoms, existential distress and anxiety, or the desire to avoid consciously experiencing what remains of his or her life (“let me sleep until I die”) (3). Is it medically, legally, and ethically justifiable to grant this wish? Even in the absence of relevant (physical or psycho-existential) symptoms? How should the medical and nursing staff carry out the sedation if the patient still has weeks or even months to live and they are following the ethical premise that the palliative sedation measures should not end life any sooner than the patient’s illness would have done? How much monitoring should take place to insure against accidental death (e.g., from drug-induced respiratory depression)? Is artificial nutrition and hydration then needed to avoid any implication that the inability to drink is ending life more swiftly than the underlying illness? How much effort should be put into regular repositioning to prevent decubitus ulcers? How much “collateral damage” can be accepted as the risk of unintentional shortening of life by palliative care that is indicated per se? Or: As a direct consequence, is it not also permissible to ask whether, under the assumption that sedation constitutes a justifiable procedure in the presence of unbearable physical or mental pain, it should also be offered to patients who do not have a life-shortening disease (4)?

It just needs a scenario in which palliative sedation is being discussed for a patient who is not close to death, leading to consideration of the extent of monitoring and the intensity of the accompanying medical care, to prompt heated debate among the members of the therapeutic team. Not infrequently, a situation where a patient who is still mobile requests particularly rigorous measures (e.g., deep, continuous or escalating sedation right up to the time of death) arouses in the team an uncomfortable feeling that what is actually happening is the implementation of a concrete wish to die, not just symptom control by other means. Since in such extreme scenarios the physicians are administering (deeply) sedating drugs, e.g., intravenously perfused benzodiazepines or propofol, and the patient is not taking the medication him- or herself, the conceptual proximity to euthanasia on demand cannot be overlooked in cases of particularly rigorous implementation (5).

Conceptualization and objectification

These sometimes only implicit perceptions that palliative sedation could reach or even cross the line to the realm of medically, ethically, and legally unjustifiable actions may explain the effort and outlay devoted to the investigation and differentiation of the concept of palliative sedation in recent years. Examples are the recent and ongoing projects of the German Federal Ministry of Education and Research (BMBF) (SedEoL, SedPall, iSedPall), with the recently published treatment recommendations for palliative sedation (6), and the EU Horizon 2020 project Palliative Sedation.

In this context of conceptualization and objectification, Prof. Eva Schildmann et al. (7) are the first researchers to analyze the data of patients who died in different hospital departments—two of hematology/oncology and one each of neurology, geriatrics, and gynecology—and in whose medical records the use of sedating drugs was documented. This focus on objective data (instead of the customary subjective appraisals by the therapeutic team) and on non-palliative hospital wards (instead of the usual specialized palliative care units) fills in a previously blank spot in the description and understanding of the use of sedatives (for symptom control) at the end of life. Despite the retrospective design and the intrinsic problem of missing data, especially with regard to the intention behind sedative administration, the authors present a real-world depiction of sedation at the end of life in different treatment contexts.

What remains?

The most commonly encountered situation in daily clinical routine is not the extreme example portrayed above, demanding ethical reflection and in some cases the definition of clear normative boundaries, but rather the well-considered and appropriate use of sedatives at the end of life described in Schildmann’s study. With these data, palliative sedation can be understood above all as a straightforward, perhaps even unavoidable treatment option in particularly severe and distressful states at the end of life—free of the shadow cast by the euthanasia debate.

Conflict of interest statement
The author declares that no conflict of interest exists.

Manuscript received on 7 April 2022, revised version accepted on 25 April 2022

Translated from the original German by David Roseveare

Corresponding author
Prof. Dr. med. Bernd Alt-Epping
Klinik für Palliativmedizin
Universitätsklinikum Heidelberg
Im Neuenheimer Feld 305, 69120 Heidelberg, Germany

Cite this as
Alt-Epping B: Palliative sedation: controversial discussions and appropriate practice. Dtsch Arztebl Int 2022; 119: 371–2. DOI: 10.3238/arztebl.m2022.0212

References

1. Cherny NI, Radbruch L, Board of the European Association for Palliative Care: European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009; 23: 581–93

2. Kremling A, Schildmann J: What do you mean by „palliative sedation“? Pre-explicative analyses as preliminary steps towards better definitions. BMC Palliat Care 2020; 19: 147

3. Alt-Epping B, Nauck F, Jaspers B: Was ist das Problematische an der Palliativen Sedierung? – eine Übersicht. Ethik in der Medizin 2015; 3: 219–31

4. Cellarius V: Terminal sedation and the imminence condition. J Med Ethics 2008; 34: 69–72

5. Anquinet L, Raus K, Sterckx S, et al.: Similarities and differences between continuous sedation until death and euthanasia—professional caregivers’ attitudes and experiences: a focus group study. Palliat Med 2013; 27: 553–61

6. Forschungsverbund SedPall in Kooperation mit der Deutschen Gesellschaft für Palliativmedizin. Handlungsempfehlungen Einsatz sedierender Medikamente in der Spezialisierten Palliativversorgung. www.dgpalliativmedizin.de/images/210422_Broschuere_SedPall_Gesamt.pdf (last accessed on 30 March 2022).

7. Schildmann E, Meesters S, Grüne B, et al.: Sedatives and sedation at the end of life in the hospital—a multicenter retrospective cohort study. Dtsch Arztebl Int 2022: 119: 373–9.