Dr Paulina Taboada
Profesor Centro de Bioetica
Pontificia Universidad Catolica de Chile
Alameda 340 Correo Central 1
Santiago, Chile
Last year, a call for "terminal sedation" to be covered by the same legal regulation as euthanasia gave rise to a public debate in The Netherlands. Doctors, supported by the health minister, strongly argued that terminal sedation and the withdrawal of artificial feeding and hydration are "normal medical treatment" and therefore "different from euthanasia" (Cf. Sheldon T: "Terminal sedation" different from euthanasia, Dutch ministers agree. BMJ 2003; 327: 465)
The debate on "terminal sedation" still continues around the world. While some consider this praxis as normal medical treatment, others wonder whether it does rather represent "euthanasia in disguise" (Cf. Tännsjö T (ed): Terminal sedation: Euthanasia in Disguise? Kluwer, Dodrecht, 2004).
In an attempt to shed light on this debate, Josep Porta has provided an interesting clarification of the concepts (Cf. Porta J: Aspectos clínicos de la sedación en cuidados paliativos. In: Sedación y ética al final de la vida. Fundació Víctor Grífols i Lucas, Barcelona, 2003, pp. 9-28). Commenting on the ambiguity of the use of the expression "terminal sedation" in the medical literature, Porta analyzes various definitions that have been used during the past years. In order to avoid such misunderstandings, this author suggests introducing the terms "palliative sedation" and "palliative sedation in agony".
Along with the SECPAL, Porta defines "palliative sedation" as the deliberate administration of drugs in a dose and combination required to reduce a terminal patient's consciousness to the extent needed to adequately alleviate one or more refractory symptoms, with the patient's explicit, implicit or surrogate's consent. When used to alleviate refractory physical, or psychological symptoms near to death, this praxis is called "palliative sedation in agony".
Key aspects of this definition are the ideas that sedation is used 1) with a therapeutic intention, 2) as a "last resort", i.e., when all other alternatives have failed to provide adequate symptom control, 3) only to the extent it is strictly needed, and 4) after a process of ethically valid informed consent. In other words, the definition stresses the importance of securing a due "proportionality" in the level to which a patient's state of awareness is reduced. As long as the deprivation of consciousness is "tolerated" only to the extent needed to control refractory symptoms, the classical doctrine of "double effect" applies.
This definition captures the traditional way of understanding the role of sedation in palliative care, as stated already - for instance - in the Oxford Textbook of Palliative Care (p. 407): "The goal of palliative terminal sedation is to provide the dying patient relief of otherwise refractory, intolerable symptoms, and it is therefore firmly within the realm of good, supportive palliative care and is not euthanasia."
Nevertheless, if "terminal sedation" would be differently understood, it might represent "euthanasia in disguise". This would be the case if one would deprive a patient of his state of awareness while simultaneously withdrawing nutrition and hydration with the intention of hasten his death ("terminal dehydration". Cf. Ann Intern Med. 1998; 128: 559-562).
Dr. Paulina Taboada, MD, PhD
Palliative Care and Bioethics
