Am Fam Physician. 2011 May 1;83(9):1094-1095.
A 46-year-old woman was admitted to the hospital several weeks ago with sepsis. She has squamous cell carcinoma of the tongue, which was diagnosed one year ago. Her cancer has been previously treated with multiple resections and chemotherapy, and is thought to be terminal. She also has chronic graft-versus-host disease from a stem cell transplantation for treatment of multiple myeloma several years ago.
Her infection was treated successfully; however, because of her multiple illnesses, she has developed severe electrolyte abnormalities. She requires large doses of intravenous electrolyte replacement at least once per day for hypokalemia, hypophosphatemia, and hypomagnesemia. She is completely dependent on this supplementation and cannot be discharged from the hospital.
We recommended that the patient have a palliative care consultation to discuss her goals. She told them that her quality of life in its current state is unacceptable. She wants to stop the laboratory draws and electrolyte replacement. However, she does not want to experience the symptoms and suffering she envisions this will bring. Thinking of pursuing this option makes her extremely anxious, and prevents her from giving us permission to stop the interventions. Controlling her anxiety has been a challenge. She has requested to be heavily sedated after cessation of the electrolyte replacement. Her family has expressed concern that this is euthanasia. Is the patient's request for sedation appropriate? Is sedation before withdrawing supplementation the same as euthanasia?
A patient has the right to make an informed decision about discontinuing life-prolonging treatments. The patient in this scenario is requesting palliative sedation to control her anxiety while electrolyte replacement is stopped.1
Palliative sedation is defined as the use of sedative medication “to relieve intolerable suffering from refractory symptoms by reducing a patient's consciousness.”2,3 A refractory symptom is a symptom for which all treatments have failed, or a symptom for which there are no treatments available for palliation.4 In this case, the patient is anticipating refractory anxiety caused by her knowledge of imminent death and the fear of being awake and alert while undergoing the process.
Palliative sedation is not euthanasia. Euthanasia is the administration of a medication with the intent to end life. The intent of palliative sedation is not to shorten life, but to alleviate symptoms that cannot be controlled by more standard palliative treatments. This patient requests sedation to control anxiety, but death will ultimately be caused by her electrolyte imbalances from her terminal comorbidities.
There is some evidence that palliative sedation does not affect survival, as noted in a multicenter study of patients with cancer.5 Therefore, there should be no concern about a double effect, which refers to the intent of alleviating a patient's pain with the risk of causing unintended consequences, such as shortening life.6 Palliative sedation will not shorten life, but will allow the disease process to take its natural course.
In June 2008, the American Medical Association House of Delegates accepted a report from the Council on Ethical and Judicial Affairs affirming that palliative sedation to unconsciousness is medically ethical under appropriate circumstances.7 Other medical organizations have supported palliative sedation for relieving suffering in patients with uncontrollable symptoms.8
Patients with terminal illness deserve to be informed of the option of palliative sedation if all other treatment modalities have failed.8 In this case scenario, we would encourage the patient and her family to meet again with a palliative care expert or team to discuss sedation after electrolyte replacement is discontinued, and to explain that the goal is to alleviate her anxiety and not to shorten life.
REFERENCESshow all references
1. Ackermann RJ. Withholding and withdrawing life-sustaining treatment. Am Fam Physician. 2000;62(7):1555–1560....
2. de Graeff A, Dean M. Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. J Palliat Med. 2007;10(1):67–85.
3. Broeckaert B, Olarte JMN. Sedation in palliative care: facts and concepts. In: ten Have H, Clark D, eds. The Ethics of Palliative Care: European Perspectives. Buckingham, United Kingdom: Open University Press; 2002:166–180.
4. Cherny NI, Portenoy RK. Sedation in the management of refractory symptoms: guidelines for evaluation and treatment. J Palliat Care. 1994;10(2):31–38.
5. Maltoni M, Pittureri C, Scarpi E, et al. Palliative sedation therapy does not hasten death: results from a prospective multicenter study. Ann Oncol. 2009;20(7):1163–1169.
6. Quill TE, Dresser R, Brock DW. The rule of double effect—a critique of its role in end-of-life decision making. N Engl J Med. 1997;337(24):1768–1771.
7. O'Reilly KB. AMA meeting: AMA OKs palliative sedation for terminally ill. Am Med News. 2008;51(25):28. http://www.ama-assn.org/amednews/2008/07/07/prsi0707.htm. Accessed April 11, 2010.
8. Quill TE, Lo B, Brock DW, Meisel A. Last-resort options for palliative sedation. Ann Intern Med. 2009;151(6):421–424.
Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous.
Please send scenarios to Caroline Wellbery, MD, at email@example.com. Materials are edited to retain confidentiality.
Copyright © 2011 by the American Academy of Family Physicians.
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