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 Continuing Sedation a Fig Leaf for Euthanasia, Study Finds

Palliative sedation, which has often been held up as a more legally and morally sound alternative to euthanasia, may in fact have become a different form of euthanasia, Belgian researchers say.

 

Rather than putting chronically ill patient under heavy drugs to help make their deaths as painless as possible, continuous sedation “is frequently used to hasten the patient’s death,” Vrije Univesiteit Brussel researcher Sam Rys says in a surprising new study.


“In some cases,” Rys and four colleagues found, palliative, continuing sedation until death (CSD) “can even be considered a substitute for legal euthanasia.”

 

Matter Of Motive

Doctor-assisted suicide has been illegal in the United States for ages, but the modern legal standard was set by two cases in 1997, when the Supreme Court ruled, in part, that people don’t have “a right to die” and that the option of continuing sedation (or “terminal sedation,” as the justices termed it) was more acceptable than outright euthanasia because putting a patient into a drug-induced coma and then withholding care didn’t require actual intent to kill, as prohibited by law.

 

Just as a state may prohibit assisting suicide while permitting patients to refuse unwanted lifesaving treatment,” then-Chief Justice William Rehnquist wrote for the majority in Vacco v. Quill, “it may permit palliative care related to that refusal, which may have the foreseen but unintended ‘double effect’ of hastening the patient's death.”

 

In much of Europe, however, both euthanasia and terminal sedation are legal, and Rys’ findings, published in the August issue of the Journal of the American Medical Directors Association (JAMDA), suggest that palliative sedation is increasingly just a fig leaf for doctor-assisted suicide. In the Belgian region of Flanders, sedation and euthanasia rates have doubled over the past decade.

 

In Flemish nursing homes, though, sedation has tripled; it factored in less than 3 percent of all deaths in 2001, but in 9.4 percent of deaths in 2007, even while “euthanasia remains a rare practice in nursing homes compared with other care settings,” Rys writes.

 

‘Explicit Intention’ To Hasten Death

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ys and the team surveyed nearly 400 doctors in Flemish nursing homes, asking about their approach to sedation. Of the 156 physicians who (anonymously) reported their motives for sedating critically ill patients, more than three-fifths denied wanting to hasten their patients’ deaths. But nearly one-third reported “a partial” hope and another 5 percent said their “explicit intention” was to hasten death.

 

More than 37 percent of those doctors who were partially or explicitly hoping to speed up their client’s death had talked with their patients about euthanasia before sedating them. About 22 percent of those sedations came because the patients had expressly asked to be euthanized, Rys says. Of those who were asked by their patients for assisted suicide but who opted for aggressive sedation rather than outright fatal doses, nearly 40 said that they didn’t want to go through the legal hassles of state-sanctioned euthanasia.

 

“Bearing in mind the restrictive policies on euthanasia in nursing homes in Flanders,” Rys says, “and the significantly low rate of legal euthanasia in this care setting, our findings strongly suggest that CSD is sometimes being used as a substitute for euthanasia.”

 

But those patients who were sedated in the partial or explicit hopes of accelerating their death were also more likely to have been involved in their own care planning. Nearly two-thirds of those patients who were sedated in the hopes of speeding up death were “actively involved in decision making,” the Belgian researchers say. For those patients who were already incompetent, the doctors consulted with their families in more than two-thirds of the cases where sedatives were administered in the hope of hastening the patient’s death.

 

Important Questions

In a separate editorial in the same issue of JAMDA, Dutch palliative care expert Daisy Janssen says the Flemish study “raises several important questions” and that doctors everywhere should think about palliative sedation carefully.

 

First, Janssen says, there are conflicting studies about whether the sedation actually speeds up death. Rys’ team found that the average patient in their study died within about two weeks of being given aggressive sedation, but other studies have come back with different net time periods.

 

Then there is the question of motive. Many physicians say they only wish to relieve suffering, Janssen says. But some evidence suggests that sedation only makes it worse. “A case series of continuous deep sedation until death in nursing home patients with dementia,” for instance, “has shown that patients may suffer from symptoms such as fear, pain, restlessness, and breathlessness, despite the use of deep sedation. For three of 11 sedated residents, nurses experienced the dying process as a struggle,” Janssen says.

 

Docs Conflicted Over ‘Good Death’

Other studies have clouded the notion of motives in different ways—a 2002 “vignette study” among Japanese oncologists and palliative medicine physicians, for example, “revealed that physicians who demonstrated higher levels of emotional exhaustion were more likely to choose continuous deep sedation for patients with refractory physical and psychological symptoms,” Janssen says. “Moreover, physicians with more experience in end-of-life care were less likely to choose continuous deep sedation for patients with depression or delirium, but considered other treatment options.”

 

Janssen wonders, also, if some doctors aren’t simply in over their heads. She cites a 2012 study in her native Holland that found that only 22 percent of doctors were asking the advice of palliative care experts before sedating their patients.

 

“The study from Rys et al. in this issue of the Journal shows the complexity of the process of decision making concerning continuous deep sedation,” Janssen concludes. “Both the feeling of physicians that they have the duty to provide a good death and pressure from family members or other health care professionals pose a challenge on physicians caring for dying patients.”

 

Bill Myers is Provider’s senior editor. Email him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers. 

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