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Existential distress as a special case
Existential distress as an indication for sedation is controversial and is frequently considered separately from physical distress. Not only are there variations in terminology, but there is no standard definition or even universal acceptance of its existence as an entity (Strang, et al, 2004). The phenomenon of existential distress is poorly understood and treatment strategies are less developed than for physical symptoms (3, 10? 27). The ethical and moral arguments about sedation are intensified around its use for existential distress (2,27, Rousseau). Because of the variable severity of existential distress authors recommend serial trials of intermittent sedation prior to inducing a permanent deep sedation (2,3,10,27, Morita Nov 2004).
A few authors have proposed guidelines for determining appropriateness of sedation for existential distress (2,10,27), and have provided 3 rules for decision-making in the case of severe existential distress (2,10):
- Designation of psychological symptoms as refractory should be made only after an unsuccessful process of repeated assessment and standard intervention by clinicians skilled in psychological care
- The assessment process and outcome of interventions is evaluated in a case conference
- Sedation is initiated on an intermittent basis and, if necessary, becomes permanent only after repeated trials of intermittent sedation and intensive intermittent therapy
Rosen (44) asserts that the needs of family and patient should be separated and clearly defined through comprehensive clinical evaluation by a multidisciplinary team, particularly in the case of sedation for existential distress.
Religion, law, and culture influence the use of sedation for existential distress. Ducharme labels sedation for existential distress as “existential euthanasia” (43). Deep continuous sedation for existential distress is illegal in Japan (Morita Sep? 2004). Sedation for existential distress is commonly requested in Spain ( ), but is very controversial in most other countries (Rousseau; 10, Hallenbeck).
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