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ETHICAL CONSIDERATIONS
Sedation to relieve otherwise intolerable suffering for patients who are dying as normative practice
There is no distinct ethical problem in the use of sedation to relieve otherwise intolerable suffering for patients who are dying. Rather, the decision making and application of this therapeutic option represents a continuum of good clinical practice. Good clinical practice is predicated on careful patient evaluation ) that incorporates assessment of current goals of care.
Since all medical treatments involve risks and benefits, each potential option must be evaluated for their potential to achieve the goals of care. Where risks of treatment are involved, the risks must be proportionate to the gravity of the clinical indication. In these deliberations, clinician considerations are guided by an understanding of the goals of care and must be within accepted medical guidelines of beneficence and non-malfeasance.
Finally, the penultimate decision to act on these considerations depends on informed consent or an advance directive of the patient. In this clinical context, the decision to offer the use of sedation to relieve intolerable suffering to terminally ill patients, presents no new ethical problem (14, 15).
As with any other high risk clinical practice, potential for non beneficent abuse exists. Wein has described prerequisites to ensuring that sedation of the imminently dying remains on an ethically sound footing (16):
- Physician skill in patient selection
- Candor and consent
- Cross-consolation
- Documentation
- Knowledge of medications and illness
- Commitment to titrate and monitor
Despite the potential for shortening life, this approach has been endorsed as acceptable normative practice by legal precedent. In the 1957 English case of R v Adams, Justice Devin wrote in his judgement “If the first purpose of medicine, the restoration of health, can no longer be achieved, there is still much for a doctor to do, and he is entitled to do all that is proper and necessary to relieve pain and suffering, even if the measures he takes may incidentally shorten life.” He justified this approach rejecting the notion that this is a special defense, but rather by endorsing the clinical pragmatist approach that “The cause of death is the illness or the injury, and the proper medical treatment that is administered and that has an incidental effect on determining the exact moment of death is not the cause in any sensible use of the term “(17). This approach was lent further support by the recent decision of the Supreme Court of the United States that rejected a constitutional right that encompasses assisted suicide, but that endorsed the use of sedation as an extreme form of palliative care in the management of refractory symptoms at the end of life (4).
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