Forum.
Issues to consider in discussing sedation
The UK General Medical Council guidance (1998 p8) provides the following, generic, guidance regarding issues to raise with patients about potential treatments:
- Any consent cannot be an isolated event but part of a continuing dialogue
- Written, visual and other aids should be employed where appropriate
- Arrangements should be made to overcome specific language or communication difficulties
- Where appropriate, discuss with patients the possibility of involving a friend or relative or possibly recording the conversation.
- Explain the probabilities of success, or the risk of failure or harm.
- Ensure that information which patients may find distressing is given to them in a considerate way
- Allow time for patients to reflect and come to a conclusion. In complex situations information may be communicated over a period of time.
- Involve other members of the health care team in the discussions
- Ensure the patient is given a clear route for reviewing the decision
The guidance goes on to state that sufficient information should be supplied and only withheld if “serious harm” would result. “This does not mean the patient would become upset, or decide to refuse treatment”.
Recognition is also given to a patient’s right to not want to be involved in decision-making but stresses the need for the health professional to ensure they fully understand the implications of this decision. (GMC 1998)
The ways of communicating delicate information should be a basic skill in palliative care and will not be expanded on further here except to highlight the role of non-verbal communication in these situations although as Morita (1996) points out this may vary between different cultures.
A number of authors (Morita 1996, Quill 1997, Chan KS 2004, Cherny and Portenoy 1994) have suggested an approach to discussing sedation at the end of life. It is suggested that the following points be included in any discussion
- The poor chance of recovery, that death is inevitable and the severity of present suffering whether this is physical or existential.
- The need to establish that all palliative methods have been applied before coming to a decision on sedation
- That the side effects of sedation may include: life shortening potential and decreased conscious level; though the exact content of this discussion depends on the physician’s judgement.
- That the opinion of the multidisciplinary team is that the benefits of sedation should outweigh the burdens
- That the intention of sedation is to relieve the distressing symptom and not to cause sedation directly or to end life.
- That continuous review will be undertaken and there is the possibility to discontinue sedation if necessary
- Discussion around other end of life issues that may also be appropriate at this time
Cherny and Portenoy (1994) sum this up with the guidance: “In this situation the clinician should explain that by virtue of the severity of the problems and the limitations of the available techniques the goal of providing the needed relief without the use of drugs that may impair the conscious state is probably not achievable. The offer of sedation as an available therapeutic option is often received as an empathic acknowledgement of the severity of the degree of patient suffering”.
Such guidance is helpful but does leave a number of unanswered questions and dilemmas. Suffering and distress are subjective symptoms and so can only really be judged by the patient. It is therefore debatable as to whether the patient or the professional should decide when the symptoms become refractory and whether all palliative treatments need to have been “applied” or just “offered”.
Quill reviewed the anaesthetic literature and found conflicting evidence as to whether sedation relieves suffering or just makes people unable to report it. What are the implications of this in our discussions with patients? Do we say to people that sedation will relieve their suffering or that they will be unaware or unable to report their suffering? (Quill 1997).
Cherny and Portenoy’s (1994) further summary seems highly pertinent: “No patient should have to ask to be killed for persistently unrelieved pain, and contra wise, no patient should be sedated without appropriate consideration of other options and informed consent by the patient or proxy”.
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