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Safeguarding the incompetent, sedated patient
The final consideration for incompetent patients is the place of routine treatment safeguards that would help to prevent abuses of patients in this vulnerable state. These would be a matter of debate and research but Cherny and Portenoy (1994) put forward a number of suggested safeguards that should be employed:
- Both patient and their family wish for sedation rather than endurance of symptoms and are fully involved in the decisions making
- The decision is made rationally, voluntarily and consistently.
- The intention of all should be the relief of symptoms and not to shorten the patient’s life which comes under the doctrine of double effect
- Diagnostic and prognostic clarity should be established
- Use of a second opinion
- Explicit processes for documentation and review
- The symptom being refractory
Additional points that could be added to this list are:
- Multidisciplinary agreement and review
- Regular training to ensure effective steps are taken to treat any reversible conditions before commencing sedation
- Protocols for the initiation of sedation
Cherny and Portenoy (1994) defined a situation as refractory if any intervention:
- Will not bring adequate relief
- Will be associated with intolerable morbidity
- Will not bring relief within a reasonable time.
They emphasise the need for expert input into this situation and these symptoms should be “refractory” and not “difficult”
Side-effects that impair cognition or run the risk of shortening life become more acceptable when the goals of care of the patient are clearly understood, when the patient’s time is limited and when the clinical situation demands an intervention that will have the desired effect in a prompt and effective manner (Cherny and Portenoy 1994).
No matter how the process proceeds, there are always value judgements for the health care professional involved in assessing competency, which options to discuss, how much info to give. Such decisions are individual to each patient and cannot be determined by guidelines removed from the actual case (Randall and Downie 2004). Similar to consent, it is unlikely that strict criteria for capacity in decisions regarding sedation at the end of life will be achievable. The ongoing knowledge and relationship between patient and professional would be more important. There are certain themes that appear particularly relevant to explore though these need validating. Advance statements or proxies may be useful, but their exact place in this area of healthcare is still to be proven.
The evidence in this section is level IV and V.
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