THE ETHICS OF SEDATION

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THE ETHICS OF SEDATION ARTIFICIAL HYDRATION IN
THE TERMINALLY ILL
To do or not to do?

• Mr R Becker Senior Lecturer in Palliative Care
• Staffordshire University and Severn Hospice
  Shropshire

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• Intent
• whether a decision to sedate and/or hydrate
  reflects an intention to relieve pain and
  suffering, discontinue burdensome or ineffective
  treatment, or to cause death

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The Doctrine of Double Effect

• If doing something morally good has a morally bad
  side-effect it's ethically OK to do it -
  providing the bad side-effect was not intended.
  This is true even if you foresaw that the bad
  effect would probably happen.

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Other ethical issues of significance

• Benefit to the patient
• Possible harm caused to the patient
• Respect for patient autonomy and the right of
  self determination i.e. choice
• Respect for the moral integrity of the health
  professionals codes of practise
• Sanctity of life ethic

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Sedation?
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The challenge of palliative sedation

• Confusion and inconsistency in the literature
  related to conceptual definitions of the term
  terminal sedation
• Disagreements over the clinical indications for
  its use
• Inconsistency in pharmacological approaches to
  sedation
• A paucity of qualitative research examining the
  contextual factors and processes influencing the
  attitude and behaviour of health professionals
  and family members

Beel et al 2002
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A Question of Definition?

• In the beginning was terminal sedation
  (Enke1991)

• Negative association with the word terminal.
  Palliation is a positive response to distressing
  symptomatology
• The term does not give a clear indication of
  what sedation is all about i.e. the intent
• The term suggests that terminal sedation is
  about terminating the life of the patient.

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• Palliative Sedation
• the intentional administration of sedative drugs
  in dosages and combinations required to reduce
  the consciousness of a terminal patient as much
  as necessary to adequately relieve one or more
  refractory symptoms
• Broeckaert B 2002

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Clinical Indicators for PalliativeSedation
Unendurable and refractory symptoms?

• Uncontrolled physical pain
• Respiratory distress
• Delirium
• Nausea and vomiting
• Terminal agitation and restlessness
• Psychological and/or spiritual distress

Ventafridda et al 1990, Cherny Portenoy 1994,
Chater et al 1998)
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The incidence of refractory symptoms

• 16 hospice patients (Fainsinger et al 1991)
• 26 hospital patients (Stone et al 1997)
• 36 in the last 48 hrs (Lichter Hunt 1990)
• 48 hospice patients (Morita 1996)
• 50 hospital patients (Braun et al 2000)
• 52.5 unendurable symptoms (Ventafridda 1990)

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Limitations of the current research into
palliative sedation

• Most studies appear to be either surveys of
  existing practise or empirical observations of
  practise
• We lack in understanding of the context of
  sedation and the human interactions that
  influence the decision to sedate.
• Qualitative methodology grounded theory,
  clinical ethnography

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The drugs most commonly used for palliative
sedation

• Benzodiazepines Midazolam Lorazepam
• Neuroleptics Haloperidol
• Barbiturates Phenobarbitol
• Opioids alone should never be used for sedation
• Opioids where px should be continued alongside
  the sedative drugs.

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Mean survival of patients after starting sedation

• Porta Sales et al (1999) 3.2 days
• Porta Sales (2001) 2.4 days
• Fainsinger et al (2000) 2.4 days

Other studies Fainsinger (1998) 4hrs 12
days Menten (2000) 1 18 days
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Artificial Hydration?
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Artificial hydration The Current Issues

• The literature currently demonstrates
  considerable differences in clinical practice
  regarding the use of artificial hydration in
  dying patients
• Varied opinions a crucial part of the management
  strategy, or unnecessary burden
• There is only a small body of research available
  much of which is now quite old, and clinical
  experience appears to provide the basis for most
  current practice
• There appears to be no consistency in the amounts
  prescribed or the rates and efficiency of delivery

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A Selection of Viewpoints

• Dehydration can be seen as a normal part of the
  dying process, patients who are dying of cancer
  usually give up eating and then drinking, they
  become too weak to even take fluids (Fox 1996)
• In the same way that hunger is not a feature of
  anorexia/cachexia, thirst is not a symptom
  associated with decreasing fluid intake in those
  close to death (Dunlop et al 1995)
• Most patients failing to drink in the terminal
  phase of their illness, not given artificial
  hydration, do not suffer the normal symptoms of
  dehydration (Dunphy et al 1995)

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The symptoms of natural dehydration close to
death include

• Dry mouth
• Headache
• Fatigue
• Cognitive Impairment
• Circulatory collapse
• Renal failure
• Anuria

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Potential Burdens of Artificial Hydration close
to Death

• Can lead to fluid retention and overload leading
  to the development of peripheral or pulmonary
  oedema
• Can result in dyspnoea
• Cannula in the arm can be uncomfortable
• Risk of infection or phlebitis
• Changes in body image
• Can give confusing messages to the family false
  hope of cure and extended life
• May be a physical barrier between the patient and
  family

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Pain reduction in natural dehydration at the end
of life

• A reduction in oedema around tumours leads to
  decreased pain from nerve compression (Zerwekh
  1997)
• The increase in ketones caused by reduced
  calorific intake, causes a loss of sensation
  (Printz 1989)

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Research Into Artificial Hydration

• Marin et al (1989) Surveyed 448 doctors and found
  that 53 would administer IV fluids to a comatose
  patient with widespread malignant metastases. 83
  would resite the cannula as required and 26
  would insert a central venous line if no other
  route were available. patient comfort was the
  reason given.
• Collaud et al (1991) Surveyed 397 doctors and
  found that 28 would use artificial hydration in
  conscious, but dying patients and 44 in
  unconscious ones. When asked to assess the
  discomfort of dehydration 42 felt that dying
  patients suffer significantly and 33 that
  patients scarcely suffer.

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• House (1992) Compared views of hospice nurses and
  doctors with general hospital staff and found
  that hospice staff did not advocate artificial
  hydration whereas 43 of hospital nurses felt
  that the patient suffered if hydration was not
  maintained in the dying.
• Malone (1995) Surveyed doctors in an acute
  hospital setting and found that 75 would use IV
  fluids with the dying and 40 would consider a
  central line if access was difficult.
• Harvath et al (2004) Studied attitudes of hospice
  nurses social workers to a patients voluntary
  refusal of food fluids. Results indicated a
  positive perception by staff for this choice by
  patients.

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UK National Council for Palliative Care
Guidelines (1997 updated 2005)

• A blanket policy of artificial hydration or no
  artificial hydration is ethically indefensible.
• Towards death a persons desire for food and drink
  lessens.
• Thirst or dry mouth in the terminally ill may be
  caused by medication..Good mouth care is
  essential
• Good palliative care includes the option of
  artificial hydration where there is a correctable
  cause.
• Assessment should be made on a daily basis re -
  benefits and harm
• Health professionals must not subordinate the
  interests of patients to the wishes of distressed
  relatives..

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Key Questions and Care Strategies

• Engage in early discussion with the patient and
  family to determine the patients wishes
• Establish whether the patient has an advance
  directive
• Reassure the patient and family that at all times
  the priority is the comfort and support of the
  patient.
• Be tactfully resistant to sacrificing the
  interests of the patient to the emotional
  distress of the relatives
• Always present the facts carefully and
  sensitively - understand the context and dynamics
  around the bedside

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Key Questions and Care Strategies

• Remember - thirst in the conscious patient should
  always be actively addressed
• Does the patient appear to feel better as a
  result of the infusion? Is his/her well being/
  alertness enhanced?
• What are the psychosocial effects? i.e. is the
  infusion interfering with family interactions
• Ensure pain and symptom relief is adequate and
  assessed regularly

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Key Questions and Care Strategies

• Essential comfort measures Regular mouth care,
  offer ice cubes and sips of water if tolerated.
  Provide cream for lips to prevent cracking,
  pressure area care, keep the patient clean and
  dry at all times
• Reassure the family that sedation is a valid
  means of symptom control where no other measures
  are possible to relieve distress
• Reassure the family that stopping IV fluids is
  not stopping care

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Thank you for listening.
Email bobb_at_severnhospice.org.uk