Background Studies describing physicians’ experiences with sedation at the end of life are indispensible for informed palliative care practice, but they are scarce. We describe the accounts of physicians from the USA and the Netherlands, two countries with different regulations on end-of-life decisions regarding their use of sedation.Methods Qualitative face-to-face interviews were held in 2007–2008 with 36 physicians , including primary care physicians and specialists. We applied purposive sampling and conducted constant comparative analyses.Results In both countries, the use of sedation (...) was described in diverse terms, especially in the USA, and was often experienced as emotionally challenging. Respondents stated different and sometimes multiple intentions for their use of sedation. Besides alleviating severe suffering, most Dutch respondents justified its use by stating that it does not hasten death, while most American respondents indicated that it might hasten death but that this was justifiable as long as that was not their primary intention. While many Dutch respondents indicated that they initiated open discussions about sedation proactively to inform patients about their options and to allow planning, the accounts of American respondents showed fewer and less-open discussions, mostly late in the dying process and with the patient's relatives.Conclusions The justification for sedation and the openness with which it is discussed were found to differ in the accounts of respondents from the USA and the Netherlands. Further clarification of practices and research into the effect and effectiveness of the use of sedation is recommended to enhance informed reflection and policy making. (shrink)

In assisted dying, the end-of-life trajectory is shortened to relieve unbearable suffering. Unbearable suffering is defined broadly enough to include cognitive (early dementia), psychosocial or existential distress. It can include old-age afflictions that are neither life-threatening nor fatal in the “vulnerable elderly”. The voluntary refusal of food and fluids (VRFF) combined with continuous deep sedation (CDS) for assisted dying is legal. Scientific understanding of awareness of internal and external nociceptive stimuli under CDS is rudimentary. CDS may blunt the wakefulness component (...) of human consciousness without eradicating internal affective awareness of thirst and hunger. Patients may suffer because of the slow dying process following dehydration and starvation. The difficulty to adequately control distress, without bringing the dying process to a rapid conclusion by lethal pharmacological interventions, can cause feelings of guilt among hospice and medical staff. Furthermore, the double-effect principle is not applicable in these situations because the primary objective of VRFF is to hasten death. Legal and societal debate should focus on sharpening the boundaries between assisted dying and palliative care. This separation is necessary to: 1) uphold trust in the patient-phyician relationship, and 2) preserve integrity and ethics of the medical profession. (shrink)

An influential objection to the view that intentions are non-derivatively relevant to the moral permissibility of actions states that if intentions were relevant to permissibility in such a way, one would have to take them into account in decision making, which would be odd (in some morally relevant sense of ‘oddness’). The paper outlines and assesses three candidates for the oddness: that considering intentions in decision making is an unordinary practice, that it is impossible or conceptually confused, and that it (...) assigns intentions the weight as moral considerations that they intuitively do not have. The paper rejects the first two and shows that the third is probably what motivates most critics of the relevance of intentions who raise this objection. If this is correct, the objection is a non-starter as it assumes what it has to prove. Towards the end, it is argued that the objection does not serve as a plausible error theory either. (shrink)

Despite advances in palliative care, some patients still suffer significantly at the end of life. Terminal Sedation (TS) refers to the use of sedatives in dying patients until the point of death. The following limits are commonly applied: (1) symptoms should be refractory, (2) sedatives should be administered proportionally to symptoms and (3) the patient should be imminently dying. The term ‘Expanded TS’ (ETS) can be used to describe the use of sedation at the end of life outside one or (...) more of these limits.In this paper, we explore and defend ETS, focusing on jurisdictions where assisted dying is lawful. We argue that ETS is morally permissible: (1) in cases of non-refractory suffering where earlier treatments are likely to fail, (2) where gradual sedation is likely to be ineffective or where unconsciousness is a clinically desirable outcome, (3) where the patient meets all criteria for assisted dying or (4) where the patient has greater than 2 weeks to live, is suffering intolerably, and sedation is considered to be the next best treatment option for their suffering.While remaining two distinct practices, there is scope for some convergence between the criteria for assisted dying and the criteria for ETS. Dying patients who are currently ineligible for TS, or even assisted dying, should not be left to suffer. ETS provides one means to bridge this gap. (shrink)

In 2016, France passed a major law that is unique in giving terminally ill and suffering patients the right to the controversial procedure of continuous deep sedation until death (CDS). In so doing, the law identifies CDS as a sui generis clinical practice, distinct from other forms of palliative sedation therapy, as well as from euthanasia. As such, it reconfigures the ethical debate over CDS in interesting ways. This paper addresses one aspect of this reconfiguration and its implications for the (...) intentions at work in this complex time at the end of life. The concept of intention is often considered central to the ethics of end-of-life care, but its role is recognized to be problematic, with charges of elusiveness and ambiguity. I aim to show that consideration of the French law affords a new understanding of the intentionality of CDS, and that in addition to the obvious importance of this for clarifying the ethics of the practice, it may suggest new ways of addressing the wider problem of ambiguous clinical intentions at end of life. (shrink)

A recent administrative law decision in Victoria, Australia, applied double effect reasoning in a novel way. Double effect reasoning has hitherto been used to legitimate treatments which may shorten life but where the intent of treatment is pain relief. The situation reviewed by the Victorian tribunal went further, supporting actions where a doctor agrees to provide pentobarbitone to a patient at some time in the future if the patient feels at that time that his pain is unbearable and he wants (...) to end his life. The offer to provide the drug was described as a palliative treatment in that it gave reassurance and comfort to the patient. Double effect reasoning was extended in this instance to encompass potentially facilitating a patient’s death. This extension further muddies the murky double effect reasoning waters and creates another challenge to this concept. (shrink)

Two studies reported in the Journal of Medical Ethics add to the growing body of qualitative evidence relating to the use of sedatives at the end of life.1 ,2 Respondents in the two studies affirm a number of important concerns, most of which have been elaborated in the philosophy and palliative care literature, relating to the use of sedation. There seems little doubt that the common moral thread to most of these concerns is the possibility that end-of-life sedation can resemble (...) assisted death.Most of the Dutch respondents in the paper by Reitjens et al1 were reported to believe that sedation does not hasten death. That is an oversimplification. Were it not for the potential to hasten death, I doubt we would be discussing the use of sedatives so frequently in ethics journals. It is true that there is little evidence that sedation significantly hastens death when doses are carefully titrated against symptoms—giving only that amount of a drug necessary to make the patient feel less distressed, and preserving consciousness as far as possible.3 Probably most sedative …. (shrink)

ZusammenfassungDie Palliative Sedierung als therapeutische Handlungsoption in anderweitig refraktären Behandlungssituationen wird in der Öffentlichkeit und in Fachkreisen in ihrer klinischen Wertigkeit grundsätzlich akzeptiert und weitgehend positiv konnotiert. Im Widerspruch dazu fallen sowohl die Quantität der empirischen Forschung als auch die Intensität der ethischen und klinischen Diskussion ins Auge, mit der konzeptuelle als auch durchführungsbezogene Aspekte der Palliativen Sedierung beschrieben und kontrovers erörtert werden. Anstatt eines distinkten Behandlungskonzeptes stellt sich hier eher ein komplexes Spektrum verschiedener Vorgehensweisen dar. Die folgende Übersichtsarbeit fasst (...) anhand der aktuellen Literatur zusammen, welche Aspekte im Kontext der Palliativen Sedierung als problematisch bewertet werden. (shrink)