Tuesday, August 7, 2018

The Role of Palliative Care At End of Life

We have had a number of posts of late regarding medical aid-in-dying, so I was interested in this article in the Washington Post, Assisted suicide is controversial, but palliative sedation is legal and offers peace. The article opens relating one individual's experiences and explains that "[u]nder palliative sedation, a doctor gives a terminally ill patient enough sedatives to induce unconsciousness. The goal is to reduce or eliminate suffering, but in many cases the patient dies without regaining consciousness." The article makes a stark contrast between physician aid-in-dying, which is authorized in a handful of states, compared to "[p]alliative sedation [which] has been administered since the hospice care movement began in the 1960s and is legal everywhere." The article notes that palliative care is not without concerns, mainly moral lconcerns on the part of health care providers, with variations in policies throughout hospitals.

Where is the line between terminal sedation and euthanasia, ponders the article, with positions offered on both sides.

[M]any doctors who use palliative sedation say the bright line that distinguishes palliative sedation from euthanasia is intent. ... "There are people who believe they are the same. I am not one of them,” said Thomas Strouse, a psychiatrist and specialist in palliative-care medicine at the UCLA Medical Center. “The goal of aid-in-dying is to be dead; that is the patient’s goal. The goal in palliative sedation is to manage intractable symptoms, maybe through reduction of consciousness or complete  unconsciousness.”

Others, including the National Hospice and Palliative Care Organization, recommend that providers use as little medication as needed to achieve “the minimum level of consciousness reduction necessary” to make symptoms tolerable.

The question often posed is whether terminal sedation will hasten death, and in some cases, no antibiotics, nutrition or hydration are provided and whether death occurs sooner depends in large part on the person's condition. As one expert noted, "in all cases the goal isn’t death but relief from suffering."

When is the use of terminal sedation appropriate? The article discusses its use to relieve "existential suffering" which is defined by "the hospice and palliative-care group ... as 'suffering that arises from a loss or interruption of meaning, purpose, or hope in life.'" In comparing it to aid-in-dying, it may provide an option for those who are not eligible for aid-in-dying assistance.  "Whether palliative sedation truly ends suffering is not knowable, although doctors perceive indications that it does."



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