Winter 2003 Vol. 10, Issue 1
Question: A 51-year-old man suffered intractable pain from widespread bony metastases of lung cancer. Pain management required over 3000 mg per day of controlled- release oxycodone (OxyContin), high-dose daily fentanyl patches (Duragesic), high-dose glucocorticoid therapy, and large dosages of benzodiazepines. He had declined placement of an intraspinal opiate pump because of fatigue, cachexia and the wish to avoid invasive procedures. One weekend evening, his physician received a desperate call from the patient's wife that he was frantic with pain. On admission, he was writhing, moaning and restless. After discussing treatment options with his wife, the physician ordered intravenous midazolam (Versed). Impressively large doses were required to sedate him adequately but adequate sedation and pain palliation was accomplished without obvious respiratory depression. No hydration was given other than that necessary for pain palliation. The physician was concerned that sedating him in this way would accelerate the moment of death and therefore might be construed as euthanasia. How would you advise the physician?
Response: Despite widespread ethical and legal support for terminal sedation (TS), concern persists that this is a form of euthanasia. Furthermore, a few prominent proponents of the legalization of physician-assisted suicide (PAS) and voluntary active euthanasia have intentionally minimized the distinctions between TS and euthanasia and have argued that the similarities are strong reasons to legalize PAS. 1,2
Nevertheless, there are important ethical and legal distinctions between TS and euthanasia that justify permitting the former in appropriate circumstances while prohibiting the latter. Indeed, the U.S. Supreme Court, in its landmark decision stating that there is no constitutional right to PAS, explicitly endorsed TS as an acceptable legal alternative to PAS for patients with intractable suffering. 2
Before discussing the ethical issues, it is important to comment on two medical issues. First, although it is not clear from this vignette whether a hospice referral had been made prior to his admission, this patient with widespread bony metastases from lung cancer, severe pain, fatigue and cachexia appears to have been very appropriate for hospice support. Second, it should be emphasized that, when such a patient is terminally sedated, opiates should be continued at doses equi-analgesic to those previously used (usually given intravenously) to avoid worsening of pain as well as opiate withdrawal symptoms.
Terminal sedation - perhaps more properly called palliative sedation - consists of sedating a patient to the point of unconsciousness to relieve one or more symptoms that are intractable and unrelieved despite aggressive symptom-specific treatments, and maintaining this condition until the patient dies. Typically, artificial hydration and nutrition are withheld, as they no longer offer any benefit to the patient and may cause adverse effects, such as pulmonary edema. In rare cases, terminal sedation may be initiated in patients who are alert and cognitively intact but suffer from one or more severe and intractable symptoms. In such cases, because TS is likely to significantly shorten the patient's life, its use remains controversial. However, in most instances of TS, patients are suffering from terminal delirium in combination with other symptoms, such as pain or dyspnea, and are imminently dying. In these cases, because it is very unlikely that TS shortens the patient's life significantly (indeed there is some evidence is may slightly prolong it) the use of TS is much less controversial. 3-5
This patient appears to fall into the latter category. Whether sedated or not, it is unlikely that this patient will ever again take food or fluid orally or survive more than a few days to a week or two. As in most cases of TS, it is difficult to imagine an alternative method of keeping this patient comfortable for whatever time he has left. To assure that comfort cannot be achieved otherwise, once he is sedated and receiving appropriate intravenous opiates, it might be reasonable to cautiously lighten his level of sedation to determine whether he can be comfortable and awake. However, it is unlikely that this will be possible and therefore, to assure his comfort, resuming aggressive sedation will be necessary. Furthermore, because he appears to be imminently dying of his advanced cancer and has already suffered greatly, and because such an "experiment" is most likely only to increase his suffering, it is by no means obligatory.
The principle of double effect is often used to justify TS, on the assumption that it may hasten death. According to this principle, an action which may have both a good effect and a bad effect is ethical if it fulfills the following criteria: 1) the act itself is not unethical; 2) the good effect is the intended effect whereas the bad effect, though foreseeable, is not intended and there is no alternative of achieving the good effect while avoiding the bad effect; 3) the good effect is not achieved by means of the bad effect; and 4) the good effect is sufficiently desirable to compensate for the allowing of the bad effect. 6 Thus, TS is ethical because: 1) sedation itself is not unethical; 2) although TS may hasten death, death is not intended and comfort cannot be achieved without this risk; 3) comfort is achieved as a direct result of sedation and not by means of death; and 4) for a terminally ill patient, comfort is more important than slightly prolonging life. In contrast, euthanasia is unethical because: 1) killing itself is generally unethical; 2) death is intended and comfort could be achieved by other means (e.g. TS); 3) comfort is only achieved by means of death; even though 4) for a terminally ill patient, comfort is more important than prolonging life.
Therefore, even if TS does shorten the patient's life, it is not equivalent to euthanasia and is an appropriate and ethical form of palliative care for this patient.
Robert M. Taylor, MD
Medical Director
Mount Carmel Palliative Care Services
Columbus, OH
Outcome: The patient was admitted and sedated with intravenous midazolam (Versed) to produce comfort. He died on the third hospital day.
Footnotes
1 Quill TE, Lo B, Brock DW. Palliative options of last resort: a comparison of voluntary stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia.JAMA 1997;278:2099-104.
2 Orentlicher D. The Supreme Court and physician-assisted suicide: rejecting assisted suicide but embracing euthanasia. N Engl J Med 1997;337:1236-9.
3 Lynn J. Terminal sedation (letter). N Engl J Med 1998;338:1230.
4 Quill TE, Byock IR. Responding to intractable suffering: the role of terminal sedation and voluntary refusal of food and fluids. Ann Intern Med 2000;132:408-14; (see also letters: Ann Intern Med 2000;133:560-2).
5 Rousseau PC. Palliative sedation. Am J Hosp Palliat Care 2002;19(5):295-7.
6 Sulmasy DP, Pellegrino ED. The rule of double effect: clearing up the double talk. Arch Intern Med 1999;159:545-50.
in collaboration with
Dartmouth-Hitchcock Medical Center
The opinions expressed in the journal, Lahey Clinic Medical Ethics,
belong to the individual contributors and do not represent the institutional position
of Lahey Clinic on any subject matters discussed.
