Authors: Michael S. Putman, John D. Yoon, Kenneth A. Rasinski,and Farr A. Curlin

Journal of Pain and Symptom Management, December 2012 online

Intentional Sedation at the End of Life: Not the Norm

Palliative sedation therapy is an ethically acceptable means of relieving suffering at the end of life. Symptoms such as pain or anxiety may increase as a patient approaches death, and may not always be relieved by medications directed at these symptoms. The use of sedation to relieve distress may lead to unconsciousness as an unintended consequence. A debate has emerged regarding whether it is ethically permissible to sedate a dying patient in such a way as to intentionally make the patient unconscious until the patient dies. This practice has been referred to as “slow euthanasia.” Even more controversial is the use of sedation to relieve physical symptoms or to relieve psychological symptoms of impending death.

The use of sedation to intentionally make a patient unconscious until death, and opinions of this practice by US physicians was evaluated. Questionnaires were completed by 1156 physicians asking them if they had ever sedated a patient with the intention of achieving unconsciousness until death, appropriateness of sedation in response to a vignette in which a patient had control of her physical symptoms but existential suffering and attitudes towards sedation to unconsciousness. Only one in ten physicians reported having sedated a patient with the specific intention of making the patient unconscious until death in the past 12 months. These physicians were more likely to have been born in the US or had more than 11 patients die in the past year. The majority of physicians (72%) did not find it appropriate to sedate the patient with existential suffering. While most physicians agreed that unconsciousness is an acceptable side effect of palliative sedation, they did not feel it should be directly intended.

Intentional sedation of patients to unconsciousness until death is not the norm among practicing clinicians in the US. There is support for accepting unconsciousness as an unintended consequence of sedation for refractory symptoms in dying patients.

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