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Opinion 2.201 - Sedation to Unconsciousness in End-of-Life Care

The duty to relieve pain and suffering is central to the physician’s role as healer and is an obligation physicians have to their patients. Palliative sedation to unconsciousness is the administration of sedative medication to the point of unconsciousness in a terminally ill patient. It is an intervention of last resort to reduce severe, refractory pain or other distressing clinical symptoms that do not respond to aggressive symptom-specific palliation. It is an accepted and appropriate component of end-of-life care under specific, relatively rare circumstances. When symptoms cannot be diminished through all other means of palliation, including symptom-specific treatments, it is the ethical obligation of a physician to offer palliative sedation to unconsciousness as an option for the relief of intractable symptoms. When considering the use of palliative sedation, the following ethical guidelines are recommended:

(1) Patients may be offered palliative sedation to unconsciousness when they are in the final stages of terminal illness. The rationale for all palliative care measures should be documented in the medical record.

(2) Palliative sedation to unconsciousness may be considered for those terminally ill patients whose clinical symptoms have been unresponsive to aggressive, symptom-specific treatments.

(3) Physicians should ensure that the patient and/or the patient’s surrogate have given informed consent for palliative sedation to unconsciousness.

(4) Physicians should consult with a multidisciplinary team, if available, including an expert in the field of palliative care, to ensure that symptom-specific treatments have been sufficiently employed and that palliative sedation to unconsciousness is now the most appropriate course of treatment.

(5) Physicians should discuss with their patients considering palliative sedation the care plan relative to degree and length (intermittent or constant) of sedation, and the specific expectations for continuing, withdrawing, or withholding future life-sustaining treatments.

(6) Once palliative sedation is begun, a process must be implemented to monitor for appropriate care.

(7) Palliative sedation is not an appropriate response to suffering that is primarily existential, defined as the experience of agony and distress that may arise from such issues as death anxiety, isolation and loss of control. Existential suffering is better addressed by other interventions. For example, palliative sedation is not the way to address suffering created by social isolation and loneliness; such suffering should be addressed by providing the patient with needed social support.

(8) Palliative sedation must never be used to intentionally cause a patient's death. (I, VII)

Issued November 2008 based on the report "Sedation to Unconsciousness in End-of-Life Care," adopted June 2008.