Ethics

Sedation to Unconsciousness in End-of-Life Care

Code of Medical Ethics Opinion 5.6

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. When a terminally ill patient experiences severe pain or other distressing clinical symptoms that do not respond to aggressive, symptom-specific palliation it can be appropriate to offer sedation to unconsciousness as an intervention of last resort.

Sedation to unconsciousness must never be used to intentionally cause a patient’s death.

When considering whether to offer palliative sedation to unconsciousness, physicians should:

(a) Restrict palliative sedation to unconsciousness to patients in the final stages of terminal illness.

(b) Consult with a multi-disciplinary 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.

(c) Document the rationale for all symptom management interventions in the medical record.

(d) Obtain the informed consent of the patient (or authorized surrogate when the patient lacks decision-making capacity).

(e) Discuss with the patient (or surrogate) the plan of care relative to:

  1. Degree and length of sedation
  2. Specific expectations for continuing, withdrawing, or withholding future life-sustaining treatments

(f) Monitor care once palliative sedation to unconsciousness is initiated.

Physicians may offer palliative sedation to unconsciousness to address refractory clinical symptoms, not to respond to existential suffering arising from such issues as death anxiety, isolation, or loss of control. Existential suffering should be addressed through appropriate social, psychological or spiritual support.

AMA Principles of Medical Ethics: I, VII

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Code of Medical Ethics: Caring for Patients at the End of Life

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