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Guideline for Palliative Sedation – Royal Dutch Medical Association (KNMG) 2009

2.2 Definition of palliative sedation s. 18

Palliative sedation is defined by the committee as:

The deliberate lowering of a patient’s level of consciousness in the last stages of life.

The committee has deliberately opted for a definition that is as factual as possible. It does not think that the definition should include normative elements or descriptions that can be regarded as preconditions for good medical practice. These are discussed in subsequent chapters.

The definition has three elements, in that it refers to action that:

1. lowers the level of consciousness;

2. is deliberately taken;

3. relates to a patient in the last stages of life.

3.1 Indications for palliative sedation s. 22

Indications for palliative sedation are present when one or more intractable or ‘refractory’ symptoms are causing the patient unbearable suffering. A symptom is, or becomes, ‘refractory’ if the following applies:

None of the conventional modes of treatment is effective or fast-acting enough, and/or if these modes of treatment are accompanied by unacceptable side-effects.

Existential suffering as a factor in the decision-making process s. 24

Like pain, existential suffering may be among the refractory symptoms that go to make up unbearable suffering. In such cases, this existential suffering cannot be alleviated, for instance by communication or spiritual support. These patients have often been through a great deal of distress, and have gradually come to embrace the notion of continuous sedation. They are often extremely ill and weak, close to death, and have a range of physical complaints, some of them often severe. The patient’s body has reached its end, literally and figuratively, and everything that needed saying has been said. Some of these patients do not want to experience their final days consciously and may request continuous sedation. The feeling that one’s existence is empty or meaningless (existential suffering) may in itself cause unbearable suffering.

4. The decision-making process s. 28

This decision-making process can be divided into three stages:

1. the initial proposal;

2. determining whether indications for palliative sedation are present;

3. consultation with the patient and/or his representative(s).

Conclusions s. 59

Administration of fluids.

The vast majority of patients have virtually ceased eating and drinking by the time palliative sedation is initiated and die within a few days afterwards. In cases where the patient has a life expectancy of no more than one to two weeks, hydration is not a relevant factor in the decision on initiating continuous sedation. The committee feels that artificially administering fluids to patients under deep, continuous sedation is medically futile and may even exacerbate suffering.

Annexe III Relationship between continuous, deep sedation and action intended to terminate life s. 68

If practised properly, palliative sedation must be described as a normal medical procedure. This means that the indications for it and its use in medical practice are determined by current standards within the medical profession, and that it is the right of patients to receive palliative sedation (like other normal medical procedures), provided the accepted indications and preconditions are present. Euthanasia, and termination of life generally, is not regarded as a normal medical procedure; there is therefore no such thing as a right to euthanasia. Provided that continuous, deep sedation is administered proportionately (that is, using drugs and dosages tailored to achieve the requisite degree of symptom control), it cannot be regarded as a form of termination of life.