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Position Statement and Commentary on the Use of Palliative Sedation in Imminently Dying Terminally Ill Patients – National Hospice and Palliative Care Organization (NHPCO) 2010

Introduction s. 1-2

Palliative sedation is the lowering of patient consciousness using medications for the express purpose of limiting patient awareness of suffering that is intractable and intolerable. For the limited number of imminently dying patients who have pain and suffering that is (a) unresponsive to other palliative interventions less suppressive of consciousness and (b) intolerable to the patient, NHPCO believes that palliative sedation is an important option to be considered by health care providers, patients, and families.

Position Statement

• Availability

Palliative sedation is an important tool among the spectrum of therapies available in hospice and palliative care. For the small number of imminently dying patients whose suffering is intolerable and refractory, NHPCO supports making the option of palliative sedation, delivered by highly trained health care professionals, available to patients.

• Proportionality

The goal of palliative sedation is to provide relief from symptoms that are otherwise intolerable and intractable. Since the goal is symptom relief (and not unconsciousness per se), sedation should be titrated to the minimum level of consciousness reduction necessary to render symptoms tolerable.

• Interdisciplinary Evaluation

(…) NHPCO recommends the practice of convening an interdisciplinary conference specifically about the use of

palliative sedation for each patient with whom it is being considered. Such conferences should include practitioners from many disciplines who can speak to the modalities available in their disciplines and discuss

the degree to which they have been tried and exhausted.

• Education

In addition to expertise in palliative care, those involved in palliative sedation must have training and competence in this particular intervention. As with all health care providers, those involved in the process of providing palliative sedation should be engaged in ongoing education. This education should address symptom assessment and management as well as the ethical considerations related to use of palliative sedation. Education must also address family-centered care.

• Concerning Existential Suffering s. 2

Having carefully reviewed the data and arguments for and against using palliative sedation for existential suffering, the Ethics Committee is unable to reach agreement on a recommendation regarding this practice. NHPCO strongly urges providers to carefully consider this question and supports further ethical discussion. NHPCO also encourages research within and across disciplines to build an evidence base supporting multiple interventions for existential suffering.

• Relationship to Euthanasia and Assisted Suicide s. 3

Properly administered, palliative sedation of patients who are imminently dying is not the proximate cause of patient death, nor is death a means to achieve symptom relief in palliative sedation. As such, palliative sedation is categorically distinct from euthanasia and assisted suicide.

Continuation of Concurrent Life-Sustaining Therapies s. 5

Implementation of palliative sedation cannot be done without simultaneous consideration of other therapies being received by, or available to, the patient. In this document, palliative sedation is being considered for the patient whose death is imminent (defined as expected in less than two weeks). NHPCO recommends that all patients receiving palliative sedation have a do-not-resuscitate/do-notattempt-resuscitation order in effect.

Concerning Artificial Nutrition and Hydration s. 5

Patients being lightly sedated may be able to eat or drink as desired. Patient-controlled intake of food and fluids is unlikely, however, with moderate to deep sedation. Consideration of whether to begin or continue artificial nutrition and hydration (ANH) should be discussed with the patient and family before beginning palliative sedation. Any decision about ANH should be made separately from a decision about palliative sedation.

Proximity to Death s. 5

(…) there may be some situations in which patient suffering is so severe and refractory to other interventions that proximity to death becomes far less important than the relief of suffering itself.