Regarding Dr. Glick's comments, alleviation of severe symptoms by deep sedation is a rather frequently applied medical procedure for terminal patients, in the Netherlands as well as in other countries (1). We have shown that deep sedation is typically used for patients who are close to death and who have severe symptoms. Most of these patients wouldn't receive artificial nutrition or hydration regardless of whether they are sedated because they are in the dying phase. Forgoing artificial nutrition or hydration is usually not based on an explicit decision in these cases, certainly not on a decision that resembles euthanasia. Furthermore, forgoing artificial nutrition or hydration in dying patients is, at least in the Dutch context, regarded as being morally different from actively providing lethal drugs, as in euthanasia. Therefore, in general, terminal sedation cannot be seen as being equivalent to, or counted as, euthanasia.

Of course, similar to other medical procedures at the end of life, terminal sedation should meet criteria for prudent practice. For example, medical treatments should be provided for the right indications after discussion with and the informed consent of the patient or, if the patient is not competent, the patient's relatives. We have shown that these criteria are met in the large majority of cases. Dr. Glick also expresses fear that it becomes easier for Dutch physicians to actively end life after the first time they do so. Previous research has shown that this is not true (2).

Our data show that the practice of terminal sedation seems to approximate the practice of euthanasia in a limited number of cases. Dr. Zylicz is concerned about the risk that terminal sedation might be used as a "surrogate" for euthanasia. We agree that terminal sedation should be used only for the right indications, after a careful decision-making process and in a medically and technically appropriate way.