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Responding to Intractable Terminal Suffering
- Timothy E. Quill, MD; and
- Ira R. Byock, MD
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•Type with double-spacing
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Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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IN RESPONSE:
Yanow and Krakauer are concerned about misinterpretation of the term terminal sedation. This term was chosen after considerable discussion within the College's End-of-Life Care Consensus Panel. Dr. Yanow rightly sees that we are distinguishing terminal sedation from the usual situation of “double effect,” in which death is unintended but the increased risk for death is foreseen (1). He fears that adverse judicial interpretation of a physician's intention in cases of terminal sedation may cause physicians to underprescribe in other settings.
Dr. Krakauer notes that “palliative sedation,” sometimes called “heavy sedation,” is used to relieve severe symptoms in other circumstances (for example, burn patients who require extensive, painful debridement) (Goldstein-Shirley J, Jennings B, Rosen E. Total sedation in hospice and palliative care. In preparation). The expectation for survival and the use of other life-prolonging therapies help to distinguish “palliative sedation” or “heavy sedation” from the subcategory of “terminal sedation.” Terminal sedation usually precludes the concomitant use of life-sustaining therapies such as artificial ventilation and hydration. The expectation is that the patient will remain sedated until death.
“Terminal sedation” does not connote an intention to hasten death, nor does it imply that the sedative medication is the causative agent of death. The word terminal applies because death is the expected end point of the treatment. The physician's purpose in administering sedative medications is to ensure relief from intractable suffering, rather than causing death (2). Some patients and families accept terminal sedation with the hope of an earlier death, whereas others focus exclusively on the relief of suffering. The terminology finally selected should foster respect for and understanding of the gravity of the intervention, while making it accessible to those in need (3).
Sulmasy and colleagues erroneously report that our article suggests using sedation “to make people unconscious and unable to eat so that they may die more quickly … .” Instead, we explicitly stated that “The purpose of the medications is to render the patient unconscious to relieve suffering, not to intentionally end his or her life.” Patients in the terminal phase of illness can refuse to eat and drink and have the right to refuse artificial nutrition and hydration. These decisions by autonomous patients must not preclude the use of terminal sedation should intractable suffering subsequently develop.
The guidance proposed is intended to restrict these “last resort” practices to the relatively rare patients whose suffering does not adequately respond to standard palliative care measures. A second opinion is required by a palliative care specialist and by a mental health specialist (if there is uncertainty about the patient's mental capacity). Although they require no changes in the law, these practices are erratically available and are not subject to any oversight or monitoring. Policy statements by professional bodies could help ensure that these decisions are made with care and caution.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
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