Terminal Sedation: An Acceptable Exit Strategy?

Dying well” (1) remains an elusive goal in America (2). Only gradually is comprehensive palliative care gaining acceptance as the standard of care for alleviating suffering and promoting patient autonomy near the end of life (3). In addition to symptom management, advance care planning, and psychosocial support, such care may encompass a variety of ethically charged practices, one of which, terminal sedation, is the subject of the report by Rietjens and colleagues in this issue (4).

At one end of the ethical spectrum, end-of-life care includes withdrawal or withholding of life-sustaining treatment, which is now legally and ethically accepted in the United States and which precedes up to 84% of hospital deaths (5). At the other extreme is voluntary euthanasia, in which the physician ends a patient's life at his request, a practice that is illegal in the United States but not in the Netherlands. In between is physician-assisted suicide, where the physician provides the means, usually in the form of a prescription for a barbiturate, for a competent, terminally ill patient to end her life. Although the U.S. Supreme Court found no constitutional right to physician-assisted suicide, individual states may legalize the procedure, as did Oregon with its Death with Dignity Act, or ban it, as did Washington and New York (6). Another strategy for patients to exercise control over the dying process is to refuse food and drink. While this approach ostensibly enables patients to end their suffering without medical intervention, physicians are expected to withhold artificial nutrition and to alleviate resulting symptoms such as agitation (7). …