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Last-Resort Options for Palliative Sedation
- Timothy E. Quill, MD;
- Bernard Lo, MD;
- Dan W. Brock, PhD; and
- Alan Meisel, JD
- From the Center for Ethics, Humanities and Palliative Care, University of Rochester Medical Center, Rochester, New York; Program in Medical Ethics, University of California, San Francisco, San Francisco, California; Harvard Medical School, Boston, Massachusetts; and Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, Pennsylvania.
Abstract
Despite receiving state-of-the-art palliative care, some patients still experience severe suffering toward the end of life. Palliative sedation is a potential way to respond to such suffering, but access is uneven and unpredictable, in part because of confusion about different kinds of sedation. Proportionate palliative sedation (PPS) uses the minimum amount of sedation necessary to relieve refractory physical symptoms at the very end of life. To relieve suffering may require progressive increases in sedation, sometimes to the point of unconsciousness, but consciousness is maintained if possible. Palliative sedation with the intended end point of unconsciousness (PSU) is a more controversial practice that may be considered for much fewer refractory cases. There is more ethical consensus about PPS than PSU. In this article, the authors explore the clinical, ethical, and legal issues associated with these practices. They recommend that palliative care and hospice programs develop clear policies about PPS and PSU, including mechanisms for training and ensuring competency for clinicians, and approaching situations where individuals or institutions may conscientiously object.
Article and Author Information
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Grant Support: Dr. Lo has received financial support from the National Institutes of Health (grant MH062246) and the Greenwall Foundation.
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Potential Financial Conflicts of Interest: Royalties: A. Meisel (Aspen [Wolters Kluwer]).
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Corresponding Author: Timothy E. Quill, MD, Center for Ethics, Humanities and Palliative Care, University of Rochester Medical Center, Box 687, 601 Elmwood Avenue, Rochester, NY 14642.
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Current Author Addresses: Dr. Quill: Center for Ethics, Humanities and Palliative Care, University of Rochester Medical Center, Box 687, 601 Elmwood Avenue, Rochester, NY 14642.
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Dr. Lo: Program in Medical Ethics, University of California at San Francisco, Room C126, 521 Parnassus Avenue, San Francisco, CA 94143-0903.
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Dr. Brock: Division of Medical Ethics, Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston MA 02115.
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Dr. Meisel: Center for Bioethics and Health Law, University of Pittsburgh, 3900 Forbes Avenue, Pittsburgh, PA 15260.
