Tuesday, January 24, 2012

Palliative Sedation

I once had a patient enter a hospice house for an unusual reason.  I entered the room to meet my patient, an older gentleman with cancer, who sat in bed surrounded by his wife and adult children. When I asked him about why he’d been admitted to our hospice house, his answer took me completely off guard.

I expected to hear about a pain crisis or other symptom. Instead, he very frankly said, “I am here for you to give me an injection so that I’ll die today.”  I learned that the grown children had flown in from out of state for this proposed event. I assume they had watched a similar moment in a movie, and thought one could just enter a hospice facility and request death.

Needless to say, I did not honor his request, nor could I, as his request is known as euthanasia and is illegal in the United States.

Euthanasia, as practiced in the Netherlands is the termination of life by a physician, at the request of a patient. Oregon, Washington, and Montana allow for something different known as physician assisted suicide.  It is different because the patient administers their own medication, not the physician. This practice, where a doctor gives a prescription for medication intended to hasten death is illegal in Kansas.

For both of the above procedures, one of the stipulations is for there to be suffering in lieu of a terminal illness. So, as residents of Kansas, what can be done if extreme suffering occurs as death approaches? 

As a palliative care physician, whose chief task is the reduction of suffering, this is indeed an important question. Patients on hospice do have an option to alleviate suffering without directly causing death. This process is called palliative sedation.

In brief, palliative sedation is basically putting someone in a medically induced coma to relieve intractable suffering, similar to the unconsciousness one is in during surgery. Like surgery, this coma does not cause death. There are three conditions that must be met to initiate palliative sedation. One, there are no other alternative medications that can be used to treat the suffering. Two, the goal is to relieve suffering, not to shorten life. Three, and most importantly, the patient must already be near death. Palliative sedation is not for someone who has been diagnosed with cancer, has months to live, but doesn’t want to tolerate the physical decline. 

I will be honest; I have not yet had a patient who needed palliative sedation in my practice. Perhaps I just haven’t worked long enough, but I’d like to think that the reason is aggressive medication management of symptoms before a climax point of refractory suffering is reached. 

The key is that palliative sedation is an option. For some, just knowing that something can be done for profound suffering is reassuring. It’s also yet another reason to consider hospice, not just to have the option, but hopefully eliminate the need for sedation through aggressive symptom management.

As for my patient, after the initial disappointment, he went on to live several more months, and quality months at that!

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