The Definition of Palliative Sedation.

The New York Times printed an article yesterday on the contentious use of palliative sedation. It's by the fantastic Anemona Hartocollis who has been writing about end of life care for over a year now. From the article:

Among those choices is terminal sedation, a treatment that is already widely used, even as it vexes families and a profession whose paramount rule is to do no harm.

Doctors who perform it say it is based on carefully thought-out ethical principles in which the goal is never to end someone’s life, but only to make the patient more comfortable.

But the possibility that the process might speed death has some experts contending that the practice is, in the words of one much-debated paper, a form of “slow euthanasia,” and that doctors who say otherwise are fooling themselves and their patients.

There is little information about how many patients are terminally sedated, and under what circumstances — estimates have ranged from 2 percent of terminal patients to more than 50 percent. (Doctors are often reluctant to discuss particular cases out of fear that their intentions will be misunderstood.)

While there are universally accepted protocols for treating conditions like flu and diabetes, this is not as true for the management of people’s last weeks, days and hours. Indeed, a review of a decade of medical literature on terminal sedation and interviews with palliative care doctors suggest that there is less than unanimity on which drugs are appropriate to use or even on the precise definition of terminal sedation.

Discussions between doctors and dying patients’ families can be spare, even cryptic. In half a dozen end-of-life consultations attended by a reporter over the last year, even the most forthright doctors and nurses did little more than hint at what the drugs could do. Afterward, some families said they were surprised their loved ones died so quickly, and wondered if the drugs had played a role.

Whether the patients would have lived a few days longer is one of the more prickly unknowns in palliative medicine. Still, most families felt they and the doctors had done the right thing.

Wesley J. Smith has of course weighed in on the article to try to clarify some of Hartocollis' grey areas. He does so because he (and most doctors and the US Conference of Catholic Bishops) support what is called the "double effect," the use of sedation until death in order to alleviate suffering but not hasten death, but strongly work to distinguish it from "euthanasia" or, well, hastening death. As Smith writes:

First, it shouldn’t be called terminal sedation because death isn’t the intent. The words we use matter in this debate. Second, I don’t know of any palliative expert that opposes sedation as a last resort legitimate medical tool. Indeed, if properly applied based on otherwise uncontrollable symptoms, palliative sedation isn’t slow motion euthanasia because the issue isn’t whether life is “shortened.” The issue is whether the physical suffering of the patient could not otherwise be alleviated. If not, and sedation is applied, then if death comes sooner–and as the article points out, there is usually little way to tell–it is a side effect of a legitimate treatment.

In this regard, it is important to remember that any medical treatment can have a lethal side effect. That isn’t the same thing as mercy killing. Consider: Sometimes patients die earlier than they would otherwise have during surgery intended to save life. That is no more euthanasia than dying from legitimately applied pain control

Criticisms of legitimately applied palliative sedation, as mentioned above, may be based on a vitalistic notion that anything that results in an earlier death is killing. But as noted above, that clearly isn’t true. Perhaps, more often, it is intended to blur the lines between euthanasia and palliation, to make the former easier to justify politically.

Among the intentional line blurrers is the assisted suicide advocacy organization Compassion and Choices–formerly the Hemlock Society–that clearly has ambitions to become the Planned Parenthood of death. C & C was the moving force behind pernicious legislation in California two years ago–AB 2747–that as originally written would have given a legal right to patients with one year or less to live to demand sedation and withdrawal of food and fluids–without regard to whether their symptoms warranted such radical action–so that death would be caused by dehydration. (That part of the bill was defeated.)

In fact, the lawyer for Robert Baxter argued before the Montana Supreme Court on September 2nd in an appeal case to determine the constitutionality of aid in dying that there was no "bright line" between palliative sedation and aid in dying. The only differences are the documentation required of aid in dying (or Death with Dignity in Washington and Oregon where it is legal) and the "intention of the doctor."

It is this intention that Smith and others wish to judge as part of "the culture of death" or the "double effect," one of the other. From Hartocollis, it becomes quite clear that doctors wish only to prevent suffering.