Terminal Sedation as Part of End-of-Life Care

New York Times: “Hard Choices for a Comfortable Death: Drug-Induced Sleep”

Seems that while I have been spending most of my waking hours thinking about care models for frail old people, a new and somewhat disturbing practice has been in play at hospice centers around the world. Terminal sedation or palliative sedation are terms used to describe the intravenous administration of powerful sedative drugs intended to keep dying, suffering patients under deep sedation, until death, while withholding artificial nutrition or hydration.

Most end-of-life practitioners make a distinction between terminal sedation and euthanasia. Euthanasia is the deliberate administration of a lethal drug, at the request of the patient, with the explicit intention to accelerate death. Terminal sedation is not intended to hasten death—it’s used to keep a suffering patient comfortable while the dying process takes its course. The unanswerable question is, What will actually kill the patient: dehydration, starvation, the drugs themselves, or the underlying terminal medical condition(s)?

The New York Times article “Hard Choices for a Comfortable Death: Drug-Induced Sleep” lists the drugs that can be used for palliative sedation, and it is a frightening list indeed: antipsychotics, anesthetics, antianxiety drugs, painkillers. Ironically, some of the drugs on the list are the same used when administering a capital punishment lethal injection.
 
Apparently, terminal sedation is fairly common in hospice centers. Guidelines from the American Medical Association (AMA) were issued in 2008. Unfortunately, however, guidelines at individual hospitals and hospice centers are, understandably, far from uniform. Given the recent flap about “death panels,” health care organizations may be leery about putting too much in writing, preferring instead to keep guidelines general, rather than specific. A notable exception is that of the Metropolitan Hospital Center in New York, where Dr. Lauren Shaiova has written 20 pages of palliative sedation guidelines that cover the topic well.

I would guess that the conversation about the use of powerful sedative drugs takes place in the gray, rather than in the clear-cut black and white. Years ago, I recall my friend Deneen telling me about the conversation she had with her mother’s doctor about the use of sedative drugs. Deneen told the doctor that she wanted to “keep her mother comfortable,” which she thinks was code for permission to give just a bit more sedative drug than necessary for sedation. She felt as if she and the doctor had entered into an unspoken agreement. Deneen’s mother died within hours.

I was about eight months pregnant with my first son when my grandmother died. I was in Phoenix, where my grandmother lived, because my father was in intensive care, and not expected to live much longer. The same weekend (and what a weekend it was), my grandmother began to fail. My aunts and uncles came to her bedside; I was also there. As my grandmother audibly began to take her last breaths, I said, in something of a panic, “Don’t you want to call the nurse? Don’t you want to do something!”

Calmly and quietly, my mother touched my arm and said, “No, I think we need to just let her go. It’s her time.” I’m imagining that’s how it’s going to go for my mother—at least I hope so. I don’t want to deal with the drugs.

By Sara Myers
A Good Enough Daughter Blog