1. TERMINAL SEDATION TERMINAL SEDATION- Ethical implications in different situations James Hallenbeck, MD, Medical Director, VA Hospice Care Center, Stanford Hospice

2. Objectives Define terms Review the historical context of terminal sedation Consider the ethical implications of sedation relative to two hypothetical cases: –a patient with severe, unrelieved pain, who is actively dying –a disabled, but not dying patient, who requests sedation

3. Alphabet Soup PAS (Physician Assisted Suicide) VE (Voluntary Euthanasia) TS (Terminal Sedation)

4. Terminal Sedation- a Definition “…[T]he intention of deliberately inducing and maintaining deep sleep, but not deliberately causing death in very specific circumstances. These are: 1. For the relief of one or more intractable symptoms, when all other possible interventions have failed and the patient is perceived to be close to death, or 2. For the relief of profound anguish (possibly spiritual) that is not amenable to spiritual, psychological, or other interventions, and the patient is perceived to be close to death.” Chater, ‘98

5. Historical Context of Terminal Sedation Term first introduced 1991 Growing debate over interventions that do or might hasten death –Oregon Death with Dignity Act –Supreme Court hears two cases on PAS 1997 –Jack Kevorkian TS- a football between pro-assisted suicide and anti-assisted suicide camps

6. Terminal Sedation Pro PAS Anti PAS Hastens death via direct physician intervention- slow euthanasia Lack of standards/oversight Causes death via dehydration Lacks dignity + costly, as patients linger Alleviates suffering without hastening death Differs from euthanasia as intent NOT to hasten death Evidence lacking that death significantly hastened

7. Case 1 Mr. Jones Terminal cancer Pain poorly relieved despite appropriate analgesics Very close to death –No longer eating or drinking –likely will die in a matter of days Patient/family agree that sedation is indicated to relieve pain

8. Case 2 Mr. Smith Patient is paralyzed secondary to spinal cord trauma, but able to eat Suffering arises from a sense of indignity and economic burden on family No physical discomfort Patient not depressed, mentally competent Patient requests sedation to end his suffering

9. What Do These Cases Have in Common? Requests for sedation from competent patients Both patients suffering mightily Physician could sedate with only the intent of alleviating suffering, not hastening death

10. How Do They Differ? Mr. Jones’ suffering is primarily related to physical pain Mr. Smith’s suffering is more purely psychic Mr. Jones actively dying –Doubtful sedation would hasten death Mr. Smith is not overtly dying –If not given artifical hydration/nutrition, sedation would hasten death

11. Questions Raised by These Cases Would the use of TS in these cases be morally equivalent? –If not, why note? Is there a causal relationship between sedation and death in both cases- does it matter? Is it essential that the patient be terminally ill? Does it matter what nature of suffering is experienced?

12. The Autonomy Argument Competent, people, who are free from coercive forces, have a right to act autonomously unless a great harm would occur through such action

13. Arguments for Not Complying with Requests for Death Hastening Interventions Contrary to God’s will Contrary to physician’s role as healer Requests may not be made free of coercion Societal impact –slippery slope, less attention to palliative care Loss of potential for growth at the end-of-life

14. The Mercy Question How do we demonstrate mercy for suffering that might only end with death? –what are the limits of mercy? Do we have different obligations in trying to relieve different forms of suffering?

15. Intent and it’s Relation to Outcome Vacco v. Quill –“The law has long used actor’s intent or purpose to distinguish between two acts that may have the same result…” Renquist Difficulty of determining intent (Quill) If the outcome is a hastened death, does intent matter?

16. Terminally Ill Important or Unimportant? Principle of proportionality –From Rule of Double Effect: An unintended bad effect may be accepted as an unavoidable consequence if the good effect (relief of suffering) is proportionately greater in magnitude than the bad effect (hastened death) Potential for finding other means to relieve suffering less in those closer to death Proximity to death more useful concept

17. Mr. Smith and Mr. Jones Does it matter that Mr. Smith’s suffering is largely physical and Mr. Jones’ suffering is psychic?

18. Hydration and Nutrition in Terminal Sedation Not a problem in dying patients, who have already stopped eating and drinking Where sedation would keep a patient from eating/drinking- –Address through informed consent Declining of hydration/feeding- act of patient Sedation- act of physician

19. Summary Opinion Mr. Jones- sedation OK because: –no other way to relieve pain –close to death –no evidence sedation would substantially hasten death Mr Smith- sedation NOT OK because: –dangerous precedent (sedation for economic suffering) –potential for suffering to end via other means –disproportionate burden in hastening death in this patient not otherwise dying