Terminal sedation

The terminal sedation is a procedure doctor for that conceptually there is still no clear definition and is still controversially discussed. Essentially it is the administration of drugs with a strong calming effect and sedative to a person who is on the verge of death. Because there is in principle the possibility of accelerating the death of the patient through a measure of this kind, the boundary between terminal sedation and euthanasia is diffuse and controversial. For this reason, many doctors prefer to use the concept of palliative sedation . In addition, in the case of some medical associations, terminal sedation practices are considered as a subset or a particular type of palliative sedation that is applied in the agony phase.

In palliative medicine 

Specialized professionals in palliative medicine understand the concept of terminal sedation medication administration that reduce the level of consciousness of the dying patient, or even completely disabled, in order to alleviate their most pressing, such as pain symptoms, Anguish or fear in the last vital phase. Thus, this sedation – which should univocally serve life and not death – would make the time remaining to death live in a more acceptable and bearable way.

According to this definition, control of the symptom would be the only goal of terminal sedation. In the same vein, the anesthetist and Berlin physician, Hans-Christof Müller-Busch, a specialist in palliative medicine, published in (2004) in the Zeitschrift für Palliativmedizin (Journal of Palliative Medicine) studies to demonstrate that patients under terminal sedation They would not die faster than those who do not receive these medicines with a strong tranquilizing and analgesic effect. The researcher reports that, for example, two thirds of his own patients undergoing terminal sedation in the last hours of life were able to ingest liquids and that 13% could even consume solid foods.

In palliative medicine, terminal sedation is considered an obvious and natural component of symptom control; a procedure that according to current standards would not lead to the shortening of life and therefore it has been unfairly placed as a neighboring practice to euthanasia or killing tendiendes to patients illegally measures.

An international group of experts developed and published guidelines for the indication and procedure of palliative sedation. In the final report they elaborated, the most critical aspects of this concept are discussed: is terminal sedation really only used as a last possibility in relieving symptoms? Is it lawful to use it also in the case of psychosocial burden (“vital suffering”)? Is it permissible to apply it only at the end of life, or can it be used also in the course of serious illness? As the Müller-Busch investigations show, with the increase of this practice has increased the fraction of terminal sedation due to psychosocial causes. 1

For its part, the Spanish Society of Palliative Care has developed some guidelines, definitions and ethical considerations. It was preferred to distinguish clearly the concepts of “palliative sedation” and “terminal sedation”, defining them separately. 2 In conjunction with the Medical College, has developed an accurate guide that aims to regulate the procedure in this type of sedation 3 Similarly, the Spanish Association Against Cancer, has also tried conceptual boundaries, defining the terminal sedation That particular type of palliative sedation that occurs in the agony. The Association emphasizes the correct identification of the moment when it can be safely affirmed that an agonizing phase has already begun and in the use of a standard procedure, by a professional qualified especially for the application of this type of measures. 4

The situation in the United Kingdom is not without controversy and there too scientific investigations have been undertaken to objectify the problem. According to a 2009 study, 16.5% of deaths in the UK between 2007 and 2008 occurred under the effects of continuous deep sedation. 5 6 7 8 Moreover, a survey conducted in 2009 among almost 4,000 UK patients whose care had taken effect following the rules of the ” Care Pathway Liverpool for the dying patient , ” yielded the result that while 31% Had received low doses of medication to control anxiety, agitation or restlessness, only 4% had required higher doses. Referring to Fig.

Procedure

Terminal sedation is generally performed using a benzodiazepine , mainly Midazolam and then in combination with morphine or other pain reliever like that is hard cash. These drugs are administered usually in a intravenously or subcutaneously .

Sedation may be carried out continuously or intermittently and may have a deep sedative effect (with loss of consciousness) or a flatter or shallow sedation (with preservation of the state of consciousness). There are no precise guidelines or uniform practice for feeding fluid and nutrient solutions during terminal sedation.

Critical Reflections

In the medical technical literature whether terminal sedation should or should not be classified as discussed again and again euthanasia and, if so, if that would be a an active, passive or indirect. 10 Ultimately this depends essentially on the intention of the treating physician, which in each individual case is strongly colored by subjectivity and in many ways eludes any objective criterion. eleven

Heike Faller said in 2004 in the weekly Die Zeit :

Diese terminale Sedierung umstritten ist, kann sie das Leben oder die letzten verkürzen bewussten Momente rauben. Ohne begleitende Schmerztherapie könnte es sein, dass ein Kranker nur ruhiggestellt wird, aber dennoch Schmerzen hat. Ein Arzt, der selbst solche Beruhigungsmittel bekam, berichtete von entsetzlichen Alpträumen und schwor, sie niemals mehr einem Patienten zu verabreichen. “This terminal sedation is controversial, it can shorten life or steal the last conscious moments. Without simultaneous therapy for pain, it may be that a patient is only sedated, and yet has pain. A doctor who received sedatives such recounted after having suffered terrible nightmares and vowed never more give them to a patient. ” 12

The Deutsche Gesellschaft für Humanes Sterben (German Society for Human Death) stated in 2003 in its institutional magazine Humanes Leben – Humanes Sterben ( “Living human – human Die”) the risk of abuse associated with the concept of terminal sedation and The risk of minimization or makeup:

Der Trend, auch in Deutschland läuft auch auf eine versteckte Euthanasie ohne den Willen des Patienten, die durch sogenannte ‘terminale Sedierung’ (englisch: ‘terminal sedation’) hinaus. Unter ‘Sedierung’ versteht man (auch euphemistisch, also beschönigend und verhüllend verwendet) die Dämpfung von Schmerzen und die Beruhigung eines Kranken durch Beruhigungsmittel und Psychopharmaka; Ein natürliches Sterben kann auf diese Weise vorgetäuscht werden (wie auch bei der sogenannten ‘indirekten Sterbehilfe’). “The tendency, also in Germany, is directed towards hidden euthanasia, even without the patient’s will, through the so-called ‘terminal sedation’ (sedation) (also used as euphemism, That is, made up, concealed) is understood as the attenuation of pain and the reassurance of a patient through tranquillizers and psychotropic drugs, so that a natural death can be simulated (as in the so-called indirect euthanasia).

Last but not least, the experiences in the Netherlands also indicate the risks of terminal sedation. There, under certain conditions, active euthanasia is not punishable since 2002. According to a survey published in 2004 ( Annals of Internal Medicine ) behind every sixth terminal sedation is the intent to cause death. In 47% of cases, the acceleration of death was indicated as part of the formulation of indications and in 17% of cases it was the explicit intention of the doctors.

A recent investigation by Murray et al. published in the British Medical Journal 13 shows that between 2001 and 2005 the number of neerladeses killed in the framework of a terminal sedation increased, while it decreased the number of those killed by active euthanasia. This may indicate that terminal sedation is increasingly being considered as an alternative to euthanasia. In fact, according to these investigators, one out of every ten patients who received end-stage sedation would have previously been refused access to their desire for active or passive euthanasia.

The Spanish Association of Bioethics and Medical Ethics (AEBI) has also not withdrawn from the international debate on the regulations of this practice and has opined against the possible use of this type of sedation for “psychosocial” purposes, stating that “it is necessary to avoid In intention, word and action the most remote indication that sedation in agony is established to relieve the pain of family members or the workload of the people who attend