Journal of Palliative Care & Medicine
Open Access

Palliative sedation is a medical practice recognized and commonly used at the end of life for patients who are experiencing refractory symptoms that cannot be controlled by other means of medical management. This practice involves the administration of sedative medications to alleviate severe distress, particularly when other interventions have proven insufficient. However, concerns about potentially hastening death by suppressing a patient's respiratory drive have surrounded palliative sedation [1 -3]. Traditionally, this medical practice has been considered ethically justifiable via the application of the ethical doctrine known as the principle of double effect. Despite recent evidence suggesting that palliative sedation is safe and effective when properly titrated and does not hasten death, the principle of double effect continues to be utilized to justify this practice, even if it entails a small risk of hastening a patient's death. One less common clinical scenario where the Principle of Double Effect may still be appropriate ethical justification for palliative sedation is when it is pursued concurrently with the active withdrawal of life-sustaining treatment, particularly in the case of compassionate extubation [4].

Understanding palliative sedation

Palliative sedation, often referred to as terminal sedation, is employed when a patient is experiencing unbearable suffering, typically in the final stages of a terminal illness. The primary goal is to provide relief from refractory symptoms such as severe pain, dyspnea, or agitation [5]. This practice involves the administration of sedative medications, carefully titrated to achieve the desired level of comfort while maintaining the patient's comfort and dignity.

The principle of double effect

The Principle of Double Effect is an ethical doctrine that has been invoked to justify certain medical practices that may have both a positive and negative consequence. In the context of palliative sedation, it provides ethical guidance for healthcare professionals. The principle stipulates that an action may be morally permissible if it meets the following criteria:

• The action in question is morally good or at least morally neutral.

• The good effect is intended, while the bad effect is merely foreseen but not intended.

• All other options to achieve the good effect have been exhausted.

The unconventional case: palliative sedation and compassionate extubation

Compassionate extubation is a medical practice in which lifesustaining mechanical ventilation is withdrawn when further treatment is deemed futile or when the patient or their surrogate decision-maker chooses to discontinue such support. In this challenging scenario, a patient may be experiencing distressing symptoms, such as air hunger, as they are taken off the ventilator [6,7]. Palliative sedation can be employed in these cases to ensure that the patient remains comfortable and free from suffering during the process of extubation.

In the described case study, the application of the Principle of Double Effect was particularly relevant. The healthcare team faced the ethical dilemma of discontinuing life-sustaining treatment while simultaneously initiating palliative sedation. The intention was to provide compassionate care by withdrawing futile interventions while ensuring the patient's comfort and dignity. The use of palliative sedation was not meant to hasten the patient's death but rather to relieve suffering [8 -10 ].

Conclusion

Palliative sedation remains a crucial tool in providing compassionate end-of-life care for patients with refractory symptoms. While recent evidence suggests its safety and effectiveness, the ethical doctrine of the Principle of Double Effect continues to guide its use. In unconventional cases where palliative sedation coincides with compassionate interventions like extubation, this ethical framework can help healthcare providers navigate complex moral decisions, ultimately prioritizing the well-being and comfort of the patient as they approach the end of life.

Acknowledgement:

Not applicable.

Conflict of interest:

Author declares no conflict of interest.

1. Hackett J, Ziegler L, Godfrey M, Foy R, Bennett MI (2018) Primary palliative care team perspectives on coordinating and managing people with advanced cancer in the community: A qualitative study. BMC Fam Pract 19:177.

Indexed at, Google Scholar, Crossref

2. Nordly M, Vadstrup ES, Sjogren P, Kurita GP (2016) Home-based specialized palliative care in patients with advanced cancer: a systematic review. Palliat Support Care 14:713-724.

Indexed at, Google Scholar, Crossref

3. Plas AG, Pasman HRW, Scweitzer B, Onwuteaka-Philipsen B (2018) Improving palliative care provision in primary care: A pre- and post-survey evaluation among PaTz groups. Br J Gen Pract 68:351-359.

Indexed at, Google Scholar, Crossref

4. Higgins JPT, Thomas J, Chandler J, Cumpston MLT, Page M, et al. (2022) Cochrane Handbook for Systematic Reviews of Interventions Version 6.3. John Wiley & Sons: Hoboken, New Jersey, USA.

Google Scholar

5. Silva M, Barros T, Baixinho C, Costa A, Sa E, et al. (2023) The Effectiveness of Home Care Coordinated by Primary Health Care to Improve the Care Management of People in Palliative Cancer Care: A Systematic Review Protocol.
6. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, et al. (2021) The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 88:906

Indexed at, Google Scholar, Crossref

7. Stone MJ (2001) Goals of care at the end of life. Proc Bayl Univ Med Cent 14:134-137.

Indexed at, Google Scholar, Crossref

8. Haj-Ali W, Moineddin R, Hutchison B, Wodchis WP, Glazier RH (2020) Role of Interprofessional primary care teams in preventing avoidable hospitalizations and hospital readmissions in Ontario, Canada: A retrospective cohort study. BMC Health Serv Res 20:782.

Indexed at, Google Scholar, Crossref

9. Duggleby WD, Degner L, Williams A, Wright K, Cooper D, et al. (2007) Living with hope: initial evaluation of a psychosocial hope intervention for older palliative home care patients. J Pain Symptom Manag 33:247-257.

Google Scholar , Crossref

10. Walsh K, Jones L, Tookman A, Mason C, McLoughlin J, et al. (2007) Reducing emotional distress in people caring for patients receiving specialist palliative care. Br J Psychiatry 190:142-147.

Indexed at, Google Scholar , Crossref