PVH 13e jaargang –
2006 nr. 1/2, p. 7-8
Palliative Sedation
Dr. J. Keen
Jeremy
Keen is palliatief consulent in Groot-Brittannië
The use of sedative medication in those with life
threatening illnesses continues to cause significant intellectual and
emotional discussion and often disharmony among professional and lay
carers alike. The basic difficulty for professional carers lies in our
objectives and basic tenets of our professions; to relieve suffering
but to do no harm.
“First I will define what I conceive medicine to be. In general
terms, it is to do away with the sufferings of the sick, to lessen the
violence
of their disease…..
… I will follow that method of treatment which, according to my ability
and judgement,, I consider for the benefit of my patients, and abstain
from whatever is deleterious and mischievous. I will give no deadly
medicine to anyone if asked, nor suggest any such counsel.”
Hippocrates
(460-377 B.C.)
But
what is suffering? Clearly this is a question that has occupied
philosophers and theologians throughout human history. But
if we are called as doctors to “…do away with the suffering
of the sick…” it is incumbent upon us, corporately and perhaps
more importantly, as individuals, to have some form of working
definition.
“Suffering occurs when an impending destruction
of the person is perceived; it continues
until the threat of disintegration has passed
or until
the
integrity of the person can be restored in some other manner.”
Cassell
(1991)
The
specialty of Palliative Medicine was recognised by the Royal
Colleges of Physicians in the UK in 1987 in attempt to formalise
training and coordinate research so that the ‘integrity’ of
the person with incurable illness can be restored / maintained
by aggressive attention to all possible interventions, physical
(pain and symptom control), social and psycho-spiritual. In
the UK there are now over 200 specialist palliative care inpatient
units in which approximately 25% of all cancer deaths occur.
There are over 300 hospital support teams involved in the care
of patients with life limiting illnesses in hospital and a
similar number of community-based teams assisting in the care
of patients in their own homes.
Specialist palliative care has made an enormous impact in the easing
of suffering both directly and indirectly through education programmes delivered
to non-specialist health care providers. However, it is clear that no intervention,
other than euthanasia, can take away all suffering, particularly the non-physical
aspects associated with incurable illness. At best physical and non-physical
suffering can be relieved to an extent which preserves personhood and allows
individuals to live to their optimum potential. This requires time and effort
in those professional and non-professional carers accompanying the patient
on their journey. Indeed the profound effect of the mere fact of ‘being accompanied’
is often underestimated and undervalued by health care professionals. It is
not surprising, therefore, that if the situation of patients entering the final
stages of life is viewed superficially, solutions such as euthanasia or palliative
sedation (used in some contexts as an alternative with little legal governance
surrounding its practice) are allowed to flourish.
Palliative Sedation has been defined variously as ‘Sedation for intractable
distress in the dying’ (Chater et al., 1998) to ‘Slow euthanasia’ (Billings
et al., 1996). I wish to argue for the former definition and against any use
of sedation used intentionally to either partly or explicitly hasten death
(Rietjens et al., 2004). The practice of rendering a patient unconscious who
is not obviously in the last hours / day of life and not providing hydration
or nutrition so that death ensues primarily from renal failure should justifiably
be termed ‘slow euthanasia’ and be subject to the same legal and ethical controls
as euthanasia by lethal injection.
However, the judicious use of sedatives to relieve distress remains an
intrinsic part of good palliative care. Such distress may be secondary
to refractory physical symptoms, of which pain and breathlessness are
the most common or,
more frequently, psychospiritual anguish. Refractory symptoms have been
defined as; Symptoms that cannot be adequately controlled despite aggressive
efforts to identify a tolerable therapy that does not compromise consciousness
(Cherny and Portenoy, 1994). The vast majority of patients receiving
palliative care
will require the intermittent use of sedatives for episodes of psychospiritual
distress, fewer will need regular sedatives at a level which does not
cause unconsciousness, fewer still at a level which does cause loss of
consciousness and, lastly a very small minority needing continuous sedation
for control
of
refractory physical symptoms. If the use of continuous sedation is being
contemplated there are several important questions that need to be asked
by the responsible
care team before and during the use of sedatives:
Whose
distress
is being treated?…….the patient, relative,
carer, ours?
Is
the distress truly refractory?
What
is the patient’s interpretation
of their situation?
What
religious views are held?
Are
there any less drastic means
to relieve the distress?
If
these questions are asked and alternative approaches have not
proved helpful, it is important to consider which drug to use
and also to consider a short period (approximately 48 hours)
of deep sedation followed by a lightening to review the ongoing
need to render unconscious. It is outwith the scope of this
short article to review the pharmacology of sedation but if
sedation is the desired effect it is necessary to use sedatives.
Opioids are not sedatives but sedation is one of the many side-effects
of this group of drugs. Side-effects that include delirium,
restlessness, myoclonus and hyperalgesia (often manifested
as a total body, superficial pain). Patients at the end of
life with reduced fluid intake and hence reduced drug clearance
may be particularly susceptible to toxicity. The maintenance
of renal function in the early stages of delirium is one of
the reasons that many palliative care physicians will administer
parenteral fluid, subcutaneously and overnight so as to be
as unobtrusive as possible.
Clearly it could be argued that rendering a patient unconscious with
the use of continuous sedation will, potentially, shorten life
by rendering the patient more susceptible to chest infection or thromboembolic
events. If
the team is convinced by the answers to the screening questions
and there really is no less drastic means of relieving distress,
then sedation is justified
despite the possibility of shortening life. This is of course
reliant upon the integrity of the clinical decision-making process.
“There
is a significant difference between continuing
to value the patient’s life while forseeing that
it will be shortened by giving or omitting
treatment and seeing life as having no value
and thus to deliberately curtailed.”
Catholic
Church of England and Wales, 2004
I believe
all clinicians abide closely with the wish to relieve as much suffering
as possible. Slow euthanasia will, of course, achieve this end but
it can be too easy; any body can prescribe sedatives to send someone
to sleep. Let us rise to the challenge of being more creative with
our prescribing, of daring to spend more time with our patients
learning what their journey means for them. If we do so, we may
be surprised that for a relatively small investment of time there
may be huge rewards for our patients and their families but also
for our own satisfaction as clinicians.
A
Happy View
……So
take a happy view –
This Lawn graced with the candle-flames of crocus,
Frail-handed girls under the flowering chestnut,
Or anything will do
That time takes back before it seems untrue
And, if truth were told,
You’d count it luck, perceiving in what shallow
Crevices and few crumbling grains of comfort
Man’s joy will seed, his cold
And hardy fingers find an eagle’s hold.
C. Day Lewis
REFERENCES
Billings
et al., Journal of Palliative Care 1996;12:21-30
Cassell,
Journal of Clinical Ethics. 1991; 2:81-2
Chater
et al., Palliative Medicine 1998; 12:255-69
Cherny
and Portenoy, Journal of Palliative Care 1994;10:31-38
Rietjens
et al., Annals of Internal Medicine 2004;141:178-85
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18 June, 2015 10:06