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Surveyed Neurologists Agree That Sedation for the Immediately Dying Differs From Euthanasia
A recent survey of neurologists said that the management of pain in patients who are close to death can be challenging and is not always effective. For patients that are experiencing pain that is difficult to manage, sedation is one treatment approach. This practice, known as palliative sedation and sedation for the imminently dying (SFTID), often raises concerns because many believe that it is equivalent to euthanasia. A recent survey on the use of SFTID shows that neurologists recognize that the goal of SFTID is to relieve suffering and not cause a patient's death, and thus is distinct from euthanasia.
Michael A. Williams, M.D., medical director of The Sandra and Malcolm Berman Brain & Spine Institute, a member of the Ethics Committee at Sinai Hospital, and noted expert in the area of end-of-life care, notes that, "Few healthcare facilities have guidelines, and if they do, the guidelines often lack specificity. It is hoped that this survey will increase the level of discussion in this very important area and lead facilities to develop policies so that neurologists will have clear guidance in determining the appropriate use of SFTID."
Members of the American Academy of Neurology Ethics Section were sent the survey about their views on SFTID, including its intent, and whether they thought that it is morally or legally equivalent to euthanasia. The survey also asked them to answer whether the use of SFTID was acceptable or unacceptable in five different case scenarios that were written to describe ethically and medically significant differences in context.
Results of the survey were recently reported in an article by James A. Russell, D.O.; Michael A. Williams, M.D., and Oksana Drogan, M.S., in the journal Neurology. A total of 96% of the 154 respondents agreed or strongly agreed that the primary purpose of SFTID was to relieve suffering, 83% disagreed or strongly disagreed that SFTID was morally equivalent to euthanasia, and 85% disagreed or strongly disagreed that SFTID was legally equivalent to euthanasia. For the case scenarios, 92% agreed or strongly agreed that SFTID was acceptable for imminently dying patients with metastatic cancer, while 50% agreed or strongly agreed that SFTID was acceptable for patients with end-stage amyotrophic lateral sclerosis, and only 7% agreed or strongly agreed that SFTID was acceptable for posttraumatic quadriplegic patients not at risk for imminent death.
An area of concern is whether drugs that are administered to the imminently dying to ease their pain also hasten death.
James A. Russell, D.O., director of the Curt and Shonda ALS Clinic at Lahey Clinic Medical Center in Burlington, MA, and a member of the Lahey Ethics Section, stated that, "We have no objective means by which to measure pain. That's where some of the controversy lies." He added that no evidence has demonstrated that palliative sedation hastens death.
According to James L. Bernat, M.D., professor of neurology and medicine in the department of Neurology at Darmouth Medical School, SFTID and euthanasia are differentiated by three criteria: "The intent of palliative sedation should be to palliate, not to kill. Drugs chosen for palliative sedation must have palliative indications, [and] the drugs chosen must be administered in appropriate doses for palliation."
The distinction between SFTID and euthanasia has been clearly elucidated in The Netherlands, where both procedures are regulated and practiced legally. The 2009 Guideline for Palliative Sedation of the Royal Dutch Medical Association states that "Palliative sedation is a normal medical procedure and is of a different order from euthanasia." Furthermore, the guideline concludes that "properly practiced, continuous, deep sedation cannot be used to 'get round' the requirements and procedures for euthanasia and achieve the same aim (i.e., of shortening life) in a more gradual and surreptitious way."
LifeBridge Health, one of the largest, most comprehensive providers of health services in Northwest Baltimore, includes Sinai Hospital, Northwest Hospital, Levindale Hebrew Geriatric Center and Hospital, Courtland Gardens Nursing & Rehabilitation Center, and related subsidiaries and affiliates. For more information, visit www.lifebridgehealth.org.