PALLIATIVE SEDATION. AN ETHICAL APPRAISAL Chris GASTMANS KU Leuven - Belgium

Size: px

Start display at page:

Download "PALLIATIVE SEDATION. AN ETHICAL APPRAISAL Chris GASTMANS KU Leuven - Belgium"

Ambrose Hamilton
5 years ago
Views:

1 PALLIATIVE SEDATION AN ETHICAL APPRAISAL Chris GASTMANS KU Leuven - Belgium

2 INTRODUCTION More attention for a humane end of life Great progress in pain and symptom control However, some patients experience refractory symptoms (e.g. nausea, vomiting, pain, shortness of breath, terminal restlessness): Symptoms that cause serious suffering that cannot be alleviated by currently accepted pain treatments: Do not have effects Work too slowly Have unacceptable side effects

3 INTRODUCTION In order to respond to refractory symptoms, palliative sedation (PS) is applied: Intentional administration of sedatives in dosages and combinations as required to reduce the terminal patient s consciousness as much as needed to adequately control one or more refractory symptoms (Boeckaert 2002) Light or deep, intermittent or continuous (until death) Prevalence PS in Europe varies between 2.5% and 16% of all deaths

4 INTRODUCTION Palliative sedation has severe consequences for patient (capacity to act, feel, think and interact with people) and family (loss of contact) PS requires interdisciplinary decision-making process Nurses are intensively involved in PS: Close contact with patient and family Clear overview of the situation

5 INTRODUCTION Palliative sedation and end-of-life decisions Palliative sedation versus euthanasia Ethical evaluation of palliative sedation Recommendations from a nursing perspective

6 END-OF-LIFE DECISIONS Decisions whether to initiate or withhold, continue or withdraw curative or life-sustaining treatments (e.g. cardiopulmonary resuscitation, artificial nutrition and hydration) Decisions whether to alleviate pain and other symptoms (e.g. palliative sedation) Decisions whether to administer purposefully lethal medication (e.g. euthanasia: intentionally terminating the life of a patient by someone other than the patient, at this patient s request)

7 PALLIATIVE SEDATION versus EUTHANASIA Aim: Euthanasia: intentional life terminating PS: effective treatment of refractory symptoms Act: Euthanasia: administration of high doses of lethal medication PS: administration of proportionate doses of sedative medication Result: Euthanasia: death of the patient PS: refractory symptoms and suffering are relieved

8 ETHICAL VALUES Ethics is about values that are anchored in human behaviour. What are the central values that play a role in the ethical deliberations regarding PS?

9 ETHICAL VALUES Dignity of the dying person The dying patient is en remains a person right to the very end; Menschenwürde vs dignity of identity The more than ordinary vulnerability can be a threat to the dignity of the person Caregivers should do everything they can to relieve the suffering of the dying person Being free from bodily suffering as medical and even ethical imperative

10 ETHICAL VALUES Relational autonomy Patient is to be considered as a responsible person Patient can choose and act in a free way Caregiver should inform patient about all relevant aspects of PS (timing, place, risks and benefits, alternatives, informing relatives, ) No PS without informed consent of competent patient Relatives should be involved in shared decisionmaking

11 ETHICAL VALUES Principle of proportionality PS should contribute to best interest of patient (beneficence) Negative aspects of PS (e.g. decrease of consciousness) should be limited as much as possible (nonmaleficence) The intensity of the suffering determines what dosage of sedatives will be administered Sedatives are administered in dosages and combinations required to reduce consciousness as much as necessary to adequately relieve refractory symptoms Proportionality distinguishes PS from euthanasia

12 ETHICAL VALUES Respect for a dignified end of life Life is a fundamental value, but it can in no way be considered as an absolute value When the means of prolonging life do not bring an therapeutic benefit for the patient, life has not to be prolonged Tube feeding can be withheld or withdrawn

13 ETHICAL CONCLUSION PS can be considered when: A specific therapeutic objective (relieve of refractory symptoms) is in view; There is a reasonable chance that this objective can be reached by PS (effectivity) All measures to ensure patient s comfort (e.g. pain relief) are applied; Proportionality between suffering to be relieved and the means (dosages of sedatives) that are used;

14 ETHICAL CONCLUSION Less invasive alternatives are ineffective; The competent patient gives his/her informed consent; Efforts are made to reconstruct the will of the incompetent patient; Shared decision-making with physician, nurses, patient and relatives.

15 RECOMMENDATIONS from a NURSING PERSPECTIVE Decision-making about PS Physician has the legal responsibility for decision concerning PS Nurses fulfill the role as intermediaires between patient, relatives, and physician Nurses can be suppliers of information about the patient s and relatives wishes and on the patient s condition Nurse-physician relationship should foster collaborative decision making.

16 RECOMMENDATIONS from a NURSING PERSPECTIVE Initiation and monitoring PS: Sometimes, nurses bear much responsibility during the initiation and monitoring of PS This can position nurses in a vulnerable situation Nurses responsibility should be supported by clear arrangements with the physician

17 RECOMMENDATIONS from a Education NURSING PERSPECTIVE PS should be covered in basic nursing education PS requires unique skills (working with a team; communication; bedside symptom assessment; technical skills; being culturally sensitive, etc.) and knowledge (pain and symptom control; legal and ethical issues; indications for PS; etc.)

18 RECOMMENDATIONS from a NURSING PERSPECTIVE Ethics policy and procedural guidelines Ethical view on PS (e.g. difference between PS and euthanasia, conscientious objections, informed consent) Procedural guidelines (e.g. decision making, definition, indications, implementation plans, administration and monitoring, psychological support for caregivers)

Patient Self-Determination Act

Holy Redeemer Hospital Patient Self-Determination Act NOTES:: MAKING YOUR OWN HEALTH CARE DECISIONS: As a competent adult, you have the fundamental right, in collaboration with your health care providers,