NHPCO position on palliative sedation for imminently dying patients
May 15, 2010
NHPCO has just issued its position paper on palliative sedation, “National Hospice and Palliative Care Organization (NHPCO) Position Statement and Commentary on the Use of Palliative Sedation in Imminently Dying Terminally Ill Patients.” Available from the website of the Journal of Pain and Symptom Management at the link below, the paper was written by Timothy W. Kirk, PhD, and Margaret M. Mahon, PhD, RN, FAAN, for the Palliative Sedation Task Force of NHPCO’s Ethics Committee.
The paper defines palliative sedation as “the lowering of patient consciousness using medications for the express purpose of limiting patient awareness of suffering that is intractable and intolerable.” NHPCO says that it should be considered “for the limited number of imminently dying patients who have pain and suffering that is (a) unresponsive to other palliative interventions less suppressive of consciousness and (b) intolerable to the patient.”
The statement addresses availability of terminal sedation for the patients defined above, proportionality (titration of the medication to the minimum level needed to relieve suffering), and the need for interdisciplinary evaluation, ongoing education for all involved in administering it, and the distinction between palliative sedation and assisted suicide. The Ethics Committee was unable to reach a consensus on the use of palliative sedation for existential suffering. NHPCO therefore “strongly urges providers to carefully consider this question and supports further ethical discussion. NHPCO also encourages research within and across disciplines to build an evidence base supporting multiple interventions for existential suffering.”
The commentary carefully defines all the terms used in the position statement and discusses each point. It also examines the indications for palliative sedation, and the issues which should be discussed before initiating it – concurrent life-sustaining therapies, artificial nutrition and hydration, the proximity to death, and the level of sedation.
NHPCO recommends regularly reviewing the use of palliative sedation, which should be a formal process. It also recommends “developing and implementing a written institutional policy addressing 1) the criteria and procedure for administrating palliative sedation, 2) the concomitant use of life-sustaining therapies, 3) ongoing education regarding evolving clinical evidence and best practices as well as important ethical distinctions between sedation and assisted suicide or euthanasia, and 4) careful monitoring and collection of data related to institutional practices of palliative sedation.” (Journal of Pain and Symptom Management Website, www.jpsmjournal.com)
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