CCBI News: Sedation in Palliative Care at End-of-Life

May 13, 2024

Dear Friends of CCBI,

Sedation in Palliative Care at End-of-Life

In talking about palliative care at end-of-life it is important to discuss ethical problems as well as its undoubted benefits. Dr Jose Pereira explains the benefits succinctly and clearly in the CCCB’s “Horizons of Hope” program, helping us understand what is available to make our last days on earth as comfortable and pain-free as possible.

One of the most common questions asked in that setting is about Catholic teaching on the ethics of palliative sedation. Most of us think of such sedation as treatment for pain and distress at end of life, but in recent years it is sometimes used as a way of bringing about death gradually, by steadily applying a dose beyond necessity. While Catholic teaching approves the use of palliative, or deep, sedation when used to sedate, it is completely against its use with the intention of inducing death, yet another form of euthanasia.

As long as the intention is to ease pain and suffering, Catholic teaching allows this type of sedation, even if it might bring about death slightly earlier than predicted. There have been ethical concerns about that aspect, but studies over the years confirm that earlier death is far from an inevitable result, and, in any case, such treatment remains morally justifiable when its intended use is to ease pain and suffering.

Does palliative, deep sedation hasten death?

From a clinical perspective, most articles, including one highly regarded review in the Journal of Pain and Symptom Management a few years ago, concurred that palliative sedation used as treatment for pain does not necessarily have a life-shortening effect. Used ethically as sedation, it relieves suffering and is an integral part of palliative care. This is, of course, encouraging for patients and their families. Doses vary from light to deep sedation, depending on the amount of suffering involved and the varying responses of individual patients. Some people wake up from light sedation with their pain abated, or are brought to the surface to check on their condition and assessment, which can be a blessing for themselves and an opportunity to communicate with their families as life draws to a close.

Framework for Use

Palliative sedation was adopted by the European Association of Palliative Care (EAPC) and described in the journal, Palliative Medicine, as:

…the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family, and health-care providers.

The Association strongly emphasizes that all clinical aspects of palliative sedation must be ethical and involve careful explanation of procedures to patients, families and staff. It makes clear that:

Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations.

When is palliative sedation advised?

Sedation is considered for patients in the terminal stage with severe physical distress when there is a lack of other measures that could be used without adverse results. It may also be considered for what the article describes as “severe non-physical symptoms such as refractory depression, anxiety, demoralization or existential distress.”

Current practice is that the level of sedation should be the lowest necessary to provide adequate relief. Some patients react well, enabling them to continue to respond in some way to those interacting with them, while, at a higher dosage level, some do lose that capacity. It is reassuring for both patients and families that doses can be lowered at times to check on the patient’s condition, to decide whether to continue their level of sedation, and to interact with their family. Deeper sedation may be required and advised if mild sedation is ineffective.

Care of the Family

Situations in which a patient is sedated are likely to be distressing to family members, who are usually encouraged to stay close to their loved ones, providing the opportunity to pray and talk with them where possible, and to say goodbye. Care teams usually provide regular information to the family about the patient’s condition, degree of suffering, anticipated changes or, when appropriate, notification that death is approaching, pointing out what can be expected in the dying process. Dr Pereira explains much of this in the “Horizons of Hope” program, which is extremely useful for those of us in these situations who have no medical background. Given the nature of deep sedation, families need reassurance that other methods have been ineffective, that it can be discontinued if needed, and that from the ethical point of view it does not hasten death. It is intended to relieve pain and suffering and is not a form of euthanasia. As such, it is an important part of end-of-life decision making in ensuring a comfortable and peaceful death in situations where its need is clearly indicated.

Horizons of Hope: A Toolkit for Catholic Parishes on Palliative Care – Canadian Conference of Catholic Bishops (cccb.ca)
European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care – PubMed (nih.gov)
Clinical Aspects of Palliative Sedation in Prospective Studies. A Systematic Review – Journal of Pain and Symptom Management (jpsmjournal.om)

Pope Francis’ Intentions for May:
For the formation of religious and seminarians

We pray that religious women and men, and seminarians, grow in their own vocations through their human, pastoral, spiritual and community formation, leading them to be credible witnesses to the Gospel.

Moira and Bambi