Rethinking Guidelines for the Use of Palliative Sedation

The use of continuous palliative sedation to unconsciousness rests on a consensus that leads quickly to controversy. Although there is consensus that it should be used only for terminally ill patients and even then reserved for cases in which severe symptoms persist despite efforts to find an alternative palliative treatment, authorities disagree about whether PSU is appropriate for existential suffering and about how close to death the patient should be before PSU is introduced. Some authorities stipulate that PSU should be withheld until the patient is within hours to days from death, while others specify no particular time frame. A patient sedated to unconsciousness generally dies from dehydration in two weeks or less unless—as in fact typically happens—they die first from the underlying disease.

There is also a consensus within medicine that PSU is a medical treatment and is therefore not tantamount to active euthanasia. However, the consensus also holds that PSU should be subject to restrictions that do not otherwise apply to medical treatments. In short, PSU is both a medical treatment and subject to restrictions that are extraordinary in medicine. Medical authorities have not articulated a cogent medical and ethical rationale for this seeming contradiction. Hastings Center