Dutch doctors turn to ‘continuous deep sedation’ to keep official euthanasia figures low

Christian Medical Comment: The Lancet report showing that euthanasia rates have not increased in the Netherlands since legalisation in 2002 will no doubt be seized upon by enthusiasts for decriminalisation in the UK and elsewhere but the figures are not at all what they seem at first sight and the press release sent out by the journal is selective and misleading in its reporting of the facts.

If you read the press release sent by the Lancet (reproduced by Medical Xpress) it all seems cut and dried. . . . But if you read the abstract along with the full article and accompanying comment you get a very different picture altogether.

The key fact which should alert people to something odd going on is the reference to ‘continuous deep sedation’ in the Netherlands which appears in the article’s abstract but tellingly (and perhaps even disingenuously) not in the Lancet press release.

The abstract states, ‘Continuous deep sedation until death occurred more frequently in 2010 (12.3% [11.6—13.1; 789 of 6861]) than in 2005 (8.2% [7.8—8.6; 521 of 9965]).’ But what was the rate of ‘continuous deep sedation until death’ in 2001 and previously?

On examining the article we learn from table 1 that it was not measured in 1990 and 1995 and was 5.6% in 2001. In other words there has been a steady increase in this category of cases which in 2010 accounted for 16,700 deaths. Over the same period the number of deaths after ‘intensified alleviation of symptoms’ has also increased from 20.1% to 36.4% and now accounts for over 49,500 deaths annually.

Sedated to death? When "comfort care" becomes dangerous

When the unknown actual incidence of terminating awareness-or insuring unawareness-in patients with stroke, dementia or other serious illnesses is factored in, the use of terminal sedation as a form of "comfort care" may well be approaching epidemic proportions, even outside the hospice area. As a former hospice nurse and now as an ICU nurse caring for some patients who turn out to be dying, I support the appropriate use of pain and sedating medications as ethical comfort care. However, even in circumstances where such medications are necessary, I have never seen a case where a patient "needed" to be made permanently unconscious.HLA

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

The death of euthanasia

It is time to discard the word euthanasia because it mixes ideas and values that confuses the debate about dying, states an editorial in the Canadian Medical Association Journal.

The term, euthanasia, is from the Greek and was coined in 1646. It was intended to mean a gentle and easy death. A nuance was introduced, by 1742, referring to the means of bringing about such a death and, in 1859, to the action of inducing such a death. Modern dictionaries have a variety of definitions, but they all imply the same meaning, an intentional action to bring about death in someone who is suffering.

"Euthanasia's broad meaning has inadvertently enveloped a set of actions that also involve the relief of symptoms in dying people," write the authors. "For example giving enough narcotic to relieve pain in cancer patients and adding enough sedation to enable comfort and minimize agitation is appropriate and compassionate care, even when the amounts required increase the probability of death. It can be argued that, in such circumstances, death becomes an acceptable side-effect of effective palliation. But, in our view, it is not euthanasia."

Physicians can help by not using "euthanasia" to refer to actions taken to assist dying patients and instead, can clearly name and define each action as well as its possible repercussions. PhysOrg

Ethics at the end of life

A recent study of dying children in Boston suggests doctors ended their lives with morphine, sometimes at the urging of parents. Bioethicist Jeffrey Kahn talks about the dilemmas faced by doctors who are in a position to assist a suicide or hasten death. MPR

What makes a 'good death'?

In Leo Tolstoy's famous novella The Death of Ivan Ilyich, the title character is suddenly struck down by a terminal illness. In his dying days, he screams in agony and rails against his misfortune, blind to the fact that he has lived a selfish life, putting his career before his wife and children. In his last hours he finally gives in to his fate and becomes reconciled to his family.

The story is cited in a recent paper by the Lancet which addresses the controversial issue of pain control in terminally-ill patients. The article says there is such a thing as a “good death” and the desire, especially among relatives to control pain whatever the cost, can have unintended consequences. Chief among these is that many dying patients do not get a chance to make their farewells at the end of life because they are too sedated. Irish Times

Quebec Doctors Want "Euthanasia" Practices Acknowledged, Legalized

Doctors are already euthanizing patients in Quebec hospitals, the Quebec government's legislative committee on the “right to die with dignity” heard yesterday. The Federation of Quebec Medical Specialists and the Quebec College of Physicians asked for the province to develop clear policies on how doctors can bring about a patient's death, stating that currently doctors believe they could be charged with murder for giving a “palliative sedative” to a patient before they have reached the point of death.

Palliative sedation is the practice of relieving the pain of a patient on his or her death bed by administering pain medication. In the effort to relieve a patient's pain, it can sometimes happen that the dose of pain medication is increased to lethal levels, resulting in the patient's death. Ethicists have typically clearly delineated between palliative sedation, in which death is an unintended effect of legitimate care, and euthanasia, which is the intentional ending of a patient’s life.

Alex Schadenberg, executive director of the Euthanasia Prevention Coalition, insists that the proper use of palliative sedation does not constitute euthanasia, and that the medical practice has been upheld by the courts. Doctors, he says, are not risking criminal charges for the practice. LifeSiteNews

Hard Choice for a Comfortable Death: Sedation

In almost every room people were sleeping, but not like babies. This was not the carefree sleep that would restore them to rise and shine for another day. It was the sleep before — and sometimes until — death. NY Times