Palliative sedation

The term palliative sedation is preferred rather than terminal sedation and is in general use. The term terminal sedation could lead to misunderstandings. Linguistically, it would appear that this form of sedation leads to death. That cannot indeed be entirely excluded, but it is certainly not the intention. Palliative sedation should be understood to be sedation in the terminal phase.

This can be described as ‘Keeping a terminal patient in a state of reduced consciousness by means of high dosages of a sedative (= strongly relaxing) drug’. This can be temporary or continuous, superficial or deep.

Motives

The reasons for palliative sedation are serious symptoms that cannot (or can no longer be) influenced, such as serious shortness of breath/impending suffocation, serious restlessness/confusion, serious long-term nausea or (peaks of) untreatable pain. This is purely the treatment of symptoms, in order to reduce the patient's suffering. This last point is essential. Often, drugs are administered at the request of close relatives because they ‘cannot bear to see it any longer’. The question is: who suffers the most?

Difference

The difference with palliative pain treatment lies mainly in the fact that pain is usually not the primary factor of the suffering referred to, or cannot be treated with the appropriate means or techniques.

In practice

As mentioned above, palliative sedation (if indicated) is applied to a terminal patient, so a patient for whom the condition is such that death is inevitable and will soon take place. This can be deduced from a few physical characteristics: strongly reduced and eventually completely stopped fluid and food intake and often a changed breathing pattern.

It is of great and principle importance to distinguish between whether the patient no longer wants to take fluids and food because he is dying, or whether the patient no longer wants fluids and food (or receives them!) in order to speed up the dying process.

In the first case it is a natural dying process, while in the second case it is conscious terminal dehydration that is difficult to defend on Biblical grounds.
Even if it is clear that the dying process has started, it is still a good thing to continue to offer food, and especially fluids. Proper oral care is essential, while everything should be done to make things as pleasant as possible for the patient, including any medicines that can provide relief. In this phase, artificial food and fluids and (other) medical measures are usually no longer administered.

The application of deep and continuous sedation in this last stage of life lasts for a period of no more than a week. Usually the drug midazolam (Dormicum®) is used, this substance resembles Valium, with which for instance IC departments have decades of experience. The drug causes a seemingly natural sleep which does not shorten the life itself. Consequently the patient dies from the underlying illness. Morphine is unsuitable for this purpose: it is primarily an analgesic with some sedation as a side-effect, but it may make some patients euphoric or confused.