19.8 () Medical and ethical considerations in pall sedation at EOL

Question 1

List common symptoms for pall sedation

Answer 1

Pain
SOB
Vomiting
Delirum

Question 2

What should an MD do if a patient has severe symptoms and patient cannot consent + has no SDM

Answer 2

Seek consensus from at least 1 other senior MD (pall care MD if possible) and hospital ethics committee

Question 3

What is the principle of double effect?

Answer 3

An action with 2 or more effects (at least 1 possible good and 1 possible bad effect) is morally permissible if 4 provisos are met:

• Action must not be immoral itself
• Action must be taken with the INTENTION of achieving good effect(s); possible bad effects may be foreseen but must not be intended
• Action must not achieve the good effect by means of a bad effect
• The action must be taken for a proportionally grave reason

Question 4

When deep pall sedation is being considered, what should MD suggest if patient is on artificial nutrition/hydration

Answer 4

For them to be withdrawn (although this is not an absolute prohibition as long as harms do not outweigh benefits)

Question 5

Pall sedation should be considered only under what circumstances?

Answer 5

1. Patient has severe chronic life threatening illness
2. Patient has severe refractory symptoms
3. Patient GOC focus on comfort
4. Patient GOC must be DNR/do not intubate
5. Informed consent
6. All staff members should be informed if possible (esp nurse, RT, pharmacist)
7. In non-emergent situations, staff members who conscientiously object should be given opportunity to excuse themselves

Question 6

When might “respite” sedation be offered?

What potential possibility must be discussed as part of consent?

Answer 6

1. Incident pain (e.g. during procedure)
2. Severe refractory social/existential suffering - to break cycle of anxiety/distress
3. Patient requests as temporary respite to severe refractory symptoms

Must discuss patient may not reawaken and that death may be unintentionally hastened

Question 7

When starting sedation for patients discontinuing ventilation:
- What medication should be added?
- What medication should be stopped?
- How long to observe patient after ventilation is reduced/removed?

Answer 7

Opioid should be added

Neuromuscular blocking agents should be stopped and effects worn off before starting pall sedation such that resp is not depressed and patient can express discomfort

Observe for 10-15 min