Wednesday, 31 August 2011

Liverpool care Pathway – Doubletalk Or Newspeak?

The coupling of the word “terminal” with sedation refers to the intention and effect, as does the use of “palliative” with sedation. The intention of terminal sedation is that the person dies from the action. The withdrawal of fluids and nutrition seems to be the method by which this is achieved. It is legally tolerated as part of a medical protocol that is unchallenged and, apparently, unchallengeable. This protocol is the Liverpool Care Pathway.
 It is important to note that when a person is deeply and continuously sedated and hydration and nutrition is withdrawn, that the outcome is clear. This person will die of dehydration. 
Alex Schadenberg

“The act of deep continuous sedation of a person, who is not yet nearing death, combined with the withdrawal of hydration and nutrition, when death by dehydration occurs — this is an act of euthanasia.

“In this circumstance, the death was not caused by the person’s condition but rather by the intentional decision to dehydrate the person to death.
“This is often referred to as ‘slow euthanasia’ because the death is intentionally caused by dehydration, and yet it takes longer to complete the act of euthanasia than giving a person a lethal injection….
“When a person is terminally ill and actually nearing death, the withdrawal of hydration and nutrition is not euthanasia because the person dies of their medical condition.”

It may be that the use of the word “terminal” in the context under discussion is designed deliberately to confuse. Those who promote doctor-assisted death or euthanasia often blur the natural and obvious distinctions by the use of emotive but otherwise meaningless catchphrases.
Early Terminal Sedation (ETS)

Victor Cellarius writes in the Journal of Medical Ethics -
Although terminal sedation has received widespread legal and ethical justification, the practice remains ethically contentious.…
It is clear that providing terminal sedation in combination with the withholding or withdrawing of life-prolonging treatments such as fluid and nutrition can foreseeably hasten death significantly.

There are ethical justifications for the use of sedation in palliative care and thus it would seem that ETS is an ethically and legally acceptable practice.

However, what emerges from the literature is the repeated assertion that terminal sedation must be restricted to use in imminently dying patients — the ‘imminence condition’ — and that therefore ETS is unacceptable.
This restriction has taken on greater significance with the trend of palliative care to include the care of patients who are not imminently dying.

Continuous Deep Sedation (CDS)

Every year more than 1,000 people are admitted onto the wards at St Christopher's Hospice in Sydenham, South London. It is at the forefront of research and education in end-of-life palliative care.

Dr Nigel Sykes, medical director at St Christopher's, said CDS can be appropriate for patients who become confused and deeply agitated - but only when nothing else can relieve their distress. 

Research by Clive Seale, professor of medical sociology at Bart’s Hospital and the London School of Medicine and Dentistry, suggests the use of CDS across the UK
is far from “uncommon”. This should not be the case. Dr Sykes has pointed out, “There are sources of advice available because specialist palliative care is now available and accessible across the country”. He said there was a need for further research to establish how much sedation patients are getting, who is giving it to them, and why.

Paul Russell comments -
 We recognise that human suffering may lead someone to request euthanasia or assisted suicide, but we also recognise that these requests often represent a "cry for help". We need to care for the person, even when caring is difficult, and not kill the person who is difficult to care for.
Alex Schadenberg
While Dr Cellarius supports the use of the term “terminal sedation”, he does so in a restricted application to what he calls “imminently dying patients”.

In such usage, “terminal” would merely describe the person’s state, not the intended outcome of sedation. The author further confirms this by acknowledging the use of sedation in patients who are not imminently dying.

It is difficult and probably wrong to attribute motives to those who deliberately use the combination of sedation and the withdrawal of fluids and nutrition to hasten a patient’s death.

There is little doubt that sedated patients are probably a great deal easier to manage, and death by starvation or dehydration in such circumstances has a predicable time-line, whereas death from the underlying disease may not.

With an ageing population and increasing health care budgets, this sort of “nudge-nudge, wink-wink” approach to reducing costs must be a great temptation.

Wiley Online Library


Early terminal sedation (ETS) refers to palliative sedation in which deep, continuous sedation is combined with cessation of nutrition and hydration in patients capable of receiving life-sustaining nutrition and hydration, orally or parenterally. In the typical case, the patient is able to eat and drink sufficiently to sustain life, and the sedation given is deep enough to make eating and drinking, even with assistance, impossible. In uncommon instances, the patient may be receiving life-sustaining nutrition and hydration parenterally, for example through an intravenous line or a percutaneous feeding-tube, prior to sedation. The sedation itself is understood to be similar to that employed in deep, continuous palliative sedation – the patient is unrousable, but breathes without assistance. This treatment is ‘early’ in the sense that deep and continuous sedation is given before the patient's condition has reached a point at which it is unalterably and imminently fatal. The actual occurrence of this point will depend on what treatments are employed or rejected, and remains a matter of clinical judgement. But despite this dependence on clinical criteria, ETS is best understood temporally in the sense that it is given before the patient is, in the common clinical idiom, ‘actively dying’.

In contrast to sedation given to patients for whom hydration and nutrition is no longer life-sustaining, ETS will certainly hasten death and it is, in this regard, contentious.5 The central claim of this paper is that ETS is a distinct entity and should be treated clinically, ethically and legally as such. This point has recently been made by van Delden, but without explicit justification.6 The aim of this paper is therefore to strengthen the point. EST is best treated as neither completely analogous to terminal sedation given to the imminently dying nor completely analogous to euthanasia or assisted suicide.

This paper will introduce several specific claims:

Including -
1) ETS is a contentious practice;
2) Seen as the sum of two parts – deep and continuous sedation given as palliation, and treatment refusal – ETS appears analogous to terminal sedation;
3) Seen as a whole differing from the sum of its parts, ETS appears analogous to assisted suicide or to euthanasia;
4) Notwithstanding the above analogies, ETS cannot be reduced to either analogy and remains in an ethical tension;
5) Understanding and treating ETS as a distinct entity is conceptually and ethically the best way to address this ethical tension.

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