Sedation: Hard choice for a comfortable death

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.

In some of the rooms in the hospice unit at Franklin Hospital, in Valley Stream on Long Island, the patients were sleeping because their organs were shutting down, the natural process of death by disease. But at least one patient had been rendered unconscious by strong drugs.

The patient, Leo Oltzik, an 88-year-old man with dementia, congestive heart failure and kidney problems, was brought from home by his wife and son, who were distressed to see him agitated, jumping out of bed and ripping off his clothes. Now he was sleeping soundly with his mouth wide open.

“Obviously, he’s much different than he was when he came in,” Dr Edward Halbridge, the hospice medical director, told Oltzik’s wife. “He’s calm, he’s quiet.”
Oltzik’s life would end not with a bang, but with the drip, drip, drip of an IV drug that put him into a slumber from which he would never awaken. That drug, lorazepam, is a strong sedative. Oltzik was also receiving morphine, to kill pain. This combination can slow breathing and heart rate, and may make it impossible for the patient to eat or drink. In so doing, it can hasten death.

Oltzik received what some doctors call palliative sedation and others less euphemistically call terminal sedation. While the national health coverage debate has been roiled by questions of whether the government should be paying for end-of-life counselling, physicians like Dr Halbridge, in consultations with patients or their families, are routinely making tough decisions about the best way to die.
Among those choices is terminal sedation, a treatment that is already widely used, even as it vexes families and a profession whose paramount rule is to do no harm.
Doctors who perform it say it is based on carefully thought-out ethical principles in which the goal is never to end someone’s life, but only to make the patient more comfortable.

But the possibility that the process might speed death has some experts contending that the practice is, in the words of one much-debated paper, a form of ‘slow euthanasia’, and that doctors who say otherwise are fooling themselves and their patients.

There is little information about how many patients are terminally sedated, and under what circumstances — estimates have ranged from two per cent of terminal patients to more than 50 per cent.
While there are universally accepted protocols for treating conditions like flu and diabetes, this is not as true for the management of people’s last weeks, days and hours. Indeed, a review of a decade of medical literature on terminal sedation and interviews with palliative care doctors suggest that there is less than unanimity on which drugs are appropriate to use or even on the precise definition of terminal sedation.

Discussions between doctors and dying patients’ families can be spare, even cryptic. In half a dozen end-of-life consultations attended by a reporter over the last year, even the most forthright doctors and nurses did little more than hint at what the drugs could do. Afterward, some families said they were surprised their loved ones died so quickly, and wondered if the drugs had played a role.
Whether the patients would have lived a few days longer is one of the more prickly unknowns in palliative medicine. Still, most families felt they and the doctors had done the right thing.

Oltzik died after eight days at the hospice. Asked whether the sedation that rendered Oltzik unconscious could have accelerated his death, Dr Halbridge said, “I don’t know.”

“He could have just been ready at that moment,” he said.
With their families’ permission, Dr Halbridge agreed to talk about patients, including Oltzik and Frank Foster, a 60-year-old security guard dying of cancer. He said he had come to terms with the moral issues surrounding sedation.
“Do I consider myself a Dr Death who is bumping people off on a regular basis?” he asked. “I don’t think so. In my own head I’ve sort of come to the realisation that these people deserve to pass comfortably.”

An uncomfortable topic
For every one like Dr Halbridge, there were other doctors who, when asked about their experiences, would speak only in abstract and general terms, as if giving a medical school lecture, and declined requests to arrange interviews with families who had been through the process. It is a difficult subject to discuss.
The medical profession still treats its role as an art as much as a science, relying on philosophical principles like the rule of double effect. Under this rule, attributed to the 13th century Roman Catholic philosopher Thomas Aquinas, even if there is a foreseeable bad outcome, like death, it is acceptable if it is unintended and outweighed by an intentional good outcome — the relief of unyielding suffering before death. The principle has been applied to ethical dilemmas in realms from medicine to war, and it is one of the few universal standards on how end-of-life sedation should be carried out.

At Metropolitan Hospital Centre, a city-run hospital in East Harlem, Dr Lauren Shaiova, the chief of pain medicine and palliative care, has issued 20 pages of guidelines for palliative sedation. The guidelines include definitions, criteria, what to discuss with family and hospital workers and a list of drugs to induce sleep, control agitation and relieve pain.

The checklist of topics to be discussed with the family includes whether to offer intravenous food and water. Another checklist anticipates that some hospital workers may be upset by the process, and recommends a discussion with questions like: “Were you comfortable with the sedation of this patient? If not, what were your concerns?”

But clarity, doctors say, is hardly the rule. In 2003, Dr Paul Rousseau, then a Veterans Affairs geriatrician in Phoenix, wrote an editorial in the Journal of Palliative Medicine calling for more explicit guidelines and research. He noted that some researchers include intermittent deep sleep in the category of palliative sedation, while others limit it to continuous sedation, which he said might explain some of the variance in estimates of how often it occurs.
And he proposed more systematic research into the types of medications used, how long it takes for patients to die, and the feelings of family and medical staff.
The New York Times