Continuous deep sedation at the end of life and the 'natural death' hypothesis

Bioethics

Volumn 26, Issue 6, 2012, Pages 329-336

  Raus, Kasper ^a   Sterckx, Sigrid ^a,b   Mortier, Freddy ^a  

^a GHENT UNIVERSITY   (Belgium)

^b FREE UNIVERSITY OF BRUSSELS   (Belgium)

Author keywords

'natural' death; Continuous deep sedation; End of life decision making; Ethics

Indexed keywords

ARTICLE; ATTITUDE TO DEATH; DECISION MAKING; DEEP SEDATION; ETHICAL THEORY; ETHICS; HUMAN; PALLIATIVE THERAPY; TERMINAL CARE;

ATTITUDE TO DEATH; DECISION MAKING; DEEP SEDATION; ETHICAL THEORY; HUMANS; PALLIATIVE CARE; TERMINAL CARE;

EID: 84862592092     PISSN: 02699702     EISSN: 14678519     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2010.01861.x     Document Type: Article

References (53)

1. Many different forms of sedation can be distinguished in medical care. Sedation can for example be light (the patient can still be woken with mild arousal). It can also be deep, but only used for a short time (for example anaesthesia for surgery).This article will focus on one particular form of sedation, namely sedation that is both deep and deliberately continued until the patient dies.
2. American Medical Association (AMA). 2008. Sedation to Unconsciousness in End-of-Life Care. Report of the council on ethical and judicial affairs: 1, lines 18-19. Available at [Accessed 13 July2010]
3. T.E. Quill, B. Coombs Lee & S. Nunn. Palliative Treatments of Last Resort: Choosing the Least Harmful Alternative. Ann Intern Med 2000; 132: 488-493
4. N. Cherny, L. Radbruch & The Board of the European Association for Palliative Care. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009; 23: 581-593.
5. C. Seale. End-of-life Decisions in the UK Involving Medical Practitioners. Palliat Med 2009; 23: 198-204.
6. J. Rietjens et al. Continuous Deep Sedation for Patients Nearing Death in the Netherlands: Descriptive Study. BMJ 2008; 336: 810-814.
7. J. Bilsen et al. Medical End-of-Life Practices under the Euthanasia Law in Belgium. NEJM 2009; 361: 1119-1121.
8. Rietjens et al., op. cit. note 4, pp. 810-814
9. A. van der Heide et al. End-of-Life Practices in the Netherlands under the Euthanasia Act. NEJM 2007; 356: 1957-1965.
10. G. Miccinesi et al. Continuous Deep Sedation: Physicians' Experiences in Six European Countries. J Pain Symptom Manage 2006; 31: 122-129.
11. American Medical Association (AMA), op. cit. note 2, p. 4.
12. T. Tännsjö, 2004. ed. Terminal Sedation: Euthanasia in Disguise? Dordrecht: Kluwer Academic Publishers: 20-21.
13. The method they used was a comparison of a baseline study (2003-2005) with a follow-up study (2007). One of the things physicians were asked was what they perceived as the differences between euthanasia and CDS. In the baseline study 53.2% of doctors agreed with the statement: 'During sedation, the patient dies a natural death'. During the follow-up study this number had increased to 60.7%.
14. J. Hasselaar et al. Changed Patterns in Dutch Palliative Sedation Practices After the Introduction of a National Guideline. Arch Intern Med 2009; 169: 431.
15. M. Battin. Terminal Sedation: Pulling the Sheet over Our Eyes. Hastings Cent Rep 2008; 38: 28
16. Two important things have to be noted here. The first is that Battin uses the term 'terminal sedation', and not CDS, but this refers to the same practice as the one we call 'continuous deep sedation at the end-of-life'. Secondly, when Battin questions the 'naturalness' of death after CDS, she is primarily targeting that form of CDS where all artificial hydration and nutrition is withheld. For Battin these are the cases where CDS most clearly causes death
17. T.E. Quill, B. Lo & D. Brock. 2004. Palliative Options of Last Resort. In Terminal Sedation: Euthanasia in Disguise? T. Tännsjö, ed. Dordrecht: Kluwer Academic Publishers: 1-14. Like Battin, these authors note that patients receiving CDS often die of dehydration rather than the underlying disease. We will return to the subject of the withholding of artificial hydration and nutrition.
18. I. Illich. 1979. Limits to Medicine. Medical Nemesis: the Expropriation of Health. Harmondsworth: Penguin Books: 210.
19. J. Rietjens et al. Physician Reports of Terminal Sedation without Hydration or Nutrition for Patients Nearing Death in the Netherlands. Ann Intern Med 2004; 141: 178-185. They interviewed 410 physicians on their most recent use of CDS. In 37% of the cases both euthanasia and CDS were suggested during the process of decision-making. In these cases one of the main reasons for preferring CDS over euthanasia was that the patient herself viewed CDS as less disturbing to the natural process of dying (p. 181).
20. J. Seymour, R. Janssens & B. Broeckaert. Relieving Suffering at the End of Life: Practitioners' Perspectives on Palliative Sedation from Three European Countries. Soc Sci Med 2007; 64: 1687Seymour et al. as well as some other commentators use the term 'palliative sedation' to refer to what we call CDS.
21. S. Chater et al. Sedation for Intractable Distress in the Dying - a Survey of Experts. Palliat Med 1998; 12: 257. Emphasis added.
22. R. Pool. 'You're not going to dehydrate Mom, are you?': Euthanasia, Versterving, and Good Death in the Netherlands. Soc Sci Med 2004; 58: 955-966, who notes: 'I think there is a general consensus that , at the very least, natural death can be said to consist of fading away peacefully at the end of a long and full life' (p. 963).
23. Seale, op. cit. note 3, pp. 198-204.
24. M. Oehmichen & C. Meisser. Natural Death. Gerontology 2000; 46: 105-110
25. L. Sandman. Should People Die a Natural Death?. Health Care Anal 2005; 13: 275-287. Both articles talk about the classical conceptions of 'natural' death, but reject the pertinence of the concept in general.
26. G. Howarth. 2007. Death and Dying. Cambridge: Polity Press: 165.
27. Pool, op. cit. note 18, p. 963
28. He thinks that an 'unnatural' death is synonymous with a death controlled by medicine
29. B. Hart, P. Sainsbury & S. Short. Whose Dying? A Sociological Critique of the 'Good' Death. Mortality 1998; 3: 65-77
30. J. Seymour. Revisiting Medicalization and 'Natural' Death. Soc Sci Med 1999; 49: 691-704. These articles draw on extensive sociological literature, and seem to underpin the view that the ideal of a 'natural' death is a cry for not letting doctors determine the timing of the dying process.
31. D.M. High. Is 'Natural Death' an Illusion? Hastings Cent Rep 1978; 8: 41.
32. T. Chiu et al. Sedation for Refractory Symptoms of Terminal Cancer Patients in Taiwan. J Pain Symptom Manage 2001; 21: 467-472.
33. T. Morita et al. Effects of High Dose Opioids and Sedatives on Survival in Terminally Ill Cancer Patients. J Pain Symptom Manage 2001; 21: 282-289
34. N. Sykes & A. Thorns. Sedative Use in the Last Week of Life and the Implications for End-of-Life Decision Making. Arch Intern Med 2003; 163: 341-344.
35. Hasselaar et al., op. cit. note 12, p. 434.
36. L. Van den Block et al. Euthanasia and other End-of-life Decisions: a Mortality Follow-back Study in Belgium. BMC Public Health 2009; 9: 83.
37. This argument is used, for example, in the guideline on sedation, issued by the Royal Dutch Medical Association in Some data can be used to support this line of reasoning 2009, p. 29
38. Rietjens et al., op. cit. note 4 According to this source 94% of all patients receiving CDS in the Netherlands die within the time span of one week., pp. 810-814.
39. D. Callahan. 2004. The Artefactual Fallacy. In Terminal Sedation: Euthanasia in Disguise? T. Tännsjö, ed. Dordrecht: Kluwer Academic Publishers: 93-102.
40. A. Billings & S.D. Block. Slow Euthanasia. J Palliat Care 1996; 12: 21-30.
41. A. Bandura. Selective Moral Disengagement in the Exercise of Moral Agency. J Moral Educ 2002; 31: 101-119.
42. J. Seymour. Negotiating Natural Death in Intensive Care. Soc Sci Med 2000; 51.
43. J. Harris. 1994. The Value of Life. London: Routledge: 38.
44. R. McCoubrie. AND ('Allow Natural Death') - Could it Make a Difference? BMJ 2008; 337
45. S.S. Venneman et al. 'Allow Natural Death' versus 'Do Not Resuscitate': Three Words that can Change a Life. JME 2008; 34: 2-6.
46. Bandura, op. cit. note 31, pp. 106-108.
47. Seymour, op. cit. note 32.
48. J. Seymour. 2001. Critical Moments: Death and Dying in Intensive Care. Buckingham: Open University Press.
49. P. Ariès. 1981. The Hour of our Death. New York: Alfred A. Knopf.
50. J.S. Mill. 1884. Nature. In Three Essays on Religion. New York: Henry Holt and Company: 3-68.
51. A.R. Birley. 1997. Hadrian. The Restless Emperor. London: Routledge: 297-299
52. In this book, the story of the death of the Roman emperor Hadrian is told. At the end of his life, Hadrian became very ill and wanted to commit suicide, which proved impossible since no one dared to provide Hadrian with a sword or poison, for fear of being executed afterwards. Hadrian finally persuaded Mastor, his hunting master, to help him, using threats and promises of riches and immunity. At the last moment, however, Mastor refused to help. Anthony, Hadrian's successor and the father of Marcus Aurelius, and the prefects received news of Hadrian's search for assistance in dying. When they asked Hadrian to bear his disease, he ordered the person who informed Anthony and the prefects to be executed. Anthony himself could have helped Hadrian, but, as an adopted son, assisting Hadrian would have required him to kill his own father. When Hadrian made another attempt to commit suicide, the knife he was planning to use was taken from him. When Hadrian asked his physician, Hermogenes, to provide him with poison, Hermogenes chose to take his own life rather than help Hadrian. Not receiving assistance in dying, Hadrian had to let his disease run its course until he finally passed away.
53. For example, the Vatican's Declaration on Euthanasia notes: 'However, painkillers that cause unconsciousness need special consideration. For a person not only has to be able to satisfy his or her moral duties and family obligations; he or she also has to prepare himself or herself with full consciousness for meeting Christ. Thus Pius XII warns: 'It is not right to deprive the dying person of consciousness without a serious reason'.' (Sacred Congregation for the Doctrine of the Faith. May 5, 1980. Declaration on Euthanasia. quoted in Catholic Bishops' Conference of England and Wales. 2010. A Practical Guide to the Spiritual Care for the Dying Person: 32, available at ) [Accessed 13 July 2010].