To "Sleep Until Death"

To the Editor: It was with great interest that our Canadian Palliative Sedation Therapy Guideline working group read Jeffrey Berger's recent article ("Rethinking Guidelines for the Use of Palliative Sedation," May-June 2010). Given our own group's efforts to develop national guidelines, we have rethought the issue of palliative sedation therapy several times over the past year.

The use of clear and concise definitions is fundamental to the development of any consensus guidelines on this topic. In the article, the term "palliative sedation to unconsciousness," or PSU, implies the concerning assumption that sedation will knowingly be to unconsciousness in the palliative case under consideration. This conflicts with the underlying principle of palliative care—that symptom treatment should be carefully titrated to control of that symptom. Thus, there is no set dose of opioid or antiemetic, but the patient is given just enough medication to be comfortable. In keeping with this principle, our working group proposes the creation of a guideline that considers palliative sedation therapy as a proportionate response to the clinical symptoms being managed. Sedation to unconsciousness happens only in cases where this level of sedation is required to effectively palliate symptoms, but the degree of sedation cannot and should not be predicted from the onset.

Dr. Berger assumes that it would be standard practice not to hydrate the sedated patient. However, we believe that linking the decision to start palliative sedation therapy with a decision to automatically withhold (or even to provide) artificial hydration is not helpful. Both issues are important to discuss, but they should not be made contingent upon each other. Based on clinical indicators and other specifics (like cultural practices), the decision regarding nutn-tion or hydration is made in the same way as for any other patient near the end of life.

Dr. Berger's recommendation that, for patients "for whom PSU is not expected to additionally shorten survival, the requirements of having refractory symptoms and a survival of hours to days should be lifted … [and decisions] should be contingent on efficacy, proportionality, … and an analysis of the benefits and burdens" is worrisome. Namely, well-developed guidelines should give clinicians a decision-making process for the use of palliative sedation therapy that meets all of the criteria listed: efficacy, proportionality, informed consent, and an analysis of risks and benefits. We are concerned that lowering the palliative sedation therapy "threshold" to allow a patient to "sleep until death" may well mean overlooking some psychological, emotional, or existential concerns. Any request to forgo consciousness until death obligates a sensitive and thorough search to find and mitigate, so far as is possible, the reasons for such a request.

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