In lieu of an abstract, here is a brief excerpt of the content:

  • To "Sleep Until Death"
  • Blair Henry, Mervyn Dean, Victor Cellarius, Larry Librach, and Doreen Oneschuk

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.

On The Web

Bioethics Forum

www.bioethicsforum.org

Pink Boys with Puppy Dog Tails
By Alice Dreger
A lot of "gender nonconforming" kids dont have a simple story of being "trapped in the wrong body. " They are expressing more subtle, more complex, and more varied messages of self. What they need isn't therapy; what they need is to know that it's okay to be gender nonconforming. It's perfectly okay to be a male who has feminine-typical interests, behaviors, and desires, or a female who has masculine-typical interests, behaviors, and desires.

Pretty in Pink: Is This Women's Health Activism?
By Colleen Farrell
While perhaps raising money for breast cancer research and educating women about the risk of breast cancer—claims that need to be examined themselves—the "Stiletto Stampede" and pink Kitchen Aid mixers do so at a cost: in such campaigns, participation in women's health activism is paradoxically positioned alongside the symbols of unattainable beauty and the burden of domestic duties that have all too often held women back, both personally and politically.

Belmont's Ethical Malpractice
By Zachary M. Schrag
Throughout the discussions that led to the Belmont Report, the members ofthat commission ignored objections put forth by Albert Reiss and other social scientists. The result was a report that is a notable achievement in the exploration of the ethical challenges raised by medical research...

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Additional Information

ISSN
1552-146X
Print ISSN
0093-0334
Pages
p. 4
Launched on MUSE
2011-01-21
Open Access
No
Archive Status
Archived 2012
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