On Decision-Making at the End of Life: A Singaporean Perspective

The author discusses ethical issues related to palliative sedation in an incurably ill patient. The basic issue was appropriateness of sedation till death in a terminally ill patient in distress. The option of sedation to ameliorate suffering was considered against the background of the patient’s expressed wish to remain alert as long as possible and to be nursed in his own home. The decision-making process was further complicated by a lack of consensus among close family members. The final decision to go for sedation was based on the application of the best interest principle. Issues related to the application of the best interest principle in this case and also patient and physician autonomy are discussed.

Palliative sedation is very often a difficult decision, but can be defended as the last option to address intractable suffering in a terminally ill patient. Suffering is distress that occurs when an impending destruction of the person is perceived and continues until the threat is gone or the integrity of the person can be restored. Suffering is an affliction of persons, not bodies (Cassel 1982). Intractable suffering, as seen in the case of the patient discussed, causes major distress to the patient and family. It also undermines the objective of dignified death and hence need to be ameliorated. One can also see that the option of sedation was not against the patient’s expressed wish to remain alert as long as possible because the irreversible disease process had already made it impossible for the patient to be lucid. It was also possible to offer sedation at home in line with the patient’s wish to remain with his family in the last days (Porzio et al. 2010). But the author has not discussed some of the other important ethical issues here.

Palliative Sedation and Euthanasia

Many consider the ethical issues involved in opting for palliative sedation as similar to those involved in opting for euthanasia or physician assisted suicide. (Morita et al. 2004; Seymour, Janssens, Broeckaert 2007; Rietjens et al. 2009). In fact, there are studies which show that palliative sedation has the potential to shorten life (Rietjens et al. 2006). Although the purpose of palliative sedation is to relieve otherwise intractable suffering, the patient is most often rendered unconscious as an end point and therefore cannot take food and fluids by mouth. The effect of sedation on the intake of food and fluids was also needed to be discussed with the family especially since food has an important role in Chinese culture.

Double Effect

It is known that palliative sedation can have the unintended effect of hastening death (Quill, Lo, Brock and Meisel 2009). Relief of suffering is the physician’s primary intent, and although there may be a foreseen risk for hastening death, this is unintended. Intent can thus distinguish palliative sedation from euthanasia. Double-effect reasoning crucially involves this distinction between what one foresees and what one intends, as well as the ability to make a proportionate judgment about the good and bad outcomes of an action (Sulmasy 2007). The decision to sedate the patient needed to be taken as it was the only option to ameliorate suffering and to support a dignified death; but also knowing that the action had the potential unintended effect of shortening life.