Palliative Sedation within the Duty of Palliative Care within the Singaporean Clinical Context

The idea of Palliative Sedation (PS) is wrapped within myth, fear and misunderstanding. ^1-7 Indeed, Billings et al. and later Schadenberg et al. have strongly suggested PS was a means of "slow euthanasia", without due consideration of the intervention and its armatorium of specialist palliative medicine as a course treatment of last resort and one not taken without long and deep consideration. ^5,6 As a result of these misconceptions, many physicians feel the need to invoke the Doctrine of Double Effect (DDE) when considering its implementation. Yet with growing evidence to its safety, PS use should not be considered the hazardous, life-shortening intervention, as Younger would have us believe. ¹ Rather, this paper will argue that it be considered a part of the treatment options that are available under the aegis of the Duty of Palliative Care (DoPC). ^8-19

In order to explain why and how PS plays a proper role in the DoPC, clear terminology needs to be furnished for the concepts of PS and its diagnostic background, and the DoPC. This article will adopt an adaptation of the definitions of PS forwarded by the European Association for Palliative Care (EAPC) and Charter et al. ^{7, 36} This adapted definition seeks to place a specific therapeutic window that delineates its applicability to patients with a prognosis of two weeks given the efficacy of prognostication using prognostic tools available to physicians and the chances of significantly attenuating life is diminished. ^20-24 Such a condition attempts to address the fears voiced by physicians in Singapore, Malaysia and Indonesia during private consultations that whilst PS is for the most part used mainly for the treatment of intractable terminal agitation, fears still persist of misuse and the ensuing descent to euthanasia. Limited experience compounds the restricted availability of certain medications that in turn further heighten such fears. Additionally, cultural and religious considerations in enacting this procedure too need to be considered. Thus, this paper has further stressed the need for PS to be utilised in a manner in keeping with the spirit of local mores and laws as well as the need for it to be monitored by palliative care physicians. This article therefore defines PS "as the deliberate inducing and maintaining of deep sleep through the defined and monitored use of medication so as not to deliberately cause death for the relief of one or more intractable symptoms in patients perceived to have a prognosis of two weeks. It is carried out in very specific circumstances under the auspices of palliative medicine and in an ethical manner acceptable to and in keeping with the goals and wishes of the patient, the family and the healthcare providers as well as being in line with local legislature". ^{7, 36} Intractable symptoms in turn are defined as symptoms "that cannot adequately be controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness". ²⁵ The Oxford Textbook of Palliative Medicine sets out the diagnostic criteria for intractability as follows: "the clinician must perceive that further invasive and non-invasive interventions are incapable of providing adequate relief, associated with excessive and intolerable acute or chronic morbidity or unlikely to provide relief within a tolerable time frame". ²⁵ It should be added that intractable spiritual and psychological distress, though included in this definition, is liable to require more in-depth elucidation particularly given the regnant views, religious and cultural leanings of this region. ^37-39

Indeed, cultural, social and religious beliefs within the Singaporean context are amongst the main reasons for this elucidation of a set of guidelines that is more in keeping with local clinical practice. Singapore with its multi-ethnic, multi-religious, multi-cultural background finds itself benefiting from the influence of both eastern and western ethical frameworks. Principal amongst these is Confucianism, which remains the paradigm ethical conception for the majority Chinese populace. ^39-45 Here, the influence of filial piety, familialism, dignity, righteousness and benevolence amongst others place different impetus on care goals and decision-making processes. ^39-45 Thus, this framework...