Terminal sedation

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Terminal sedation (also known as palliative sedation, or sedation for intractable distress in the dying/of a dying patient) is the practice of relieving distress in a terminally ill person in the last hours or days of a patient's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug.

1 Drugs used
2 Nutrition and fluids
3 Risk assessment
4 Legal position
5 See also
6 External links

[edit] Drugs used

A typical drug is midazolam, a short acting benzodiazepine. Opioids such as morphine are not used as tolerance to sedation develops rapidly (unlike pain relief to which tolerance does not occur), and the doses of opioids needed for sedation can cause increased agitation (unlike the doses needed for pain relief). However, if a patient was already on an opioid for pain relief, this is continued subcutaneously at the same dose as before.

[edit] Nutrition and fluids

As patients are already in the last hours or days of their lives, they are not usually receiving nutrition, although some can benefit from fluids (usually given subcutaneously) and other comfort measures such as antibiotics (again given subcutaneously) for a distressing infection.

[edit] Risk assessment

There is no evidence that titrated sedation causes the death of the patient and sedation does not equate with euthanasia. At the end of life sedation is only used if the patient perceives their distress to be unbearable, and there are no other means of relieving that distress. In palliative care the doses of sedatives are titrated to keep the patient comfortable without compromising respiration or hastening death.
For more information on the palliative care use of sedatives and the safe use of opioids see Opioids and the subsection Dangerous opioids or dangerous prescribers?

Patients (or their legal representatives) do have the right to refuse life-sustaining treatment (such as with a living will), which is legally considered neither euthanasia nor suicide. However, once unconsciousness begins, the patient is no longer able to decide to stop the sedation or to request food or water and the clinical team needs to act in the patient's best interests.

Sedation at the end of life should be a treatment response to the symptom distress of terminal restlessness and agitation. There can be a problem for the nurse or doctor in deciding who is distressed: the patient themself, the family, or the professional. Sedation is not routine in palliative and most patients die comfortably without the need for sedation.

[edit] Legal position

As sedation is titrated to avoid harm (including death), there is no legal or ethical uncertainty in a treatment which is purely for comfort. Consequently, terminal sedation is generally considered legal and acceptable, as belonging to normal medical practice, even in jurisdictions where euthanasia and physician-assisted suicide are not.