The Use of Palliative Sedation for Terminally Ill Patients: Review of the Literature and an Argumentative Essay

Palliative sedation for terminally ill patients, with a life expectancy of less than two weeks to control patients’ intolerable pain and symptoms, is an intervention that raises many legal and ethical controversial issues. The purpose of this paper is to write an argumentative essay to support the use of palliative sedation for terminally ill patients, taking into consideration the legal and ethical points of view of opponents and proponents. Although it is illegal in some countries such as France, Jordan and New-Zealand, palliative sedation for terminally ill patients is legally sound for other countries such as USA, Canada, Sweden, Belgium, and Netherlands. Ethically, opponents consider palliative sedation for terminally ill patients as a misleading concept as it hastens death and negatively influences patients’ family members, and it may be misused by health team members. Whereas, proponents debate that palliative sedation is a multidisciplinary intervention that should be considered as a last resort for terminally ill patients with the main intention of relieving patients’ agony and having no effect on patients’ survival; moreover, it positively influences patients’ family members. The author is encouraged to support the use of palliative sedation as it is a multidisciplinary judgement which guarantees that any decision made is built on the latest evidence-based guidelines and is ethically accepted according to the principles of beneficence, autonomy, and doctrine of double effect. Additionally, it is the last and only intervention to alleviate patients’ suffering without affecting patients’ survival, thus causing family members to accept the use of palliative sedation for their loved ones.


Introduction
The massive evolution of medicine and technology during the last few decades has shifted the causes of death from acute to chronic illnesses, which increased the need for end of life care [1]. In some cases, terminally ill patients who are close to death suffer from intolerable pain and symptoms that cannot be managed with the conventional therapeutic interventions [2]. In such situations, palliative sedation is sometimes applied, which is a globally controversial issue as it causes many ethical dilemmas [3].
Palliative sedation, also termed "terminal sedation" or "continuous deep sedation", is the use of sedative medications to induce a state of decreased awareness (unconsciousness) for critically ill patients with a life expectancy of two weeks or less [4]. In terminally ill patients, palliative sedation is used as a "last resort", and not to hasten death [5]. Although refractory symptoms are associated with this type of sedation, it is still used to control patients' pain and symptoms.
Refractory symptoms are the one that cannot be adequately controlled with conventional therapy without compromising the level of consciousness, symptoms like aggressive severe pain, nausea, dyspnea or delirium [6].
An argumentative essay is a writing method that requires the researcher to investigate a topic and collect data to learn more about the topic, in order to understand the different points of view regarding it, through which the researcher establishes a position and supports it with the evidence collected during the search process [7].
The purpose of this paper is to write an argumentative essay to support the use of palliative sedation for terminally ill patients while taking into consideration the legal and ethical points of view of opponents and proponents.

Case scenario
Mr. X is a 29 year old patient working as a registered nurse. He was diagnosed with ALL with metastasis to the brain and spinal cord, and got admitted to the ICU suffering from a severe headache and agonizing back pain. A full body CT scan was done, and it showed bleeding inside the metastatic brain tumor. The other metastatic tumor was compressing the spinal cord. The patient WBC was 200, and the Platelet count was 7. The ICU consultants, along with the Neurosurgeon, decided to inform Mr. X and his family that he might die within 10 days and nothing can be done. A decision was made to put him on narcotics in order to control his pain, but the narcotics did not work. The patient informed the health team members that he wishes to be sedated to alleviate his suffering towards the end of his life, but the doctors refused as it is illegal. Unfortunately, after 6 days of suffering and screaming from the uncontrollable pain, Mr. X passed away.

Background
When it was first prescribed by Enck in the 1990s, palliative sedation gained attention in literature and generated many ethical and legal controversies [6]. To address hesitation against palliative sedation, it was stated that "It's that our anxiety that it may be confused with euthanasia encourages us to obscure or sanitize the features both practices share [8].
It's not that terminal sedation is wrong [6]. With palliative sedation, many ethical and legal questions are raised -is it a hidden definition of active euthanasia and physician assisted suicide or a good palliative intervention? Will it shorten Patient's life and hasten death? Does it reflect negatively on the patient's family and health care providers? Will it be abused by the physicians? And, is it legally accepted? The prevalence of palliative sedation in clinical practice is not specifically known, but it is reported to be used in 16-36% of dying patients [9]. In Austria, the prevalence of palliative sedation used for cancer patients in palliative care settings is 22% [10] The purpose of the current literature review is to pinpoint the different opponents and proponents' views regarding the use of palliative sedation for terminally ill patients, from both legal and ethical sides.

Legal arguments
Opponents: In France, using palliative sedation for terminally ill patients is illegal, based on the patient's rights and end of life law "Leonetti law-2005-370"; this indicates that palliative sedation is a type of physician-assisted suicide and is considered a criminal act [11]. In 2014, French president Francois Hollande tried to convince the parliament to legalize palliative sedation, but it was totally rejected [12]. Moreover, in New Zealand, palliative sedation is a crime under Section 179 of the New Zealand Crimes Act 1961. There have been two prior attempts to change the law, the death with dignity bill of 1995 and the death with dignity bill of 2003, but both attempts failed [13]. In Jordan, according to the Jordanian constitution, article number 339 of the panel code, palliative sedation is illegal; a legal penalty for who committed this crime will be imposed, which ranges from 3 months to 3 years in prison [14].
Proponents: The first mention of palliative sedation on a legal basis was in the United States (U.S.) Supreme Court in 1997. Ever since then, it has become legal with the main intent to relieve patients' suffering and control their pain and symptoms -even if the treatment might shorten their lives [1]. In 2002, Netherlands legalized palliative sedation under strict conditions: the patient must be suffering of intolerable pain, and the patient's disease must be incurable [15]. In the same year, Belgium legalized palliative sedation based on the principle of people's rights to die with dignity [16]. Furthermore, in 2010, the Association of Swedish Physicians published specific guidelines that allowed palliative sedation to be administered even if it rendered patients unconscious [17]. In Canada, in 2012, palliative sedation was legally approved to be used for a terminally ill patient, provided that it is within the consent and approval of both the patient and the clinician, respectively; if palliative sedation started without consent, it would be considered a crime [18].

Ethical arguments
Opponents: Rendering patients unconscious towards the end of their lives will influence the dynamic process of life negatively, which might have given the patients opportunities to heal [19]. Palliative sedation prevents the patients from expressing their feelings, as they might want to change any decisions made before passing away [20].
The ethical principle of non-maleficence demands clinicians to avoid causing harm to patients. However, a risk of respiratory depression and alteration in hemodynamic state might arise with palliative sedation, which in turn influences a patient's health status and may shorten their life [21].
Scott [22] considered palliative sedation a misleading concept as it is a slow way for ending a patient's life and is a hidden term of euthanasia and physician-assisted suicide, thus raising a question on how to judge a clinician's intention.
Due to patients being fully sedated, the use of palliative sedation may cause distress and grief for their family members because of the impaired abilities to interact and communicate with their loved ones during their last moments in life [21].
There are many ways in which the patients may be mistreated due to the unskilfully and abusive use of sedation. This could occur when clinicians have a hidden intent of ending their patients' lives under false pretences of controlling their suffering; as it could also occur by the intentional use of deep sedation in patients with no refractory symptoms [22].
Proponents: There are varying degrees of unconsciousness when it comes to palliative sedation for terminally ill patients; however, the aim is to constantly relieve their pain and ease their suffering, and to allow them to die in a dignified manner [4]. It is essential to understand that patients under palliative care, who are usually in the final stages of their terminal illnesses, will inevitably pass away with or without medical interventions [23]. Additionally, it is also important to differentiate palliative sedation from physician-assisted suicide (euthanasia); the intent of euthanasia is to terminate a patient's life, whereas the aim of palliative sedation is to control their pain and alleviate their suffering [24]. Moreover, Patients who are dying have the right to choose or reject procedures that may or may not shorten their lives, while the health team members have an obligation to respect their rights [24].
Beneficence, autonomy and doctrine of double effect are the bioethical principles supporting the use of palliative sedation for terminally ill patients in order to relieve their suffering. The intention of all clinicians should be based on providing the best possible care for all patients, while allowing them to decide on the course of their lives [24]. Opioids are usually used to control the patient's pain, but may unintentionally influence and shorten that patient's life; this is the doctrine of double effect. The doctrine states that the "good intention" of controlling pain balances the "less good effect" of shortening the patient's life [25]. In addition to that, the doctrine assumes that the physician's intention is to do "more good" in order to overcome the possibility of "doing harm" or "less good" [25].
Palliative sedation for terminally ill patients does not influence or shorten patient's life [26]. There was a systematic review of literature conducted on published studies, between January 1980 and December 2010, involving over 1000 patients. The researchers reported that palliative sedation does not hasten death, and that there was no association between the dosages of the medications used and the survival duration. Therefore, there are no significant differences in the overall survival between patients who needed to be sedated and those who did not [27]. Anquinet et al. in 2012 [28] conducted a study that described the experiences of cancer patient's relatives who undertook palliative sedation during their end-of life care. They concluded that the relatives believed in sedation as a contributing factor to their loved ones in having a "good death", as it gave the family members the chance to say goodbye.
Finally, the use of palliative sedation for terminally ill patients is a multidisciplinary decision, as it involves practitioners from many disciplines who are working according to the latest palliative sedation guidelines; thus preventing the abuse of palliative sedation and providing patients with a high quality of care.
In summary, legally, some countries such as France, New-Zealand and Jordan considered the use of palliative sedation for terminally ill patients as a physician-assisted suicide, which is considered illegal; while other countries such as the United States of America, Netherlands, Belgium, Canada and Sweden considered the use of palliative sedation for terminally ill patients as a legal action. Ethically, many researchers considered palliative sedation as a misleading concept as it may shorten the patient's life, and it may have a negative impact on patients and their families. On the other hand, palliative sedation has the ability to control and alleviate patients' suffering without shortening their lives; i.e. it has no effect on their overall survival. Moreover, palliative sedation is ethically acceptable according to the principles of beneficence, autonomy, and doctrine of double effect. Additionally, family members have the chance to say their goodbyes.

Argumentative Statement
Palliative sedation is not a new concept as it has always possessed legal and ethical tension about ending the life of terminally ill patients. However, it respects the dignity of these patients by alleviating their pain and suffering. The author supports the use of palliative sedation to preserve this dignity and alleviate that pain.

Legal defense
Many countries consider the use of palliative sedation for terminally ill patients legal, only when it is used to ease patients' suffering and preserve their dignity [1,18,29]. Palliative sedation has to be administered based on the patient's consent and the clinician's approval [18].

Ethical defense
The use of palliative sedation for terminally ill patients is an ethical intervention justified by the bioethical principles of Beneficence, Autonomy and Doctrine of double effect [23]. Palliative sedation of terminally ill patients is not euthanasia or physician-assisted suicide; its main goal is to alleviate patients' pain and ease their suffering [24].
The use of palliative sedation for terminally ill patients has no effect on patient's survival; i.e. it will not hasten death [26,27]. It will give the family members the chance to say goodbye [2]. It is a multidisciplinary decision based on global and evidence-based guidelines.
The author insists that no dying patient should suffer from pain and struggle if "palliative sedation" is available. The author assert on using palliative sedation for terminally ill patients as the "last resort" when there is no treatment available to stop patients' pain and symptoms. The author also strive to support the use of palliative sedation in order to stop patients' suffering and preserve their dignity, which are the basic aspects contributing to a good quality of life at the terminal stages of their illnesses. Therefore, the author composed the following recommendations regarding the use of palliative sedation for terminally ill patients: 1. Palliative sedation aims to control and alleviate patients' struggles towards the end of their lives.
2. Palliative sedation is to be used as a last resort for terminally ill patients.
3. Nearing the end of life, palliative sedation includes aggressive and comprehensive pain and symptom management. 4. The patients and relatives should be fully educated about the pros and cons of palliative sedation.
5. Palliative sedation needs to be supported by governmental and organizational policies. 6. Palliative sedation is a multidisciplinary act based on the latest guidelines, with the patient always being the centre of care.
Furthermore, the author: -Asserts on the importance of establishing and maintaining the awareness of healthcare organizations and societies to adopt the concept of palliative sedation for terminally ill patients.
-Confirms the importance of teaching all healthcare professionals and undergraduate students about palliative sedation for terminally ill patients, as it the first step to establish social awareness.
-Maintains ongoing education regarding palliative sedation for terminally ill patients in undergraduate and graduate courses built on clinical evidence-based practice.
Palliative sedation is an important medical option in treating terminally ill patients near the end of their lives, especially in areas related to unresolved pain and symptoms. Such an option, which is legally and ethically accepted in some countries, has to be supported in order to provide a better quality of life and a dignified death.

Summary and Conclusion
The purpose of this paper was to write an argumentative essay to support the use of palliative sedation for terminally ill patients taking into consideration the legal and ethical points of view of both opponents and proponents.
Palliative sedation in terminally ill patients is an important part of the health continuum of appropriate palliative care near the end of life. It is an appropriate therapy for uncontrolled pain and symptoms, since it is to be used as the last resort for a dying patient. Although it is legally and ethically sound in some countries, other countries oppose its concept, as they perceive it to be euthanasia or physician-assisted suicide.
In addition to that, palliative sedation for terminally ill patients does not affect the patient's life expectancy. Even though relatives and family members seem to accept the use of palliative sedation for their loved ones, few may experience some substantial distress.
Based on it being a multidisciplinary decision, the risk of palliative sedation being misused is reduced. Because of that, educating healthcare professionals about the latest guidelines is critical. All in all, there is a need to establish and increase organizational and societal awareness about the use of palliative sedation for terminally ill patients.