Opponents and Proponents Views Regarding Palliative Sedation at End of Life

Palliative sedation is sedating a patient to the point of unconsciousness to relieve one or more symptoms, when all other possible measurements have failure. Palliative sedation is charged with controversy since developed. The purpose of this position statement paper is to support and discussing opponents and proponents' views comprehensively around palliative sedation in terminally ill patients. The most important dispute was if palliative sedation hastens death or not, if it can be used as physician-assisted suicide, if it legalized euthanasia and (or) if it violate patient's autonomy. The current authors are supporting palliative sedation with advanced incurable patients in order to alleviate patients suffering, palliative sedation offer to terminally ill patients' comfortable experience at end of life and allow them to die in peace. Palliative sedation should be encouraged to get health care facilities and legal support.


Introduction
Palliative care is an approach focuses on improving quality of life for patient by managing current symptoms and preventing developing new symptoms [1].About (50-84) percent of advanced oncology patients will suffer from (1 to 27) of unmanageable refractory symptoms [2].In such these cases a high-quality aggressive palliative care fails to provide relief and comfort [3].So, palliative sedation came as a therapy for refractory symptoms using pharmacological agent to induce deep sleep [4].
The literature describes palliative sedation -also called terminal sedation, continuous deep sedation, or primary deep continuous sedation -as sedating a patient to the point of unconsciousness to relieve one or more symptoms when all other possible measurements have failed, or to relieve profound anguish that is not amenable to spiritual, psychological, or other interventions [4,5].
A symptom is considered "refractory" when it cannot adequately be controlled by therapies that do not seriously compromise consciousness [6].Mostly the diagnostic criteria for "refractoriness" are based on the clinician's determination [7].
Position statement paper as the term implies, a comprehensive discussion on a particular topic or topics in order to provide a more complete understanding of the issues involved and to clarify the rationale behind the position (American Academy of Family Physicians, 2015).Therefore, the purpose of this position statement paper is to discuss opponents and proponents' views regarding palliative sedation at end of life and provide suggested recommendations in order to solve the problems facing palliative sedation.
The current author is supporting palliative sedation with advanced incurable patients in order to alleviate refractory severe symptoms that are not responded to other forms of treatment with the intent to relieve suffering only.

Background
The palliative sedation in terminally ill patient is charged with controversy opinions since developed by Enck in the 1990s.The purpose of this literature review is to pinpoint different opponents and proponents' positions regarding palliative sedation for terminally ill patient.

Opponents of palliative sedation for terminally ill patients
Palliative sedation may be used by clinicians as a means of hastening death, and this is the most common abuse of palliative sedation, it may occur by the planned use of deep sedation in patients who have no refractory symptoms, this has been called 'slow euthanasia [8,9].Or it may be used as a means of death by planned use of overdose much more than what is enough to provide adequate comfort, this has been called physician-assisted Suicide; excess doses can compromise physiological functions such as spontaneous respiration and hemodynamic stability [8,10].
Palliative sedation may be used to inappropriate patients due to inadequate patient assessment that may have overlooked a potentially reversible cause of distress without consultation with palliative care experts or a multidisciplinary team [10,11].
Higgins and Altilio argued that the sedation may be given as family's -or others -wishes and not as a response to the patient him or herself [12], and this may mean violate patients autonomy.
Other researchers argued that at times palliative sedation is tantamount to euthanasia.The issue whether the combination of inducing sedation and withholding nutrition and hydration is cause to shorter time to death [13,14].Also, sedation in managing refractory psychological symptoms is different from other situations, due to the nature of the symptoms; it is much more difficult to judge if it truly refractory or not, and the severity of symptoms very difficult to predict, as well as the psychological symptoms or existential distress are not intrinsically lifethreatening.Unlike physical symptoms, a psychological symptom does not essentially indicate advanced state of physiological deterioration [15].

Proponents of palliative sedation for terminally ill patients
Bharathi and Chandra supported the fact that palliative sedation does not hasten death in terminally ill cancer patients and does not support the argument that palliative sedation is slow euthanasia [16].
Claessens et al. argued that the palliative sedation dose not hasten death even while withholding artificial nutrition and hydration, and shows that the withdrawal is not a fixed policy but is always based on a profound and individual decision-making process [5].
A qualitative study done by Kallen et al. in 2014, they discuss the palliative sedation from different viewpoints and conclude that the most physicians who utilize palliative sedation compassionately do not support physician-assisted suicide and feel that these two practices are on different sides of the line separating the ethical from the unethical [17].
Palliative sedation ethically accepted and highly recommended, also considered an important part of the health care continuum and the last choice to stop patients suffering at the end of life [18].
From the Islamic perspective, great importance to maintaining a level of consciousness as close to normal for the longest period possible before death as possible to allow for observance of the worship rites [19].On the other hand, the laws in Islamic allows palliative sedation where it seems to be the only feasible option.Also it's important to advised patient to say their final farewell to family and friends, and to recite the syahadah before the sedating agent is administered [20].Also, the laws in Christianity, Buddhism and Jewish allows to palliative sedation [21,22].
In summary palliative sedation in terminally ill patients is debatable and charged with controversial arguments; the most important dispute was if it hastens death or not, while sedated patients to state of unconsciousness.Another important issues if palliative sedation can used as physician-assisted suicide, or if palliative sedation legalized euthanasia, and if it violate patient's autonomy or not.

Position Statement
The current author is supporting palliative sedation with advanced incurable patients in order to alleviate their suffering from many of refractory symptoms that are not responding to other forms of treatment with the intent to relieve suffering only.
Palliative sedation offers comfortable experience at end of life and allows terminally ill patients' to die in peace.In addition to that, palliative sedation gives patients a chance to manage their refractory symptoms at home.According to the literature, opponents argue that palliative sedation may be applied depends on family or others requisites, which is totally against patient's autonomy and rights.Patients must be involved in the treatment plan; also any medical decisions should be through patient preferences.Moreover, withholding hydration and nutrition during palliative sedation must be discussed separately with patients and their families to give a decision on that.
However, the following recommendations are suggested by the current authors with the purpose to resolve the most important problems which remain as hindrances in face to performing palliative sedation in terminally ill patients: All hospices and palliative care organizations should develop explicit policies and guidelines on the use of palliative sedation for relief of intractable symptoms in terminally ill patients.
Ensuring that health care providers are educated about the proper clinical context, to minimize the risks posed by palliative sedation to unconsciousness.
Education about palliative sedation should be required in palliative care training programs and in the training of all health care professionals who care for terminally ill patients.Model education programs should be developed by national palliative care organizations.
Individual practitioner knowledge about palliative sedation should be tested on certification and recertification examinations for who treat terminally ill patients.Social-worker and other health care providers should work to increase the society awareness about palliative sedation.
Palliative sedation should be supported by governmental laws for patients who surfing refractory symptoms.
The governmental laws should support the rights of patients to die without sulfuring pain and symptoms.
Palliative sedation should be implemented only after consultation with an interdisciplinary team that includes an expert.
Ensure that palliative sedation to unconsciousness is employed only as a last resort, with the intent to relieve suffering rather than to cause or hasten death.
Health care providers should preserve patient's autonomy and give sedation as a response to the patient request.

Summary and Conclusions
Palliative sedation in terminally ill cancer patients is controversial.The purpose of this position statement paper was to present opponents and proponents' viewpoints regarding palliative sedation in terminally ill cancer patients.There are various medical, legal, ethical and religious viewpoint; these should be considered for sedated patient.The current authors support performing palliative sedation for terminally ill patients as last resort.Recommendations were suggested in this paper to solve problems in palliative sedation.