Palliative sedation

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Palliative sedation is a medical term that is still not defined uniformly and is controversially discussed. Basically, it is about the administration of very calming ( sedative ) medication to the dying in order to effectively treat symptoms that cannot otherwise be controlled (therapy-refractory) such as anxiety, shortness of breath, delirious symptoms, pain, nausea and vomiting. Since, according to the guidelines, an acceleration of the dying process, which is accepted as a possible complication, is not intended, there is a clear demarcation from active euthanasia . For this reason, many medical professionals reject the term terminal sedation, which is also used .

Other terms in German are sedation at the end of life and total sedation .

In palliative medicine

Palliative physicians such as Müller-Busch understand palliative sedation to mean the administration of medication that dampens the consciousness of dying patients in order to eliminate stressful symptoms such as pain or fear in the last phase of life. So the time until death should be made more acceptable and bearable, it should clearly serve life and not death.

According to this definition in palliative care, symptom control is the only goal. In 2004, the Berlin anesthesiologist and palliative medicine specialist Hans Christof Müller-Busch referred to studies in the Zeitschrift für Palliativmedizin , according to which patients with palliative sedation did not die faster than without the calming and pain relieving medication. Two-thirds of his own patients were still able to absorb fluids in their final hours under palliative sedation. 13 percent even ate solid food.

In palliative medicine, palliative sedation is seen as a medically indicated therapy option for symptom control of therapy-resistant symptoms, which, if today's palliative medical standards are observed, does not lead to a shortening of life and is therefore wrongly placed in the vicinity of illegal patient killings.

An international group of experts has published guidelines on the indication and implementation of palliative sedation. The critical points of palliative sedation are also discussed: If palliative sedation is only used as a last resort in symptom relief, palliative sedation may also be used in the case of psychosocial stress ("suffering in life"), palliative sedation may only be used at the end of life or can be used earlier in the course of serious illnesses? - As research by Müller-Busch shows, the proportion of palliative sedations for psychosocial reasons increases with the increase in this practice.

Indications for palliative sedation

  • (psychomotor) agitation (agitated delirium )
  • Shortness of breath
  • Pain
  • Fear, stress
  • acute bleeding
  • Nausea, vomiting

execution

Palliative sedation takes place with benzodiazepines ( midazolam , flunitrazepam ), possibly in combination with morphine or similar strong pain relievers (for example ketamine ). Also propofol and barbiturates are used to sedation. The drugs are usually given intravenously or subcutaneously .

Palliative sedation can be continuous or intermittent, aiming at deep (with loss of consciousness) or shallow sedation (with retained consciousness). The supply of fluids or nutritional solutions is inconsistent during palliative sedation.

Critical considerations

The question of whether and when palliative sedation should be classified as active euthanasia, passive euthanasia or indirect euthanasia is repeatedly discussed in the medical ethical literature . Ultimately, this depends essentially on the intention of the practitioner, which in the individual case is therefore highly subjective and often eludes objective criteria.

In 2003 the DGHS referred in its association journal Humanes Leben - Humanes Dieben to the danger of abuse, belittling and glossing over associated with the term terminal sedation: “ The trend, also in Germany, is towards hidden euthanasia even without the patient's will , through the so-called 'terminal sedation'. 'Sedation' is understood to mean (also euphemistically, so euphemistically and veiled) the attenuation of pain and the calming of a sick person through sedatives and psychotropic drugs; natural death can be simulated in this way (as is the case with so-called 'indirect euthanasia'). "

Last but not least, the experiences in the Netherlands point to the risks of terminal sedation. There, active euthanasia has been exempt from punishment under certain conditions since 2002. According to a survey published in 2004 ( Annals of Internal Medicine ), every sixth terminal sedation is intended to result in the patient's death. Accelerated death was given as part of the indication in 47 percent of the cases, and in 17 percent it was the explicit intention of the doctors.

A study by Murray and others in the British Medical Journal shows that between 2001 and 2005 the number of those who died from terminal sedation in the Netherlands increased and those who died from active euthanasia decreased. This suggests that terminal sedation is increasingly viewed as an alternative to euthanasia. In fact, according to the investigators, the request for active or passive euthanasia had previously been rejected in every tenth terminally sedated patient.

literature

Individual evidence

  1. ^ Marianne Cirak: Sedation at the end of life in the palliative ward. Medical dissertation Würzburg 2018.
  2. ^ German summary by Hans Christof Muller-Busch, L. Radbruch, F. Strasser, R. Voltz: Recommendations for palliative sedation. In: Dtsch Med Wochenschr. 131, 2006, pp. 2733-2736.
  3. Hans Christof Müller-Busch, I. Andres, T. Jehser: Sedation in Palliative Care - a Critical Analysis of 7 Years Experience. In: BMC Palliative Care. 2, 2003, p. 2. biomedcentral.com
  4. G. Duttge: Legal typology: active and passive, direct and indirect euthanasia. (PDF; 1.2 MB). In: D. Kettler, A. Simon, R. Anselm, V. Lipp (eds.): Self-determination at the end of life. Universitätsverlag Göttingen, Göttingen 2006, pp. 36–67.
  5. A. Frewer: Euthanasia and "terminal sedation". Medical-ethical borderline situations at the end of life. In: Hessisches Ärzteblatt. 12, 2005, pp. 812-815.
  6. ^ SA Murray, K. Boyd, I. Byock: Continuous deep sedation in patients nearing death. In: BMJ . 2008. doi: 10.1136 / bmj.39504.531505.25 .