Medical Law and Terminal Sedation - Thesis Example

Terminal Sedation [Name of the Student] [Name of the University] Terminal Sedation Terminal sedation, is in general, deemed to be a medical intervention that in isolation cannot be considered to be an act of euthanasia. From this perspective, terminal sedation can be construed to be the treatment provided to a patient, in whose case, other palliative treatments have proved to be deficient. Terminal sedation seeks to retain a patient undergoing unbearable agony, on the periphery of death in a comatose state (Birnbacher, 2007, p. 48). Moreover, such patients depict states involving insomnia, severe pain, agitation, fear of suffocating, and nausea. From this definition of terminal sedation, it can be inferred that terminal, in this context, merely denotes temporal sedation. With regard to the causal correlation between sedation and subsequent death, this definition maintains an enigmatic silence (Birnbacher, 2007, p. 48). In general, such terminal sedation, is presumed to have no causal relationship to death, and is assumed to drastically reduce the suffering of the patient who is on the verge of death. Thus, this medical procedure is held to help in dying and not help to die. The controversy arises, when an attempt is made to classify and assess various combinations of terminal sedation with other medical interventions. Such combination is now becoming commonplace in medical practice. A striking example is provided by the Netherlands. In this country, terminal sedation is gradually supplanting active euthanasia (Birnbacher, 2007, p. 48). A survey, in this area, was conducted recently in the Netherlands. This survey has disclosed that terminal sedation had been applied in 5.6% of all deaths, as of the year 2001. In addition, this survey revealed that artificial hydration and nutrition had been withdrawn in 67% of such deaths, at the same time as the application of terminal sedation (Birnbacher, 2007, p. 48). As such, terminal sedation has emerged in aggressive palliative care, as its most virulent form. This intervention aims at relieving the suffering of patients, who are on the verge of breathing their last, by placing them in an iatrogenic coma. An instance of this is the sedation to coma of a patient suffering with advanced amyotrophic lateral schlerosis, with the objective of ensuring that the patient does not suffer after the discontinuance of a redundant respirator[Cra02]. Consequently, physicians, directors of intensive care programmes and other related authorities have developed guidelines regarding the administering of sedatives to alleviate the suffering of the terminally ill. These guidelines advocate the increase of sedative dosage, in such cases, even if this hasten the demise of the patient[Jon03]. Moreover, it has also been suggested that the patient is to be rendered unconscious, if this be the only means available to significantly reduce pain. In addition, such patients can be maintained in an unconscious state till such time as their terminal illness brings about their demise. This constitutes terminal sedation, which is being promoted as the basic difference between palliative care and euthanasia[Jon03]. However, there is every possibility for deep discontent to surface; because, a terminally ill patient, will be kept alive in a comatose state for protracted periods. Moreover, such patients will be fed by means of tubes; and stand to be deprived of even the last vestiges of their dignity, as they are compelled to await death in this despicable manner. As has been pointed out by several critics, terminal sedation is best described as slow euthanasia[Jon03]. Terminal sedation is employed in the case of patients suffering from terminal illnesses, in which agitation, pain and other such extremely distressing symptoms cannot be assuaged, via normal medical treatment. Such treatment is usually effected in conjunction with the discontinuance of artificial hydration and nutrition[van07]. The right to die societies seek to empower patients with the right to demand death. This is far removed from terminal sedation, which is at marked variance from active voluntary euthanasia. All the same, there are certain circumstances, wherein terminal sedation can be equated to euthanasia[van07]. In several instances of death, medical end of life decisions are taken prior to the demise. These decisions vary between the reduction of pain and symptoms, and non – treatment decisions to the administration of drugs that prove to be fatal[Gev03]. The greatest amount of controversy is associated with measures that are aimed at directly accelerating death. Such measures are either in response to an explicit request by the patient, or in the absence of such request, as a medical response to unbearable suffering that frustrates measures that are less drastic. The latter decision admits of the possibility of the attending physician being prosecuted. On the other hand, some of the countries, such as Belgium and the Netherlands have legalised euthanasia[Gev03]. In such instances, the right to self – determination of the patient assumes significance. In addition, the alleviation of pain by means of drugs has been a traditional medical practice, and it has also been accepted in instances where the aim was to hasten the death of the patient. In such instances, the requirement of the law is that the doctor’s objective was to reduce the suffering of the patient. There should be no intention on the part of the doctor to reduce the life of the patient, and the sedation should be adequate, necessary and not excessive[Gev03]. This principle is pertinent to the practice of sedating patients who are in a terminal phase; which implies that the patient should be sedated only to the extent required by palliative care. It is essential to realise that terminal sedation is not invariably continuous, deep and unreversed sedation. However, there will be occasions, where the sedation has to achieve continuous and total loss of consciousness, if the unbearable pain of the patient is to be eased[Gev03]. In the context of early terminal sedation, the patient should be entitled to receive medical treatment that is effective, legitimate and proportional. Such entitlement is commensurate with the notion that the objective of the patient and the health care professional should be to achieve the palliation of symptoms[Cel11]. The provision of continuous and deep sedation for palliation, admits of two distinct objectives; namely death and to achieve the palliation of symptoms. In other words, there is a commingling of the intention towards treatment and the right to treatment. Furthermore, patients are entitled to refuse treatment[Cel11]. Whenever the attendant medical practitioner concludes that there should be a withdrawal of hydration and nutrition, the decision should necessarily include respect for the autonomy of the patient. In addition, such decisions may involve other considerations. However, such considerations are legally redundant and unimportant from the ethical point of view. The choice of the patient is to be given due importance, as long as it constitutes informed consent[Cel11]. A few of the patients, who are subjected to aggressive symptom control measures, continue to be tormented by their disease or on account of the adverse effects of the therapy they are undergoing. In such cases, palliative sedation could be prescribed. The aim of such treatment is to provide relief in a manner that is morally acceptable to the patient, family and health care team[Ols10]. Nevertheless, health care professionals have, on occasion, expressed their misgivings regarding the indispensability of such treatment, and whether it is equivalent to euthanasia or physician assisted suicide. Palliative sedation finds favour with the medical practitioners, when all other therapies prove unequal to the task of relieving patients undergoing an unacceptable degree of suffering. It is employed when the opium derivative drug based therapies either fail to reduce the suffering or generate serious adverse effects[Ols10]. Palliative sedation is utilised with patients exhibiting pain, nausea, dyspnoea, delirium or other such physical symptoms Such treatment can be considered by the medical professional, if patients or their surrogate decision makers provide informed consent. In general, palliative sedation can be employed, if there is unanimity among patients, families, and staff apropos the appositeness of such treatment[Ols10]. In medical circles it has come to be recognised that a lowering of consciousness results in the relieving of suffering, and this constitutes the objective of palliative sedation. It is essential to provide palliative sedation only where required[Leg07]. Furthermore, this intervention should be adequate and proportional. The duration of the treatment and the combination and dose of sedatives injected into the patient are to be determined by the extent to which the symptoms are to be controlled, and not by the level to which consciousness is reduced[Leg07]. It is often the case that situations wherein palliative sedation is being considered, patients are already being injected with morphine, in order to treat dyspnoea or pain. In such cases, there is every inducement to enhance the quantity of morphine being injected, with the intent that unconsciousness followed by death will take place rapidly[Leg07]. In the Netherlands, such use of morphine has been observed. In fact, a study conducted in this area revealed that 19% of general practitioners, 22% of the nurses and 43% of specialists had made such use of morphine. Therapeutic doses of opioids cannot be relied upon to produce death, even on been administered in high doses. Another feature is that morphine produces major side effects, and the extant guidelines regard the employment of morphine to achieve these objectives as undesirable. Palliative sedation chiefly relies upon the drug midazolam, which is an injectable form of benzodiazepine[Leg07]. However, euthanasia and palliative sedation entertain several differences. Palliative sedation achieves relief from suffering by lowering the consciousness of the patient; whereas, euthanasia alleviates suffering by bringing about the demise of the patient. In addition, palliative sedation, of its own accord, does not shorten life and in some cases prolongs life by preventing exhaustion resulting from suffering; however, euthanasia categorically shortens life. Furthermore, euthanasia is an irreversible process; whereas, palliative sedation, in principle, is reversible[Leg07]. There are situations, in which euthanasia and palliative sedation present viable alternatives. In general, the mental or existential suffering of the patient provide the indications for euthanasia; whereas the indications are principally somatic with regard to palliative sedation[Leg07]. In the initial stages of its development, palliative sedation had been depicted as an intervention that related to the termination of life. Moreover, there is a signal absence of evidence regarding the contention that proportionately administered palliative care shortens life. The contemporary opinion is that palliative sedation constitutes normal medical practice. It is this very perspective that the Royal Dutch Medical Association stresses upon, in its guidelines related to palliative medication. Despite these developments, there is an urgent need to specify the exact conditions and criteria for utilising palliative sedation[Leg07]. These guidelines were based on the available knowledge and experience of that time. In addition, recourse had been made to the reputable national and international literature in that area. Moreover, the opinion of experts in the related fields had been considered. To their credit, these guidelines attempt to address the various issues involved[Leg07]. In fact, the Suicide Act 1961, declares that an offence is committed, whenever a person aids, abets, counsels or procures the suicide of aother person. Thus, a doctor should not provide information regarding euthanasia to a patient. However, if a competent patient refuses blood transfusion, the same cannot be given legally. All the same the doctor is duty bound to provide the best possible treatment to the patient that the latter permits. Such, treatment includes palliative measures, and the intention is to render the patient’s condition as peaceful as possible, and not to bring about the patient’s demise (Should you advise on euthanasia?, 2003). In the 1950s and 1960s, although morphine was easily available, doctors were hesitant to use it, as they were unfamiliar with the various side effects of this drug. A major apprehension among the doctors of that time related to morphine’s quality of causing addiction and what was worse fatal depression of respiration, on being used incorrectly[Woo06]. All the same, several doctors had contended that despite these shortcomings, morphine was a useful drug that significantly relived the suffering and pain of patients. Moreover, these doctors stressed that relieving the suffering of patients was paramount and that such action justified even fatal side effects[Woo06]. It has been contended that palliative sedation attempts to treat the patient and not to kill the patient, as is the intention in euthanasia. As a consequence, it is held that the doctor intends the beneficial effect, whilst foreseeing, but not desiring the demise of the patient. This important distinction was highlighted in the decision in R v Adams[Woo06]. In R v Adams, clarification regarding the doctrine of double effect was provided. This related to the entitlement of the doctor to adopt the necessary measures to relieve pain and suffering. The doctor was deemed to be justified in even bringing about a shortening of life, during the commission of such acts. Nevertheless, the court held that it was illegal to provide treatment that was aimed at causing the death of the patient (Should you advise on euthanasia?, 2003). In his ruling, Lord Devlin, stated that although it was the primary objective of medicine to restore the health of the patient, all the same, if this could not be achieved, then the doctor was justified in adopting such measures as were necessary to relieve pain and suffering. This would apply even if these measures resulted in shortening the life of the patient[Woo06]. With this ruling the doctrine of double effect made its advent into English law. It has, not unexpectedly, generated considerable debate, a major portion of which is pertinent to terminal sedation. It is to be clearly understood that Adams, who had intentionally brought about the demise of several of his patients, by administering opiates[Woo06]. Similarly in R v Moor, the defendant doctor had been accused of having murdered his patient, by administering lethal doses of morphine. As he was able to establish that he had done so in order to relieve the suffering of the patient, he was acquitted. However, in R v Cox the defendant doctor was convicted of the attempted murder of his patient, as he had injected the latter with potassium chloride. This chemical has no analgesic effect and did not have any therapeutic use in these conditions[Woo06]. The doctrine of double effect was clearly breached in this case. English law is not without idiosyncrasies; thus, it held Dr. Cox guilty of causing the death of a patient, by administering a fatal dose of potassium chloride. This doctor had done so with the express intent of bringing the suffering of the patient to an end. If he had used opiates to achieve this end, he would have not been convicted[Ham02]. In the contemporary society, intervention in the terminal stages of an illness has become commonplace. In the UK, the principle of double effect, which conjoins the relief of pain with the hastening of death, is employed around two to three thousand times a year. There are many doctors who fervently request the lawmakers to enact laws that would make it legal for them to comply with the wishes of their terminally ill patients [Ham02]. Such laws would bring about the much needed reconciliation between their duty towards patients as caregivers and their duty towards the law of the land. These suggestions were rejected by the Special Report of the House of Lords Select Committee on Medical Ethics 1993, as well as the Who Decides? green paper of 1997. It was the recommendation of this committee that euthanasia was to remain illegal, while the double effect intervention was to be continued[Ham02]. Palliative sedation is provided to a patient whose death is imminent, and should ensure that an acceptable and peaceful situation results. The focus of this intervention should be the alleviation of the suffering of the patient. Such sedation can be provided continuously till death transpires, or as a short term or intermittent measure. Thus, it can be inferred that palliative sedation provides an expedient solution to terminally ill patients undergoing acute pain. Nevertheless, medical practitioners have to exercise the utmost care and be conscientious while taking such decisions. As the relieving of pain hastens the death of these patients, the taking of hasty decisions, in the context of palliative sedation, will result in the demise of an innocent patient. In general, terminal care decisions differ significantly from the normal medical decisions. In the latter, there is hope of recovery; which is absent in decisions related to terminal care. Euthanasia, per se, is illegal in English Law; however, terminal sedation is permitted, if it relieves the suffering of the patient. In some of the cases discussed above, the medical practitioners had been convicted of murder, because they had merely shortened the life of the patient, by methods that did not reduce the suffering of the patient. It is indeed onerous for doctors to arrive at a balance between life shortening and terminal sedation, within the spheres of morality and professional ethics. Consequently, legislation that provides clear guidelines in this area is to be enacted. List of References Birnbacher, D. (2007). Terminal Sedation, Euthanasia, and Causal Roles. MedGenMed, 9(2), 48. Cellarius, V. (2011). Early Terminal Sedation is a Distinct Entity. Bioethics, 25(1), 46 – 54. Cranford, R. E., & Gensinger, R. (2002). Hospital Policy on Terminal Sedation and Euthanasia. HEC Forum, 14(3), 259 – 264. Gevers, S. (2003). Terminal Sedation: A Legal Approach. European Journal of Health Law, 10(4), 359 – 367. Hamilton, R. (2002). The law of dying. Journal of the Royal Society of Medicine, 95(11), 565 – 566. Jones, G. (2003, January 25). The euthanasia debate: 'Terminal sedation' is not death with dignity. Sault Star, p. D. 8. Legemaate, J., Verkerk, M., van Wijlick, E., & de Graeff, A. (2007). Palliative Sedation in The Netherlands: Starting-points and Contents of a National Guideline. European Journal of Health Law, 14(1), 61 – 73. Olsen, M. L., Swetz, K. M., & Mueller, P. S. (2010). Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments. Mayo Clinic Proceedings, 85(10), 949 – 954. Cra02: , (Cranford & Gensinger, 2002, p. 260), Jon03: , (Jones, 2003), van07: , (van Delden, 2007, p. 187), van07: , (van Delden, 2007, p. 188), Gev03: , (Gevers, 2003, p. 359), Gev03: , (Gevers, 2003, p. 360), Gev03: , (Gevers, 2003, p. 364), Cel11: , (Cellarius, 2011, p. 53), Ols10: , (Olsen, Swetz, & Mueller, 2010, p. 949), Leg07: , (Legemaate, Verkerk, van Wijlick, & de Graeff, 2007, p. 62), Leg07: , (Legemaate, Verkerk, van Wijlick, & de Graeff, 2007, p. 63), Leg07: , (Legemaate, Verkerk, van Wijlick, & de Graeff, 2007, p. 65), Leg07: , (Legemaate, Verkerk, van Wijlick, & de Graeff, 2007, p. 66), Leg07: , (Legemaate, Verkerk, van Wijlick, & de Graeff, 2007, p. 71), Leg07: , (Legemaate, Verkerk, van Wijlick, & de Graeff, 2007, p. 72), Woo06: , (Woods, 2006, p. 129), Woo06: , (Woods, 2006, p. 130), Ham02: , (Hamilton, 2002, p. 566), Ham02: , (Hamilton, 2002), Read More