Palliative sedation cuts patient requests for euthanasia

NEW YORK (Reuters Health) - A poll of physicians in The Netherlands indicates that patient involvement in decisions regarding continuous palliative sedation at the end of life has increased over the last few years, with fewer patients requesting euthanasia.

In 2005, the Royal Dutch Medical Association published a national guideline for palliative sedation, which restricts its application to patients who experience refractory symptoms and who are expected to die within 1-2 weeks.

To see how the guideline has affected clinical practice, Jeroen G. J. Hasselaar and associates at Radboud University Nijmegen Medical Center surveyed 160 physicians who reported having applied continuous deep sedation at least once in the past 12 months during the periods prior to the publication of the guideline (2003-2005) and afterwards (2007). Their findings appear in the March 9 Archives of Internal Medicine.

Approximately 80% of patients were over age 61. Patient involvement in decisions regarding palliative sedation rose from 72.3% to 82.2% (p < 0.001), while requests for euthanasia declined (14.5% to 6.3%, p = 0.01).

During both periods, the primary indications for continuous sedation were pain, dyspnea, and anxiety, the authors report. "Exhaustion" as a reason nearly doubled from 31% to 56%, leading the investigators to caution that this symptom is likely to have a "psychoexistential dimension" that may require multidisciplinary assessment.

As recommended by the guideline, use of benzodiazepines increased (69.9% to 90.4%, p < 0.001). However, Hasselaar's group was concerned that physicians were reluctant to use opioid medications for pain or dyspnea during sedation.

"It seems that palliative sedation and symptom-directed treatment are often regarded as opposites rather than supplements," the researchers write. They suggest that use of opioid rotation and consultation with a palliative care specialist might improve patient comfort.

The RDMA guideline advises against parenteral hydration because it increases the risk of edema and incontinence. Although more physicians decided to forgo artificial hydration during the second survey (56.3% to 78.8%), the median survival time of patients was the same in both periods: 2 days. Thus, the authors state, withholding artificial hydration is not a practice that "reduces continuous palliative sedation to a kind of slow euthanasia in principle."

They conclude: "Issues concerning the proper indication and application of continuous sedation still deserve more attention and implementation."

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