Should deep, continuous sedation at the end of life really be treated as normal medical practice in the Netherlands, ask three Dutch authors in the Journal of Medical Ethics. Although they do not appear to oppose euthanasia, they argue that “morally problematic aspects inherent to palliative sedation do not get the attention they deserve” under current guidelines. Since palliative sedation accounted for more than 12% of deaths in the Netherlands in 2010, this is an important issue.
Although euthanasia – which ends a patient’s life immediately – is the most visible and controversial aspect of end-of-life care for international observers, the innocuous-sounding treatment called “palliative sedation” (also called “terminal sedation” by some authors) also has been the centre of controversy in the Netherlands. In 2003, the then-attorney-general argued that the death of a deeply sedated patient because water was withheld was culpable homicide. However, his view did not prevail.
To clarify the situation, the Royal Dutch Medical Association (KNMG) issued guidelines for palliative sedation in 2005 (updated in 2009). These define it as the use of drugs in the last two weeks of life to induce deep unconsciousness for patients who have “refractory symptoms”, combined with the withdrawal of nutrition and hydration. The main point of the guidelines was to insist that palliative sedation is not euthanasia, not even “slow euthanasia”. It is normal medical practice. The provision of fluids for a patient under palliative sedation is regarded as medically futile.
The authors of the JME article point out, however, that this approach skates over some difficult problems. First, how can doctors be sure that the life expectancy is only two weeks? The chairperson of a regional review committees for euthanasia even said in 2007 that “It is unprofessional to render a person with a long life expectancy asleep and refrain from hydration and nutrition. That's just euthanasia with other means, because without food and fluid everyone dies after a week.”
Second, the guidelines describe it both as “a radical medical procedure” and normal medical practice. How can it be both of these? Third, because it is “normal medical practice” (which euthanasia is not), its purpose must be to alleviate suffering, not to end life. However, a 2004 study showed that in 17% of cases doctors used it to end lives.
Fourth, because it is considered “normal medical practice”, the KNMG says that a doctor does not need to consult his decision with a colleague – and in fact, almost none of them do. However, the European Association for Palliative Care and the American Medical Association insist on consultation.
The authors argue that KNMG eliminated the need for consultation in order to distinguish palliative sedation from euthanasia, which does require consultation. They point out that when consultation for palliative sedation was required at a cancer centre, the result was negative 41% of the time. “Considering consultation optional only because mandatory consultation makes palliative sedation look like euthanasia seems an unpersuasive argument,” they say.
Since it is difficult to get accurate information about what Dutch terminal sedation is, we have inserted the 2009 KNMG guidelines below.