"Is the symptom truly refractory?" or "Is
there another option that can provide
adequate relief fast enough?"
"Is this too early?" and "Will the patient
possibly need to be sedated for weeks?"
"Is there true informed consent?"
"How deep should the sedation be?"
"What should be done if the patient
appears to overdose?"
"Am I accelerating the dying process or
committing slow euthanasia?"
Within the purview of palliative care, few
issues remain as contentious or clinically and
ethically challenging as the use of sedation
to manage otherwise refractory symptoms.
For the mindful practitioner, the option of
palliative sedation is always challenging:
given the cost of loss of interactional
function and the imperative to provide
adequate relief of severe distress there are
always difficult trade-offs and difficult
questions:
Over the past 30 years, there have been
multiple attempts to systematize the use of
so-called "Palliative Sedation." The
development of thoughtful coherent
guidelines, addressing the clinical and ethical
aspects of palliative sedation have helped
establish "Palliative Sedation" as an ethically
justifiable, critical option of last resort in
palliative care that reflected normative
ethical principles of respect for persons,
autonomy, benevolence and nonmalfeasance.
Clinical guidelines play a crucial role in
4
A Reflection
ensuring the ethical use of palliative sedation
by providing healthcare professionals with
standardized, meticulously developed, and
valid recommendations for the appropriate
administration of sedation to relieve severe
and refractory symptoms in terminally ill
patients.
The 2009 EAPC framework has been the
benchmark document for many other
national regional and institutional guidelines.
Scope for revision is an integral part of any
sound guideline and with the passage of time
and the accrual of international experience,
the time had come to revise the 2009
document.
The updated EAPC palliative sedation
guidelines are the end product of the EUfunded Palliative
Sedation project (PalSed).
In contrast to the previous iteration which
was developed by a small team, the strength
and credibility of this updated version is
enhanced by an extensive literature review
of published guidelines and the application
of a rigorous Delphi consensus process
involving multiple geographically diverse
international experts as well as stakeholder
representation.
In the 2023 EAPC guideline, a total 42
by Prof. Nathan Cherny MD
Norman Levan Chair of Humanistic Medicine
Shaare Zedek Medical Center, Israel