Consultation with a specialist palliative care
team or other healthcare experts is strongly
recommended to determine the untreatable
nature of the suffering.
• The principle of proportionality was
explicitly introduced in the definition of
palliative sedation (see Chapter 1.2) which is
seen as a continuum from light to deep
sedation and from intermittent to
continuous sedation. This principle implies
that the duration and depth of the sedation
should be proportional to the patient's
individual situation.
• The use of palliative sedation and whether
or not to administer artificial hydration
during sedation involves two different
decision-making processes. Hydration should
therefore not be automatically continued or
discontinued. Artificial hydration is a medical
intervention requiring an indication, a
therapeutic goal and the consent of a
competent patient. The decision should
consider the potential results of the
treatment, the overall benefit, the quality of
life and the psychological and spiritual wellbeing of
the patient. Any disproportionate
treatment should be avoided. If the patient
has not provided any instruction regarding
hydration and there is no legal
representative, healthcare providers should
make a decision in the best interest of the
patient. The medical reasons for the decision
should be explained to the significant
other(s) to avoid any misunderstandings.
• Based on the three key principles
mentioned above 1) refractoriness of
suffering, 2) proportionality and 3)
independent decision-making for hydration,
no specific period of remaining life
expectancy has been defined for the use of
palliative sedation.
• The importance of respecting patient
autonomy has been emphasised in all phases
of the process:
- In advance care planning, where the
potential role of palliative sedation in end-oflife care
and contingency plans should be
discussed early enough in the palliative
course of the disease and repeatedly to give
the patient the opportunity to express their
preferences while they still have mental
capacity.
- In the decision-making process, where the
aim, method, benefits and risks of the
proposed palliative sedation should be
discussed with and approved by patients
capable of making decisions by means of
informed consent. If the patient lacks
decisional capacity, advance directives/
advance care planning must be considered.
In the absence of advance directives, their
previously expressed preferences should be
considered or presumed treatment
preferences should be elicited, whenever
possible, from a legal representative and/or
significant others.
- Under sedation by consultation of the legal
representative.
• The decision-making process should be,
whenever possible, multi-professional and
interdisciplinary.
• Other than in emergency situations at the
end of life, light sedation should generally be
attempted first. Deeper palliative sedation
should be considered when light sedation
has been ineffective, or when it is clear that
light sedation will not provide adequate
relief in time (e.g. in massive haemorrhage
or asphyxia). The option of continuous deep
sedation should be considered when
intermittent sedation or continuous light
sedation has been insufficient to relieve
suffering adequately. In the case of
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