Terminal sedation

Terminal sedation (also known as palliative sedation, or sedation for intractable distress in the dying/of a dying patient) is the practice of relieving distress in a terminally ill person in the last hours or days of a patient's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug.

Drugs used
A typical drug is midazolam, a short acting benzodiazepine. Opioids such as morphine are not used as the primary medicine since they are not effective sedative medications compared to benzodiazepines. However, if a patient was already on an opioid for pain relief, this is continued so pain relief while sedated is achieved. Other medications to be considered include haloperidol, chlorpromazine, pentobarbital, propofol or phenobarbital.

Nutrition and fluids
As patients undergoing terminal sedation are typically in the last hours or days of their lives, they are not usually eating or drinking significant amounts. There has not been any conclusive studies to demonstrate benefit to initiating artificial nutrition (TPN, tube feedings, etc.) or artificial hydration (subcutaneous or intravenous fluids). Before initiating terminal sedation, a discussion about the risks, benefits and goals of nutrition and fluids is encouraged. (NB: it's mandatory, not encouraged - to withdraw food and fluids in the UK without doing so is considered murder in the UK).

Risk assessment
There is no evidence that titrated sedation causes the death of the patient and sedation does not equate with euthanasia. At the end of life sedation is only used if the patient perceives their distress to be unbearable, and there are no other means of relieving that distress. In palliative care the doses of sedatives are titrated to keep the patient comfortable without compromising respiration or hastening death. For more information on the palliative care use of sedatives and the safe use of opioids see Opioids.

Patients (or their legal representatives) only have the right to refuse treatments in living wills, they cannot demand life saving treatments, or any treatments at all. However, once unconsciousness begins, as the patient is no longer able to decide to stop the sedation or to request food or water, the clinical team can  act in the patient's  best interests. A Living Will, made when competent, can under UK law, give a directive that they refuse 'Palliative Care' or 'Terminal Sedation', or 'any drug likely to supress my respiration'.

Legal position
Terminal sedation is legal in the United States of America. In 2008, the American Medical Association Council on Ethical and Judicial Affairs approved an ethical policy regarding the practice of palliative sedation. According to the principle of double effect such treatment is ethically justified if a doctor administers the drug with the intention to alleviate pain/suffering. The defense of double effect is only open to medical practitioners. Terminal sedation is illegal in the UK. The UK Legal System operates 'Courts of Law' - NOT 'Courts of Ethics' - and the views of Thomas Aquinas (responsible for the 'double effect' argument) are seen as no more valid than those of anyone else. Significant advances in analgesia made over the past 30 years may now mean there is no need whatsoever to administer any opiate or opiod drug in potentially life-threatening doseages to alleviate pain, as many alternatives with no lethal side effects are available; as a consequence, the pretense of the 'double effect' defense may be seen as invalidated by some.