Abstract
Practitioners of palliative medicine frequently encounter patients suffering distress caused by uncontrolled pain or other symptoms. To relieve such distress, palliative medicine clinicians often use measures that result in sedation of the patient. Often such sedation is experienced as a loss by patients and their family members, but sometimes such sedation is sought as the desired outcome. Peace is wanted. Comfort is needed. Sedation appears to bring both. Yet to be sedated is to be cut off existentially from human experience, to be made incapable of engaging self-consciously in any human action. To that extent, it seems that to lose consciousness is to lose something of real value. In this paper, I describe how sedation and the question of intentionally bringing about sedation arise in the care of patients with advanced illness, and I propose heuristics to guide physicians, including Christian physicians, who seek to relieve suffering without contradicting their profession to heal.
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Notes
So far, at least two ethically relevant questions can be identified: (1) is a particular intervention that results in sedation of the patient properly described as PPS or PSU? And (2) if the latter, is the intervention yet morally permissible?
Patients who are dying often suffer pain and other distressing symptoms, and the medications that effectively relieve such symptoms often reduce patients’ level of consciousness. This is obvious, but how and when it is so can be complex. In the case of Terry Matthews, as in most cases, it was pain that caused her distress. Other symptoms such as nausea, agitated delirium, and shortness of breath can cause distress, and the relief of that distress often results in decreased levels of consciousness also; but I will focus on pain in this paper.
Although in actual cases it is often hard to say precisely which categories of pain are involved, pain can be categorized into a rough typology.
The pain that is best understood, and easiest to treat, is acute nociceptive pain. From there, things get more complex, and Terry’s pain was very complex.
Neuropathic pain is often mediated by direct injury to nerves, and this was certainly the case for Terry Matthews.
Pain is ultimately subjective. Byock notes, “it is a tenet of palliative care and hospice that the nature of pain is subjective; pain is what the patient says it is” [1, p. 214]. This does not mean, however, that physicians should always treat pain until the patient says it is relieved.
Byock acknowledges, “This is as hard as it gets. I don’t think I have ever seen anyone endure so much pain” [1, p. 211].
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Curlin, F.A. Palliative sedation: clinical context and ethical questions. Theor Med Bioeth 39, 197–209 (2018). https://doi.org/10.1007/s11017-018-9446-z
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DOI: https://doi.org/10.1007/s11017-018-9446-z