Medicine, Health Care and Philosophy

, Volume 16, Issue 3, pp 533–542 | Cite as

Continuous sedation until death: moral justifications of physicians and nurses—a content analysis of opinion pieces

  • Sam Rys
  • Freddy Mortier
  • Luc Deliens
  • Reginald Deschepper
  • Margaret Pabst Battin
  • Johan Bilsen
Scientific Contribution


Continuous sedation until death (CSD), the act of reducing or removing the consciousness of an incurably ill patient until death, often provokes medical-ethical discussions in the opinion sections of medical and nursing journals. A content analysis of opinion pieces in medical and nursing literature was conducted to examine how clinicians define and describe CSD, and how they justify this practice morally. Most publications were written by physicians and published in palliative or general medicine journals. Terminal Sedation and Palliative Sedation are the most frequently used terms to describe CSD. Seventeen definitions with varying content were identified. CSD was found to be morally justified in 73 % of the publications using justifications such as Last Resort, Doctrine of Double Effect, Sanctity of Life, Autonomy, and Proportionality. The debate over CSD in the opinion sections of medical and nursing journals lacks uniform terms and definitions, and is profoundly marked by ‘charged language’, aiming at realizing agreement in attitude towards CSD. Not all of the moral justifications found are equally straightforward. To enable a more effective debate, the terms, definitions and justifications for CSD need to be further clarified.


Terminal Sedation Palliative Sedation Deep Sedation Content analysis Opinions Palliative care Terminal care 


  1. Baumrucker, S.J. 2002. Sedation, dehydration, and ethical uncertainty. American Journal of Hospice and Palliative Care 19: 299–300.PubMedCrossRefGoogle Scholar
  2. Billings, J.A., and S.D. Block. 1996. Slow euthanasia. The Journal of Palliative Care 12: 21–30.Google Scholar
  3. Braun, T.C., N.A. Hagen, and T. Clark. 2003. Development of a clinical practice guideline for palliative sedation. Journal of Palliative Medicine 6: 345–350.PubMedCrossRefGoogle Scholar
  4. Broeckaert, B., A. Mullie, J. Gielen, M. Desmet, P. Vanden Berghe, and Stuurgroep Ethiek FPZV [Ethics Commission Federation Palliative Care Flanders]. 2010. Richtlijn palliatieve sedatie [Palliative sedation guideline]. Accessed 2 Feb 2011.
  5. Chambaere, K., J. Bilsen, J. Cohen, J.A. Rietjens, B.D. Onwuteaka-Philipsen, F. Mortier, and L. Deliens. 2010. Continuous deep sedation until death in Belgium: A nationwide survey. Archives of Internal Medicine 170: 490–493.PubMedCrossRefGoogle Scholar
  6. Cherny, N.I., and L. Radbruch. 2009. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliative Medicine 23: 581–593.PubMedCrossRefGoogle Scholar
  7. Claessens, P., J. Menten, P. Schotsmans, and B. Broeckaert. 2008. Palliative sedation: a review of the research literature. Journal of Pain and Symptom Management 36: 310–333.PubMedCrossRefGoogle Scholar
  8. Committee on National Guideline for Palliative Sedation, Royal Dutch Medical Association (KNMG). 2009. Guideline for palliative sedation. Utrecht: Royal Dutch Medical Association. Accessed 29 Feb 2012.
  9. Council on Ethical and Judicial Affairs. 2008. Sedation to unconsciousness in end-of-life care. CEJA Report 5-A-08. Accessed 17 Apr 2012.
  10. de Graeff, A., and M. Dean. 2007. Palliative sedation therapy in the last weeks of life: A literature review and recommendations for standards. Journal of Palliative Medicine 10: 67–85.PubMedCrossRefGoogle Scholar
  11. Hawryluck, L.A., W.R. Harvey, L. Lemieux-Charles, and P.A. Singer. 2002. Consensus guidelines on analgesia and sedation in dying intensive care unit patients. BMC Medical Ethics 3: E3.PubMedCrossRefGoogle Scholar
  12. Hermsen, M.A., and H.A. ten Have. 2001. Moral problems in palliative care journals. Palliative Medicine 15: 425–431.PubMedCrossRefGoogle Scholar
  13. Kirk, T.W., and M.M. Mahon. 2010. National Hospice and Palliative Care Organization (NHPCO) position statement and commentary on the use of palliative sedation in imminently dying terminally ill patients. Journal of Pain and Symptom Management 39: 914–923.PubMedCrossRefGoogle Scholar
  14. Lynn, J. 1998. Terminal sedation. The New England Journal of Medicine 338: 1230–1231.PubMedCrossRefGoogle Scholar
  15. Miccinesi, G., J.A. Rietjens, L. Deliens, E. Paci, G. Bosshard, T. Nilstun, M. Norup, and G. van der Wal. 2006. Continuous deep sedation: physicians’ experiences in six European countries. Journal of Pain and Symptom Management 31: 122–129.PubMedCrossRefGoogle Scholar
  16. Morita, T., S. Tsuneto, and Y. Shima. 2002. Definition of sedation for symptom relief: A systematic literature review and a proposal of operational criteria. Journal of Pain and Symptom Management 24: 447–453.PubMedCrossRefGoogle Scholar
  17. Morita, T., S. Bito, Y. Kurihara, and Y. Uchitomi. 2005. Development of a clinical guideline for palliative sedation therapy using the Delphi method. Journal of Palliative Medicine 8: 716–729.PubMedCrossRefGoogle Scholar
  18. Mount, B. 1996. Morphine drips, terminal sedation, and slow euthanasia: Definitions and facts, not anecdotes. The Journal of Palliative Care 12: 31–37.Google Scholar
  19. National Ethics Committee, Veterans Health Administration. 2006. The ethics of palliative sedation as a therapy of last resort. American Journal of Hospice and Palliative Care 23: 483–491.CrossRefGoogle Scholar
  20. Orentlicher, D. 1997. The Supreme Court and physician-assisted suicide—rejecting assisted suicide but embracing euthanasia. The New England Journal of Medicine 337: 1236–1239.PubMedCrossRefGoogle Scholar
  21. Quill, T.E., B. Lo, and D.W. Brock. 1997. Palliative options of last resort: A comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. The Journal of the American Medical Association 278: 2099–2104.CrossRefGoogle Scholar
  22. Quill, T.E. 1993. The ambiguity of clinical intentions. The New England Journal of Medicine 329(14): 1039–1040.PubMedCrossRefGoogle Scholar
  23. Rietjens, J.A., A. van der Heide, A.M. Vrakking, B.D. Onwuteaka-Philipsen, P.J. van der Maas, and G. van der Wal. 2004. Physician reports of terminal sedation without hydration or nutrition for patients nearing death in the Netherlands. Annals of Internal Medicine 141: 178–185.PubMedCrossRefGoogle Scholar
  24. Rietjens, J.A., J. van Delden, B.D. Onwuteaka-Philipsen, H. Buiting, P. van der Maas, and A. van der Heide. 2008. Continuous deep sedation for patients nearing death in the Netherlands: descriptive study. British Medical Journal 336: 810–813.PubMedCrossRefGoogle Scholar
  25. Rousseau, P. 2002. Careful conversation about care at the end of life. Annals of Internal Medicine 137: 1008–1010.PubMedCrossRefGoogle Scholar
  26. Rousseau, P.C. 2006. Palliative sedation and the fear of legal ramifications. Journal of Palliative Medicine 9: 246–247.PubMedCrossRefGoogle Scholar
  27. Stevenson, C.L. 1969. Ethics and language. London: Yale University Press.Google Scholar
  28. Strauss, A., and J. Corbin. 1990. Basics of qualitative research: Grounded theory procedures and techniques. London: Sage.Google Scholar
  29. Swart, S.J., T. Brinkkemper, J.A. Rietjens, M.H. Blanker, L. van Zuylen, M. Ribbe, W.W. Zuurmond, A. van der Heide, and R.S. Perez. 2010. Physicians’ and nurses’ experiences with continuous palliative sedation in the Netherlands. Archives of Internal Medicine 170: 1271–1274.PubMedGoogle Scholar
  30. Thorns, A. 2002. Sedation, the doctrine of double effect and the end of life. International Journal of Palliative Nursing 8: 341–343.PubMedGoogle Scholar
  31. Van Deijck, R.H., P.J. Krijnsen, J.G. Hasselaar, S.C. Verhagen, K.C. Vissers, and R.T. Koopmans. 2010. The practice of continuous palliative sedation in elderly patients: a nationwide explorative study among Dutch nursing home physicians. Journal of the American Geriatrics Society 58: 1671–1678.PubMedCrossRefGoogle Scholar
  32. van Delden, J.J. 2007. Terminal sedation: Source of a restless ethical debate. Journal of Medical Ethics 33: 187–188.PubMedCrossRefGoogle Scholar
  33. Ventafridda, V., C. Ripamonti, F. De Conno, M. Tamburini, and B.R. Cassileth. 1990. Symptom prevalence and control during cancer patients’ last days of life. The Journal of Palliative Care 6: 7–11.Google Scholar
  34. Wein, S. 2000. Sedation in the imminently dying patient. Oncology (Williston Park) 14: 585–592.Google Scholar
  35. Zylicz, Z. 2004. Terminal sedation in the Netherlands. Annals of Internal Medicine 141: 966–967.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2012

Authors and Affiliations

  • Sam Rys
    • 1
    • 2
  • Freddy Mortier
    • 2
    • 3
  • Luc Deliens
    • 2
    • 4
  • Reginald Deschepper
    • 1
    • 2
  • Margaret Pabst Battin
    • 5
  • Johan Bilsen
    • 1
    • 2
  1. 1.Department of Public Health, Faculty of Medicine and PharmacyVrije Universiteit BrusselBrusselBelgium
  2. 2.End-of-Life Care Research GroupGhent University and Vrije Universiteit BrusselBrusselsBelgium
  3. 3.Bioethics Institute GhentGhent UniversityGhentBelgium
  4. 4.Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Expertise Centre for Palliative CareVU University Medical CenterAmsterdamThe Netherlands
  5. 5.Department of PhilosophyUniversity of UtahSalt Lake CityUSA

Personalised recommendations