The Case Against Clinical Guidelines for Palliative Sedation
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This chapter will examine the arguments against the introduction of Clinical Practice Guidelines (CPG) for Palliative Sedation. The first argument will be an historical one. The pioneers of palliative care had solid reasons for avoiding the terminology of sedation and we are foolish not to heed their warning. The second argument is a clinical one. In attempting to curb abuse, CPG imposes conditions that are burdensome to both patient and clinician. Existing CPG fail to clarify several key points and therefore are prone to abuse. Most importantly, palliative sedation is clinically unnecessary since the bedside challenges of end-of-life care can be managed using the principles of clinical proportionality that are already imbedded in traditional palliative care. The third argument examines the track record of CPG as a tool to improve care. CPG were designed to disseminate new research evidence in the context of wide expert consensus. It is ill-fitted for the task of preventing abuse in an ethically-charged environment where key definitions are controversial. The power and reputation of the methodology may, inadvertently, accentuate abuse. The fourth argument examines the evidence, albeit limited, for the impact of existing CPG for palliative sedation on actual practice and extrapolates from this to the potential negative impact of widespread introduction. In conclusion, the chapter will argue there is considerable risk that dissemination of CPG on palliative sedation will have an untoward negative impact on both clinical practice and public attitudes. The concept and vocabulary of palliative sedation can and should be avoided by returning to the roots of palliative care whereby we frame our task as the control of specific symptoms. We should develop and disseminate CPG on delirium, respiratory distress and ‘existential’ distress which would incorporate medication algorithms but avoid the confusing terminology of palliative sedation.
KeywordsPalliative Care Clinical Practice Guideline Symptom Relief Palliative Medicine Palliative Sedation
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