Hard Choice for a Comfortable Death: Sedation

By ANEMONA HARTOCOLLIS - NYT

December 26, 2009


In almost every room people were sleeping, but not like babies. This was not
the carefree sleep that would restore them to rise and shine for another
day. It was the sleep before -- and sometimes until -- death.

In some of the rooms in the hospice unit at Franklin Hospital, in Valley
Stream on Long Island, the patients were sleeping because their organs were
shutting down, the natural process of death by disease. But at least one
patient had been rendered unconscious by strong drugs.

The patient, Leo Oltzik, an 88-year-old man with dementia, congestive heart
failure and kidney problems, was brought from home by his wife and son, who
were distressed to see him agitated, jumping out of bed and ripping off his
clothes. Now he was sleeping soundly with his mouth wide open.

"Obviously, he's much different than he was when he came in," Dr. Edward
Halbridge, the hospice medical director, told Mr. Oltzik's wife. "He's calm,
he's quiet."

Mr. Oltzik's life would end not with a bang, but with the drip, drip, drip
of an IV drug that put him into a slumber from which he would never awaken.
That drug, lorazepam, is a strong sedative. Mr. Oltzik was also receiving
morphine, to kill pain. This combination can slow breathing and heart rate,
and may make it impossible for the patient to eat or drink. In so doing, it
can hasten death.

Mr. Oltzik received what some doctors call palliative sedation and others
less euphemistically call terminal sedation. While the national health
coverage debate has been roiled by questions of whether the government
should be paying for end-of-life counseling, physicians like Dr. Halbridge,
in consultations with patients or their families, are routinely making tough
decisions about the best way to die.

Among those choices is terminal sedation, a treatment that is already widely
used, even as it vexes families and a profession whose paramount rule is to
do no harm.

Doctors who perform it say it is based on carefully thought-out ethical
principles in which the goal is never to end someone's life, but only to
make the patient more comfortable.

But the possibility that the process might speed death has some experts
contending that the practice is, in the words of one much-debated paper, a
form of "slow euthanasia," and that doctors who say otherwise are fooling
themselves and their patients.

There is little information about how many patients are terminally sedated,
and under what circumstances -- estimates have ranged from 2 percent of
terminal patients to more than 50 percent. (Doctors are often reluctant to
discuss particular cases out of fear that their intentions will be
misunderstood.)

While there are universally accepted protocols for treating conditions like
flu and diabetes, this is not as true for the management of people's last
weeks, days and hours. Indeed, a review of a decade of medical literature on
terminal sedation and interviews with palliative care doctors suggest that
there is less than unanimity on which drugs are appropriate to use or even
on the precise definition of terminal sedation.

Discussions between doctors and dying patients' families can be spare, even
cryptic. In half a dozen end-of-life consultations attended by a reporter
over the last year, even the most forthright doctors and nurses did little
more than hint at what the drugs could do. Afterward, some families said
they were surprised their loved ones died so quickly, and wondered if the
drugs had played a role.

Whether the patients would have lived a few days longer is one of the more
prickly unknowns in palliative medicine. Still, most families felt they and
the doctors had done the right thing.

Mr. Oltzik died after eight days at the hospice. Asked whether the sedation
that rendered Mr. Oltzik unconscious could have accelerated his death, Dr.
Halbridge said, "I don't know."

"He could have just been ready at that moment," he said.

With their families' permission, Dr. Halbridge agreed to talk about
patients, including Mr. Oltzik and Frank Foster, a 60-year-old security
guard dying of cancer. He said he had come to terms with the moral issues
surrounding sedation.

"Do I consider myself a Dr. Death who is bumping people off on a regular
basis?" he asked. "I don't think so. In my own head I've sort of
come to the
realization that these people deserve to pass comfortably."

An Uncomfortable Topic

For every one like Dr. Halbridge, there were other doctors who, when asked
about their experiences, would speak only in abstract and general terms, as
if giving a medical school lecture, and declined requests to arrange
interviews with families who had been through the process. It is a difficult
subject to discuss.

The medical profession still treats its role as an art as much as a science,
relying on philosophical principles like the rule of double effect. Under
this rule, attributed to the 13th century Roman Catholic philosopher Thomas
Aquinas, even if there is a foreseeable bad outcome, like death, it is
acceptable if it is unintended and outweighed by an intentional good outcome
-- the relief of unyielding suffering before death. The principle has been
applied to ethical dilemmas in realms from medicine to war, and it is one of
the few universal standards on how end-of-life sedation should be carried
out.

At Metropolitan Hospital Center, a city-run hospital in East Harlem, Dr.
Lauren Shaiova, the chief of pain medicine and palliative care, has issued
20 pages of guidelines for palliative sedation. The guidelines include
definitions, criteria, what to discuss with family and hospital workers and
a list of drugs to induce sleep, control agitation and relieve pain.

The checklist of topics to be discussed with the family includes whether to
offer intravenous food and water. Another checklist anticipates that some
hospital workers may be upset by the process, and recommends a discussion
with questions like: "Were you comfortable with the sedation of this
patient? If not, what were your concerns?"

But clarity, doctors say, is hardly the rule. In 2003, Dr. Paul Rousseau,
then a Veterans Affairs geriatrician in Phoenix, wrote an editorial in the
Journal of Palliative Medicine calling for more explicit guidelines and
research. He noted that some researchers include intermittent deep sleep in
the category of palliative sedation, while others limit it to continuous
sedation, which he said might explain some of the variance in estimates of
how often it occurs.

And he proposed more systematic research into the types of medications used,
how long it takes for patients to die, and the feelings of family and
medical staff.

Doctors at two prominent New York City hospitals, Beth Israel Medical Center
and NewYork-Presbyterian Hospital, freely discussed their policies on
terminal sedation, but were reluctant to allow a reporter to talk to
patients or families. The policy adopted by Beth Israel's hospice endorses
palliative sedation to "carefully selected patients" at the end
of life. The
three-page policy reviews legal, ethical and clinical considerations in
broad strokes, but refrains from providing names of drugs and checklists.

Dr. Russell Portenoy, chairman of pain medicine and palliative care at Beth
Israel, said the policy reflected the perceived perils of too much
specificity. The hospice ethics committee decided that every patient was
different, he said, and that "it was better to present a policy at this
10,000-foot level."

The Metropolitan guidelines authorize certain drugs to induce palliative
sedation, or in conjunction with sedation for pain, delirium and agitation.
The sedation drugs are lorazepam, midazolam, phenobarbital and, in the
intensive care unit only, sodium thiopental.

For pain, the guidelines list opioid drugs, including morphine, methadone
and fentanyl.

Doctors say that other drugs used for sedation are ketamine, an anesthetic
and sedative popular at rave parties, and propofol, an anesthetic, which was
ruled, with lorazepam, to have caused Michael Jackson's death. In very high
doses, sodium thiopental is used as a sedative in the three-drug combination
used for lethal injections.

There is one ethical guidepost for all the protocols: Terminal sedation
should not become so routine that the end of life is scheduled like elective
surgery, for the convenience of the doctor or the family, or because the
patient's care is no longer economically viable.

Physicians occasionally feel pressure to turn up the medication, said Dr.
Pauline Lesage, Beth Israel's hospice medical director. The pressure may
come from weary relatives, who say, in effect, "Now it's enough; I just want
him to disappear."

Sometimes the pressure is institutional. "You may be tempted to jump over
because, oh well, 'I need the bed,' or 'That's enough, I don't see what we
are doing here,' " she explained.

The doctors resist pressure to deliberately hasten death, she said.
"Otherwise you see that you are jumping into a different field."


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