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.

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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 or phenobarbital.

Nutrition and fluids

As patients are already in the last hours or days of their lives, they are not usually receiving nutrition, although some can benefit from subcutaneous or intravenous fluids and other measures such as antibiotics for a distressing infection.

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 and the subsection Dangerous opioids or dangerous prescribers?

Patients (or their legal representatives) do have the right to refuse life-sustaining treatment (such as with a living will), which is legally considered as passive euthanasia. However, once unconsciousness begins, the patient is no longer able to decide to stop the sedation or to request food or water and the clinical team needs to act in the patient's best interests.

Sedation at the end of life should be a treatment response to the symptom distress of terminal restlessness and agitation. There can be a problem for the nurse or doctor in deciding who is distressed: the patient themself, the family, or the professional. Sedation is not routine in palliative and most patients die comfortably without the need for sedation.

Legal position

As sedation is titrated to avoid harm (including death). According to the principle of double effect such treatment is legally justified if a doctor administers the drug with the intention to alleviate pain/suffering. The defence of double effect is only open to medical practitioner.

See also

• Uniform Rights of the Terminally Ill Act
• Doctrine of double effect