US physicians show conservative approach to end-of-life sedation

Intentionally sedating patients to unconsciousness until death is neither widely practiced nor supported by US physicians, a national survey indicates.

Survey respondents did, however, indicate their broad support for unconsciousness as an unintended side effect of proportionate palliative sedation (PPS) in dying patients.

"These results should inform medical policy makers when writing clinical guidelines and inform ongoing debates about ethically appropriate care of patients at the end of life," write Farr Curlin (University of Chicago, Illinois, USA) and colleagues in the Journal of Pain and Symptom Management.

Curlin et al used a postal questionnaire to canvas opinions on the use of palliative sedation to unconsciousness. Of 1880 eligible US physicians, 1156 (62%) responded; the mean age of respondents was 45.4 years, 35% were female, 66% were White non-Hispanic, 21% were Asian, and the most common specialties were internal medicine and family medicine/general practice.

In all, 141 (10%) respondents said they had sedated a patient in the previous year with the specific intention of making the patient unconscious until death.

In response to a clinical vignette regarding sedation for existential suffering, just 8% thought it would be "very appropriate" to sedate the patient to unconsciousness until she died. Most thought such sedation would be not very (35%) or not at all (37%) appropriate.

A large majority (85%) of physicians agreed that unconsciousness is an acceptable side effect of palliative sedation but should not be directly intended. Less than one third (31%) thought that doctors should sometimes treat the psychological and spiritual suffering of terminally ill patients by sedating the patient to unconsciousness.

Two thirds (69%) of respondents agreed that each person had the right to decide whether to hasten the end of his or her life, but less than half (42%) agreed that intentionally hastening a patient's death is sometimes the right thing for a physician to do.

In multivariate analysis, physicians were more likely to report having practiced sedation to unconsciousness until death if they had been born in the USA and had had many patients die in the past 12 months, but less likely if they were of Hispanic/Latino ethnicity or Hindu religion.

"In this nationally representative survey of US physicians, we found that intentionally sedating dying patients to unconsciousness until death is neither the norm in clinical practice nor broadly supported for the treatment of primarily existential suffering," conclude Curlin et al.

"There is a broad support, however, for accepting unconsciousness as an unintended side effect of PPS for targeted refractory symptoms in dying patients."

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