Citation for Palliative Sedation

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MLA

al-Awamer, Ahmed , Isamme Alfayyad and Mohammed F. Abosoudah. "Palliative Sedation." In The Encyclopedia of Islamic Bioethics. Oxford Islamic Studies Online. Jan 27, 2022. <http://www.oxfordislamicstudies.com/article/opr/t9002/e0316>.

Chicago

al-Awamer, Ahmed , Isamme Alfayyad and Mohammed F. Abosoudah. "Palliative Sedation." In The Encyclopedia of Islamic Bioethics. Oxford Islamic Studies Online, http://www.oxfordislamicstudies.com/article/opr/t9002/e0316 (accessed Jan 27, 2022).

Palliative Sedation

Introduction

Palliative care aims to relieve the suffering of terminally ill patients and their families through the effective management of pain and other distressing symptoms. Despite advances in symptom management, a significant number of seriously ill patients suffer refractory symptoms that are unresponsive to conventional therapies. In these cases physicians may sedate patients to reduce their awareness of pain and other symptoms. Sedation is a last resort therapeutic intervention when no other effective interventions exist or are readily available. Depending on symptom severity, different levels of sedation are required to palliate symptoms effectively. These range from a milder form of sedation to deep unconsciousness. Sedation therapy has evolved over the past two decades and has become a standard medical practice for intractable suffering.

Though pain relief has been a part of medical care since ancient times, the concept of using sedation at the end of life was first formally introduced as a specialized palliative care option in the early 1990s. Many terms exist to describe this intervention, including terminal sedation, palliative sedation therapy, and continuous deep sedation. The term “terminal sedation” may misrepresent the intent of the intervention as being the premature termination of the patient’s life (euthanasia). Therefore, the term “palliative sedation therapy” has been used widely, as it emphasizes the intent to palliate refractory symptoms. The term “continuous deep sedation” describes the continuous administration of deep forms of palliative sedation therapy until the patient is unconscious. This article focuses on continuous deep sedation, given its ethical complexity, and the terms palliative sedation and sedation will be used interchangeably to describe the continuous deep form of palliative sedation. This article also discusses the use of sedation for physical symptoms and will not examine sedation for purely existential or psychological distress.

Definition

Palliative sedation therapy is defined as the proportional use of sedative medications to intentionally lower the awareness of terminally ill patients in their final hours (or days) to an acceptable level that can palliate their intractable suffering from refractory symptoms.

Western Ethics

Despite its validity as a therapeutic intervention for management of suffering, there exists a robust ethical debate over palliative sedation, given its potential for abuse and for ending a person’s life prematurely. Although the treatment is intended to relieve suffering, critics claim that it is “slow euthanasia” or a mercy killing in disguise (Billings and Block, 1996; Rady and Verheijde, 2010). For instance, some critics argue that sedation may go on for weeks, until the patient dies from dehydration and starvation (Rady and Verheijde, 2010). However, much of the controversy around palliative and continuous deep sedation in its early days stemmed from the lack of clarity about treatment intent and the inconsistent use of sedation that could result in premature death.

Palliative sedation differs ethically and conceptually from euthanasia and assisted suicide in many ways, including the intention of the act (sedation), the act itself (sedation process), and the intended outcome (Billings and Churchill, 2012; Ten Have and Welie, 2014; National Ethics Committee, 2006). The intent of palliative sedation is to relieve the patient’s suffering, not to hasten death. Death happens as a result of the progression of the terminal illness. While lethal drugs are given in high and precise doses to cause death in euthanasia and assisted suicide, palliative sedation is meant to be proportionate to the symptom and its severity. In other words, the patient is given the lowest possible dose of sedative medication to relieve the symptom. Doses are only increased if lower doses are ineffective.

Given the concern about death-hastening in the early days of palliative sedation, the principle of double effect has traditionally been used in Western ethics to justify the use of palliative sedation. In this case, “double effect” means that a moral distinction is made between the foreseen harmful effect of the act and the intent of the act. Still, a small number of patients experience unforeseen complications that can occasionally be fatal, such as airway compromise. Experts suggest that the risks of sedation can be mitigated if performed under the supervision of skilled and experienced personnel. Furthermore, there is broad agreement among palliative care experts that sedation does not hasten death, and it has become standard practice in many palliative care settings. Still, some clinical studies show no difference in the length of survival between sedated and non-sedated patients, which suggests that no such effect has been confirmed (Maeda et al., 2016; Maltoni et al., 2009; Maltoni et al., 2012; Sykes and Thorns, 2003). Scarpi et al. have also concluded that, “even if there is no direct evidence from randomized clinical trials, palliative sedation, when appropriately indicated and correctly used to relieve unbearable suffering, does not seem to have any detrimental effect on survival of patients with terminal cancer” (2011). As a result, many national and international palliative care organizations have issued standard practice guidelines for appropriate implementation of palliative sedation.

Most experts agree that palliative sedation should be considered only in patients with an expected survival of hours to days (de Graeff and Dean, 2007; Dean, et al., 2012). Theoretically, prolonged use of continuous deep sedation has significant effects on patients and their families, and may hasten death if offered prematurely. Therefore, it may not be appropriate for patients who are not imminently dying and who are expected to survive for more than two weeks. During the palliative sedation assessment, physicians typically look for signs of imminent death, such as patients who are no longer eating and drinking, suffer from severe debilitation, or are bedridden, drowsy, and disoriented. It is important to note that not all physicians are experts in end-of-life care and many will consult the expertise of a palliative care physician if in doubt. Alternatively, intermittent sedation can be used for patients who are expected to survive for relatively extended periods.

Islamic Perspective on Palliative Sedation

Palliative sedation is a relatively recent medical intervention, and there is no widely accepted Islamic ruling on its use. Islamic jurisprudence forbids and criminalizes any act intended to terminate a patient’s life. This position is compulsory and binding for all Muslim physicians and patients, which is deeply rooted in many Islamic fatāwā (rulings). For instance, the Permanent Committee of the General Presidency of Scholarly Research and Ifta in Saudi Arabia issued a fatwā stating that “It is Haram [prohibited] for a patient to hasten their death, whether by committing suicide or by taking medication to kill themselves. It is also Haram for a doctor, a nurse, or any other person to carry out the patient’s request, even if their disease is incurable. Anyone who assists in this shares in the sin, because they intentionally kill a human, whose life is protected by Shariʿah [Islamic law], without a right. There are clear indications [in Islamic texts from the Qurʾān or the sunnah] prohibiting the killing of a human being without a right. Allah (Exalted be He) says: ‘and kill not anyone whom Allah has forbidden, except for a just cause [according to Islamic law]” (General Presidency of Scholarly Research and Ifta).

However, there are a number of teachings, beliefs, and practices that create a dilemma from an Islamic viewpoint. First, in the Islamic tradition it is the patient’s right to avoid suffering, while the physician has a professional obligation to alleviate distress. Second, it is typically regarded as important for Muslim patients to maintain a level of consciousness to enable them to practice the worship rites as much as possible, to fulfill the commands of Allah (God) for obedience, and to win heaven in the hereafter. Third, there is a notable absence of Islamic rules that clearly permit or prohibit palliative sedation. Moreover, there is a lack of scholarship on the subject, specifically about how palliative sedation has been practiced in Muslim-majority societies or in Islamic healthcare settings, which might reflect substandard attention to or lack of awareness of the issue.

Legal Maxims of Islamic Jurisprudence and the Purposes of Islamic Law

Islamic legal doctrine and the analogical reasoning approach empower jurists to explicate and resolve ethical dilemmas encountered in daily Muslim life, and this applies to medicolegal dilemmas like palliative sedation. The legal maxims of Islamic jurisprudence (al-Qawāʿid al-Fiqhīyah) are among the tools that jurists use when practicing ijtihād (extrapolating legal rulings from the sources of the law). Al-Qawāʿid al-Fiqhīyah embodies ethical values substantially intended by Sharīʿah. In this context, the five universal qawāʿid (rules)—namely intention, certainty, removal of hardship, elimination of harm, and custom—are chiefly ethical (Elgariani, 2012). Moreover, these maxims are theoretical abstractions, usually in the form of short statements that express the goals and objectives of Islam (Sachedina, 2005).

Furthermore, these ethical principles—sometimes referred to as the purposes of Islam—aim to preserve and promote religion, life, progeny, intellect, and wealth. Using these ideas, as well as the legal maxims of Islamic jurisprudence, jurists have attempted to determine the permissibility of palliative sedation from an Islamic perspective. However, it should be emphasized that the prospective analysis does not constitute a fatwā (Islamic rule); rather, it represents bioethicist diligent opinion and scientific endeavor.

Preservation of Life and Religion

In Islam it is imperative to protect religion and life from any act that could potentially be misused by unprincipled or inexpert physicians. Such acts infringe on the purpose of preservation of life by assuming God’s prerogative of causing death. The likelihood of success of misuse might be affected by failure to have rigorous guidelines governing palliative sedation or by the erosion of the moral system in healthcare settings.

Based on the principle of injury, scholars have argued that when distant harm and injury are foreseen, physicians should follow the principle that “the prevention of harm has priority over the pursuit of a benefit of equal worth.” Based on this, opponents may argue that palliative sedation is unacceptable to preserve life because of the anticipated minimal risk of death from sedation and its complications. On the other side, proponents of palliative sedation may emphasize the principle of hardship and ḍarūrah (necessity): “Necessity legalizes the prohibited” (al-ḍarūrāt tubīḥ al-mahazūrāt). Medical interventions that would otherwise be prohibited are permitted if there is a necessity, such as pain medications and general anesthesia (Kasule, 2004; Van den Branden and Broeckaert, 2010). This means authorizing the practice of palliative sedation in imminently dying patients, even with the risk of injury, is permissible because of the necessity of relieving suffering. However, jurists continue to debate whether the burden of suffering is enough of a necessity to override the principle of injury, in order to complement the two views.

Further complicating the issue is the illicit use of opioids and other drugs, which is strictly prohibited in virtually all Islamic traditions. The hostility toward drugs is occasionally linked with the perception, discussed above, that palliative sedation inevitably hastens death.

Scholars can also evaluate palliative sedation using the principle of certainty. According to this principle, all medical procedures are considered permissible unless there is clear evidence to support their prohibition. Because of the studies showing that palliative sedation does not hasten death, defenders of the practice argue that it can be lawfully permitted when the aim of care is to ensure comfort until death for an imminently dying patient with a governing guideline and specific competency for quality assurance for the practicing physician. At the same time, however, palliative care physicians are expected to consult the relevant institutional clinical ethics committee. Protective measures shall take place, like discussing sedation with the multidisciplinary team, acquiring informed consent, and conducting appropriate drug selection and patient monitoring. Above all, every case should be evaluated in a case conference.

Suggested Framework for Approaching Palliative Sedation in Muslim Patients

As discussed in the previous section, there are no fatāwā, Islamic rulings, or recommendations regarding the use of palliative sedation for Muslims. The concept of palliative sedation for Muslims is still in its infancy. Further multidisciplinary discussion among Muslim stakeholders is essential to refine the concept of palliative sedation from an Islamic perspective. In the absence of an Islamic consensus or fatāwā, an individualized and vigilant approach must be considered on the use of sedation for refractory suffering. For proponents of palliative sedation, the authors of the present article (as Muslim experts in palliative care and bioethics) present a five-step (“five Cs”) framework for approaching palliative sedation in Muslim patients. This approach provides a clinical and ethical guide, but requires further validation by Muslim scholars before implementation.

1. Comprehensive Assessment

While the severity of a patient’s suffering depends on the judgment of the expert medical professionals, the tolerability of the suffering depends on the patient’s subjective feeling. Therefore, comprehensive interdisciplinary assessment is a vital step in approaching palliative sedation. The treating physician and the rest of the interdisciplinary team must conduct a thorough evaluation of the symptoms, including their potential causes and management options. The team must also explore other psychosocial factors that may contribute to the patient’s suffering. Given palliative care professionals’ expertise in end-of-life symptom management, an independent expert palliative care consultation must be obtained in order to optimize treatment.

2. Conditions and Ethical Considerations

As discussed in previous sections, the use of sedation carries a risk of abuse, cognitive and physical impairment, and potentially fatal complications if performed inappropriately. Further discussion among Muslim scholars is needed to assess if palliative sedation can be justified by the Islamic jurisprudence principle of hardship and necessity (ḍarūrah). It is worth mentioning that in Islamic literature, this principle has been used to justify the use of an array of medical interventions that may alter the patient’s state of consciousness temporarily, such as pain medication and general anesthesia. In the authors’ experience, local imams have frequently used the principle of hardship and necessity to permit individual cases of palliative sedation in Muslims. However, this principle should be applied according to other maxims of Islamic jurisprudence. Therefore, obtaining a personalized Islamic opinion is recommended. Additionally, the authors propose a set of conditions that should be applied to ensure the safeguarding and ethical use of palliative sedation for Muslim patients. (1) A sufficient consensus must be obtained among the interdisciplinary healthcare team, palliative care experts (preferably three or more expert medical professionals), the patient, and the patient’s family, which states that the patient has intolerable and refractory suffering, no conventional treatment exists, the patient is expected to die imminently, and the use of palliative sedation is appropriate. Such a consensus is essential to attain certainty (yaqīn) that palliative sedation is a necessity. (2) The therapy’s intention (al-qaṣd) is to alleviate suffering caused by physical symptoms and not to cause or hasten death. This condition applies to all parties, including physician, patient, and family. (3) Palliative sedation should be proportional to the suffering and harm and should be limited to achieving adequate relief of suffering. Palliative sedation should be provided using the lowest and lightest dose of sedatives necessary to relieve the patient’s suffering. The sedation should start with intermittent and light sedation. A deeper form of sedation should only be used if intermittent or lighter forms are ineffective.

3. Consent

The treating physician must obtain informed consent from the patient or their substitute decision-maker if the patient is incapable. The consent can be verbal or written and must include a detailed explanation of the concept of palliative sedation: the goal, benefits, possible risks, and alternative methods of relieving symptoms.

4. Conduct Sedation

After obtaining the needed assessment and consent, palliative sedation can be initiated, preferably by a palliative care professional. The administration and monitoring must follow accepted local guidelines. The physician must document the initiation time, desired level, type (whether continuous or intermittent), and duration of sedation, nutrition and hydration appropriateness, and the protocol or the standard medications that are used for this purpose.

5. Continuous Reassessment

Once the patient is sedated, they must regularly be reassessed and monitored closely to maintain a level of sedation that relieves their pain and symptoms. Dosages of the sedatives can be escalated based on subjective and objective assessments of symptom control. Assessment of other physical symptoms, such as skin care, wound care, and mouth care, is also important. If the patient survives longer than expected (e.g., more than two weeks), then the sedation decision must be readdressed by the multidisciplinary team. It is important to recognize family and caregiver distress during sedation. Psychological, social, and spiritual support should be provided to all family members throughout the process of sedation.

Limitations and Challenges

Though Islamic jurists have continued to develop best practices for palliative sedation, approaches such as the one outlined above have several limitations. The main limitation relates to the narrow recommendation for identification of patients who are appropriate for palliative sedation. Such an approach may limit the risk of abuse and misuse and allow for a more general social acceptability for the intervention.

Another limitation is the scarcity of palliative care and symptom management resources globally. Lack of timely access to resources (e.g., pain medications and other interventions) and specialists could exacerbate symptoms, as they may not be effectively addressed by nonexperts, or the needed medications may not be accessible within an acceptable timeframe. Therefore, it is the duty of the physician to make every effort to provide accurate symptom assessment and management according to the available resources. Also, the framework does not address emergency situations that require rapid sedation before meeting all the criteria (e.g., intractable delirium in which patients may harm themselves or others, stridor secondary to tracheal obstruction, or massive bleeding).

Concerning the use of artificial hydration and nutrition, sedated patients lose their ability to communicate, eat, or drink. Artificial hydration and nutrition may be considered in some patients who are unable to tolerate feeding, if medically indicated. Some scholars have argued for distinguishing artificial feeding and hydration administration decisions from palliative sedation. In other words, feeding and hydration must not be stopped (or started) because of palliative sedation. Instead, decisions about artificial feeding and hydration depend on the patient’s condition and standard medical care in compliance with the principle of avoiding or minimizing injury. In other words, if food could cause harm, then the patient must not be fed. On the other hand, if the harm of feeding is less than the benefit, the patient must be fed regardless of the decision about palliative sedation.

Conclusion

Palliative sedation is a relatively contemporary standard medical practice that may relieve the intractable suffering of seriously ill patients with death expected within hours or days. There is no fatwā or Islamic ruling on the use of palliative sedation. In applying the five purposes of Islamic law (maqāsid al-sharīʿah), palliative sedation may appear to contradict Islamic law. However, it can also be argued that palliative sedation as a last resort may be permissible in imminently dying Muslim patients based on the principle of necessity. A broad consultation among Muslim scholars and other Muslim stakeholders is warranted to achieve a better understanding of this intervention and reach a widely approved consensus.

Acknowledgements

All authors contributed to concept design of the framework and manuscript, and approved the final version of the manuscript. Ahmed al-Awamer conducted literature searches, drafted the “Introduction,” “Western Ethics,” “Limitations” and “Conclusion” sections, revised the manuscript critically, and prepared the final version. Isamme Alfayyad drafted the initial “Islamic Perspective on Palliative Sedation” section. Mohammed F. Abosoudah drafted the initial “Framework” section.

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