11 reasons why terminal sedation can be the wrong option
Just one clinical argument has run through the discussions on the rights and wrongs of voluntary assisted dying.
It is the argument voiced frequently by opponents of the system running in Victoria and it has been heard in the discussions in WA and in Queensland.
It is that terminal sedation (also known as palliative sedation) can be provided as an alternative to voluntary assisted dying to approximately 5% of dying patients who are experiencing overwhelming suffering.
However, we believe that terminal sedation can be an inferior option to voluntary assisted dying for patients who are able to choose between them.
The main differences are summarised in the following table:
|Terminal sedation||Voluntary assisted dying|
|Dying can be prolonged and uncertain||Dying is quick and certain|
|The decision is most often made by the doctor||The decision is made by the patient|
|Death is often experienced by loved ones as undignified and harrowing||Death is experienced with reverence, thankfulness, and a sense of release|
|The time of death is indeterminate; patients sometimes die alone, to the distress of family||The time of death is chosen by the patient|
|Deep sedation may remove both consciousness and all semblance of personhood||Consciousness is preserved. Death is induced by fast acting and effective medication|
|Documentation may be cryptic, and clouded in secrecy||Documentation is regulated, transparent and subject to official scrutiny|
|Doctor accountability for process and outcome is not clearly defined||Doctor accountability is fully and clearly defined|
|Legal protections for the doctor (criminal homicide), and the patient (abuse) are minimal||The doctor and the patient are well protected by the law|
|Access depends on the doctor's attitude, including religious beliefs||Access is legally available, provided the patient is eligible|
|Neither capacity to consent, nor consent itself, is necessary, even from the family||Both capacity, and consent from the patient are required|
|No beneficial effect on bereavement||Beneficial effect on bereavement compared with death from natural causes1|
With terminal sedation, dying can take weeks, and the time to death is unpredictable.
The patient may linger in a semi-comatose state, dehydrated and deteriorating.
This can be distressing to loved ones, who are unable to communicate with the dying person, or help in any meaningful way.
With voluntary assisted dying, the person has capacity, and awareness, plus the ability to communicate and to initiate the process.
With terminal sedation, the decision to administer continuous sedative medication is often that of the doctor. The patient may not be able to indicate consent.
With voluntary assisted dying, the dying person makes the decision while dignity and purpose are intact. This is both a rational and a mentally healthy choice, for those who take that option.
With terminal sedation, death can be a trial for all concerned. It can be remembered with guilt and horror.
With voluntary assisted dying, the patient chooses the timing and the arrangements. Death is dignified and peaceful. It is often described as a ‘good death’ — a fitting end that complements and rounds off a person’s life experiences and achievements.2
- Australia's first euthanasia doctor tells his story of ending the lives of patients
- Much is missing from Victoria's report into its assisted dying scheme
- First person dies under voluntary euthanasia laws: Here is her story
With terminal sedation, sedative and analgesic medications are relied on to control the dying process and associated suffering.
Even so, fluctuating levels of response mean that complete control of suffering cannot be guaranteed.
With voluntary assisted dying, the dying process is brought to a conclusion by the administration of medication that is the same as, or similar to, that used for general anaesthesia.
This can be self-administered by mouth or given intravenously. The latter can be given by a doctor or arranged for self-activated administration by the patient.
Communication channels remain open until the last minutes of life. And the most important loved ones are usually present, or close by.
With terminal sedation, documentation may be incomplete and statistical information impossible to collect. There is no regulatory framework.
With voluntary assisted dying, documentation is clear, frank and open to scrutiny.
- Here's the lowdown on WA's voluntary assisted dying laws
- Is there a major flaw in Victoria's assisted dying laws?
- The 9 steps doctors must take to help a patient die
Finally, there are some characteristics that terminal sedation and voluntary assisted have in common.
In both, the primary aim of the doctor is the relief of suffering.
In both, the patient is in the process of dying, and will inevitably die.
In both, the intent is the same, and the outcome — death — is the same.3
Voluntary assisted dying will not be acceptable to some dying people, nor will it be available to some others.
Terminal sedation will continue to be an invaluable intervention for such people, if they experience refractory suffering.
It can be well accepted, where there is accountability, and good communication and care directed toward family members.4
- This article was co-authored by Dr Richard Lugg, a public health physician from Perth.
Disclaimer: Both Dr Beahan and Dr Lugg are members of Doctors for Assisted Dying Choice — however, they are writing as individuals, rather than on behalf of the organisation.
- References upon request from [email protected]