Dutch doctors are given guidance on palliative sedation

Utrecht

Tony Sheldon

The Dutch Medical Association has laid down guidance on doctors’ use of sedation to induce a coma in dying patients and relieve their pain and suffering.

It tries to make clear the difference between such sedation, which is produced with sedatives such as midazolam and which the guidance calls palliative sedation, and euthanasia. It says palliative sedation is “normal medical treatment” that does not “accelerate death” and that it has been incorrectly associated with “life ending treatment.”

Explicitly excluded from palliative sedation is the common practice whereby the dose of morphine for pain relief in palliative care is increased until the patient loses consciousness and dies more quickly.

This is described as a “grey area between pain relief and ending life.” The guidance considers the use of morphine to achieve sedation to be an “incorrect use of this medication.”

Research indicates that “terminal sedation” occurs in up to 14 000 deaths in the Netherlands each year, or 10% of the total (Annals of Internal Medicine 2004;141:178). The public prosecution service had called for the practice to be regulated amid fears that it was being used to bypass the euthanasia law.

Alarm spread among the medical profession when a doctor, Peter Vencken, was unsuccessfully prosecuted for murder after the death of a terminally ill patient to whom he had administered pain relief and a sedative (BMJ 2005;331:473).

The government asked the association to draw up guidance. A committee chaired by the professor of medical ethics at Groningen University, Marian Verkerk, has concluded that palliative sedation should not be brought under the regime of the euthanasia law. Doctors acting within the new guidance should not be prosecuted.

Palliative sedation is defined as the “deliberate reduction of a patient’s consciousness in the last phase of life” as a means of relieving suffering. The dose and length of treatment should be “attuned to the required degree of symptom control.” The “first choice” of drug is the sedative midazolam, although levomepromazine or phenobarbital could also be considered.

The guidance recognises that research has shown that nearly half of hospital doctors and a fifth of general practitioners have used increasing doses of morphine, partly in the hope that a terminally ill patient will lose consciousness and die swiftly.

But it considers it wrong to use morphine for these goals. Morphine is particularly inappropriate for palliative sedation because, although sedation may result as a side effect, it may also cause convulsions and hallucinations.

The advice also recommends that patients should be treated on the basis of informed consent, must be suffering unbearably from untreatable symptoms, and are not expected to live more than two weeks. Once in a coma the patient is not given fluids, as this would be considered medically pointless.

The advice intentionally dropped the term “terminal” in favour of “palliative” sedation, arguing that it should be seen as part of palliative care and not intended to shorten a patient’s life.

The medical association’s chairman, Peter Holland, said the new guidance now offers “certainty” surrounding palliative sedative treatment.

“We know what is punishable and what is not, what is normal medical treatment, and, above all, what the criteria of care are for treating patients in a professional manner,” he said.