How should crisis sedation be presented to dying patients at risk of a catastrophic event?

By Dr Nathan Emmerich and Prof Bert Gordijn

When we consider the end of our life and the actual circumstances of our death the vast majority of us would prefer to go peacefully, perhaps dying of simple old age at the end of a life well lived. Unfortunately, this is not always possible. Whilst the lives we lead are, at least to some degree, within our control, the way we die is rarely a matter of our choosing. Indeed, even in those countries that facilitate physician assisted dying, this is only sanctioned when it is precipitated by some form of terminal illness and/or intolerable suffering. As such, those who are unable or unwilling to pursue assisted dying, the circumstances of ones death are largely dictated by the way in which their medical condition develops.

Of course, dying patients are not simply left to suffer the vagaries of their illness; rather they are provided with the medical and nursing care they require, at least ideally. In some cases such care can effectively mitigate a patient’s symptoms and the dying process can be managed in such a way that something close to a peaceful death can be achieved. However, in other cases a patient’s death cannot be managed as well as we would like and, inevitably, some of us will die in pain or whilst suffering in some way.

In our paper ‘The Ethics of Crisis Sedation: Questions of Performance and Consent’ we discuss certain catastrophic events that can arise in dying patients. These are events that rapidly precipitate the death of the patient, the most common of which—at least within health care institutions providing end of life care—is the rupture of a major artery, such as the carotid. This results in a terminal hemorrhage, the rapid loss of blood, both internally and externally. Although rare, this is something that can occur in patients with head and neck cancers and, quite obviously, can be a particularly distressing way to die for patients, their families and for the healthcare professionals caring for them. Indeed, the very possibility that one might die in this way is itself a source of significant distress and suffering.

Whilst there is not a great deal of literature on the topic, one of the ways that healthcare professionals respond to such catastrophic events is to provide what is often term crisis medication but what we prefer to call ‘crisis sedation’. In essence, this means giving the patient a relatively large dose of fast acting sedative, usually the benzodiazepine midazolam. However, there is good reason to think the intervention is often less than efficacious. First, following a catastrophic event, death and, for that matter, unconsciousness will occur fairly rapidly. Thus, in at least some cases, there will be insufficient time to provide crisis sedation.

Second, given the compromised state of the dying body, particularly one undergoing a terminal hemorrhage, the drug may not act as fast as it would if given to a healthy individual. Thus, even if it is provided prior to death or unconsciousness, it may not have any significant physiological effect before they occur. Nevertheless, at least in some cases, crisis sedation is physiologically efficacious.

It is in this context that we consider on the ethics of crisis sedation. In particular we focus on the level of detailed information that patients should be given about this intervention. In our paper we argue that the physiological effects of crisis sedation should not be considered the sole benefit this intervention offers. It is also legitimate to consider its value in terms of the reassurance that healthcare professionals can provide when discussing the possibility of a catastrophic event with their patients. Furthermore, whether in terms of its probable physiological effects or in terms of the likelihood healthcare professionals will be able to provide it in time, we suggest there is little to be gained by explicitly stating the intervention’s limitations.

There is, of course, a sense in which this borders on paternalism, something we discuss further in our paper. However, it is also consistent with providing the kind of care that dying patients often require. Palliative care is not just about the use of medical interventions to control or manage symptoms. It is about trying to support and meet the needs of patients and, in many cases, their families in a broader, and more holistic sense. Mitigating the fear and anxiety many feel when facing death is one aspect of this. As such we suggest that even if crisis sedation is a largely performative intervention—even if its primary benefit is derived from the reassurance discussing it can provide rather than the actual physiological effects derived from its (intended) use—this should not disqualify it from consideration.

Those at risk of catastrophic events, and those that actually undergo them, are not afforded the peaceful death that many would think of as being an important component of a good death. The parameters of crisis sedation certainly deserve further attention, both in terms of empirical research and ethical reflection. We would suggest that it is worth examining the degree to which patients at risk of catastrophic events find the possibility of crisis sedation reassuring. If, as we presume, it is seen as a source of comfort then this should be understood as an important aspect of the intervention, and taken into account when assessing the ethics of crisis sedation.

Paper title: Ethics of crisis sedation: questions of performance and consent

Authors: Nathan Emmerich1,2 Bert Gordijn2

1 School of Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
2 Institute of Ethics, Dublin City University, Dublin, Ireland

Competing interests: None

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