AMA House of Delegates

AMA meeting: AMA OKs palliative sedation for terminally ill

The seldom-used technique is deemed ethical because the aim is to relieve intractable symptoms, not hasten death.

By — Posted July 7, 2008

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When all else fails to control patients' pain at the end of life, it is appropriate for physicians to sedate such patients to unconsciousness, according to new ethical policy adopted at the AMA Annual Meeting in June.

The rarely employed practice of palliative or terminal sedation is sometimes perceived as speeding the dying process, leading critics to dub it a form of physician-assisted suicide. But evidence of such a hastening effect is lacking, according to a Council on Ethical and Judicial Affairs report adopted by the House of Delegates.

"These are unusual circumstances that require us to urgently relieve these symptoms by sedating patients to unconsciousness," said CEJA member H. Rex Greene, MD, a Lima, Ohio, oncologist and palliative medicine specialist. "This is not intended to end life."

The ethical opinion says physicians are obligated to offer palliative sedation as a last resort when "symptoms cannot be diminished through all other means of palliation, including symptom-specific treatments." Such symptoms include pain, shortness of breath, dyspnea, nausea and vomiting. Between 5% and 35% of hospice patients have intractable symptoms in the last week of life, according to a 2000 Annals of Internal Medicine study.

Doctors should consult with a multidisciplinary team or a palliative care expert to determine that sedation to unconsciousness is the right course of treatment, the policy says. The rationale for the sedation should be documented in the medical record, and patients or their surrogates should consent to the procedure.

Physicians also should talk with patients about whether the sedation will be intermittent or constant, and whether to withdraw or withhold other life-sustaining treatments.

Treating patient pain

The policy draws the line at using palliative sedation to combat emotional distress some terminally ill patients experience at the end of life. These symptoms are better addressed with social and spiritual supports, the CEJA opinion stated. Lastly, palliative sedation "must never be used to intentionally cause a patient's death."

The policy "protects patients from inappropriate use of palliative sedation," said California delegate Melvyn Sterling, MD, a palliative care specialist. "It provides guidance to hospitals that might otherwise be reluctant to allow this to occur, and it provides protection to the entire health care team involved, who might otherwise allow terrible suffering to occur."

The American Academy of Hospice and Palliative Medicine and the American Academy of Pain Medicine support the use of palliative sedation to unconsciousness. The AMA opposes euthanasia and physician-assisted suicide as being "fundamentally incompatible with the physician's role as healer."

Delegates also directed the AMA to study alternatives to "do not resuscitate" orders. The resolution said DNR terminology "is both confusing and misleading to patients and families because of the negativism in wording, which suggests that something is being denied, and the implication that all care, including comfort measures, is to be withheld."

Alternatives to be studied include "allow natural death," "limitations of emergency treatment" and "physician orders for life-sustaining treatment." In panel testimony, most delegates agreed the study was needed, but others said altering the terminology will do little to make talking with patients and families easier.

"If we think changing the name changes the task, then we are deluding ourselves," said Michael A. Williams, MD, a delegate for the American Academy of Neurology. "There is no form we can have that will make the complex challenges of this go away."

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Meeting notes: Medical ethics

Issue: To better halt the spread of chlamydia and gonorrhea, the Centers for Disease Control and Prevention recommends expedited partner therapy, in which doctors give patients antimicrobials for their sex partners. The practice, while effective, may undermine informed consent and continuity of care, and violate state laws.

Proposed action: New ethical policy saying doctors should only use EPT if they believe a patient's partner would otherwise not seek treatment. [ Adopted ]

Issue: Some hospitals have asked medical staff members to provide personal financial information as part of conflict-of-interest policies apparently aimed at shutting out doctors who work for competitors.

Proposed action: A Board of Trustees report recommending that only physicians seeking to serve in a hospital leadership position be required to disclose employment, ownership or financial interests, or leadership positions at another hospital. Also, the information requested should be no different from that requested of nonphysicians. [ Adopted ]

Issue: Treating peer physicians poses special challenges to clinical objectivity and confidentiality.

Proposed action: New policy saying doctors should not hesitate to treat peers in emergencies, but should beware of the risk of biased treatment recommendations, take care to respect privacy, and share decision-making as they would with other patients. [ Adopted ]

Issue: Drug- and device-maker funding of graduate and continuing medical education may undermine physicians' professional integrity and subtly bias doctors' practice patterns in ways that are not in patients' best interest.

Proposed action: A new ethical opinion calling on doctors, medical schools and organized medicine groups to end industry funding of residency positions and clinical fellowships, educational programs and physician speakers' bureaus -- except when new diagnostic or therapeutic devices and techniques are introduced, as industry representatives may be the only experts available to teach doctors about them. [ Referred ]

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