Tuesday, April 11, 2006

Reasons for terminal sedation vs euthanasia; heparin letters

Archives of Internal Medicine has published an interesting article comparing terminal (palliative) sedation and euthanasia in the Netherlands.  It is based on interviews of ~400 Dutch physicians who answered questions about their patients who had received terminal sedation or euthanasia, including the reason the docs thought the patient requested it or why it was otherwise used (as many of the terminal sedation patients couldn't request it).  There were a few minor reported differences in symptoms etc. between the groups, but prominent differences were found between groups regarding the reasons for terminal sedation or euthanasia.  Loss of dignity and dependency were much more associated with requests for euthanasia than terminal sedation:  63 vs 18%, 33 vs 6%.  There are some other interesting findings--17% of the decisions for terminal sedation were made deliberately to hasten death (one wonders if this represents euthanasia-like acts for patients unable to request it or whether this was for people for whom hastened death was a welcomed 'side effect' of the terminal sedation).  Additionally, the docs reported how much they thought death was actually hastened (deliberately or not) by terminal sedation--73% thought it was by less than a week.  70% of euthanasia patients had their deaths hastened by over a week, and 22% by over a month.  Over 90% of the patients receiving terminal sedation died within 7 days.

Of course all of this is based on physicians' recollections of their patients, and subject strongly to the vagaries of memory and bias.  Additionally, it's always been my opinion that the Netherland's experience with hastened death (I am not trying to set off an argument about  whether or not terminal sedation is hastened death) is unique and not necessarily directly applicable to North America.  Nevertheless, the prominent differences here regarding dignity/dependency are suggestive, and further add to the growing framework (can we call it now "well-established"?) that requests for hastened death are not to relieve unrelenting 'suffering' per se, but to preempt a dying process which is felt to be irretrievably insulting to one's dignity.  It also gives a sense that for the most part terminal sedation is not 'slow' or 'light' euthanasia.  In one of the only places on earth where they can be compared side to side terminal sedation is used for different reasons, with different goals, and in different patients than euthanasia.

2) BMJ has published a couple of letters about the tolerability of low molecular weight heparin in 'palliative patients' about which we had a lively discussion in February.  I wanted to highlight one in particular which, while not exactly validating my ravings on this article, makes some more reasoned criticisms, based in the evidence, about the advisability of this practice.

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