Wednesday, July 20, 2016
(This is the third of four posts by Drew on the language we use in hospice and palliative care. You may want to read his reflection on 10 years of practice or his other posts on euphemisms - "Comfort Care," and "Compassionate Extubation." - Ed.)
"Palliative Sedation." Golly I hate this one.
Frankly 'terminal sedation' was better, because it was at least less confusing, but neither of them are clear or transparent, and particularly 'palliative sedation' is just so confusing and potentially laden with too many meanings to be ever useful. There are so many clinical scenarios out there in which someone is sedated (deliberately, or as an aftereffect of trying to control pain/anxiety/dyspnea/etc; deeply or lightly; continuously until death vs temporarily as respite) in circumstances that the average person would agree would be 'palliative' or 'of-palliative-intent' that the term is useless.
There have been some people in the literature who call it some variation of 'deep, continuous sedation,' which I like a lot better, because it's a basically accurate description of the practice, at least the practice which is meant most of the time by 'palliative sedation' but not all the time, which sometimes gets contrasted with the 'proportionate palliative sedation' moniker, because there are so many different types of sedation-which-is-palliative, and OH MY GOD, right?
If we have a term which needs so much parsing, we need a different term.
If the thing you are talking about is deliberately inducing a state of unconsciousness, and keeping a patient in that state until they die, as a means of controlling otherwise uncontrollable symptoms in a dying patient, 'deliberate, deep, continuous sedation in a dying patient' seems about as accurate and parsimonious as you could get. There are people who propose this sort of sedation as a temporary measure, which I've never done, but you could then say 'deliberate, deep, respite sedation for severe symptoms' or some variation. If what you actually mean is aggressively managing symptoms with drugs even if some level of sedation is the consequence, then just say that, and not the reactionary, befuddled 'proportionate palliative sedation' monstrostiy.
Besides the ridiculously confusing nature of the phrase 'palliative sedation,' it's another example of the myriad ways in which 'palliative' is used: care-which-is-palliative, care-which-is-given-by-a-palliative-care-team, palliative pediatric cardiac surgeries, palliative chemo, used synonymously with 'comfort care', 'going palliative' etc etc. It just makes it worse for us to have the term pegged to this practice which, strictly defined, seems to happen very rarely in the US (deliberate, deep, continuous sedation), and reinforces an image of our care teams as people who just drug the hell out of patients. I once met a hospitalist who shook my hand and said to me kind of as an aside 'You know, I'm very pro-palliative sedation," as if he expected me to make eye contact and nod, in some sort of manly acknowledgement that I understood how forward thinking and progressive you are, what a friend to palliative care you'll be.
In all honesty, I thought to myself "OMG you are an idiot and I don't like you and I bet you're not comfortable with your patients' existential pain." Turns out, first impressions really are accurate, but that's another story.
Drew Rosielle, MD is a palliative care physician at University of Minnesota Health in Minnesota. He founded Pallimed in 2005. For more Pallimed posts by Drew click here.
Illustration Credit: Christian Sinclair CC-BY-SA-NC