Talk:Palliative sedation

Wiki Education Foundation-supported course assignment
This article was the subject of a Wiki Education Foundation-supported course assignment, between 29 June 2020 and 21 August 2020. Further details are available on the course page. Student editor(s): Mau.Shin1, VTONGUCSF, Atrinh22, Ssofeso.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 06:03, 17 January 2022 (UTC)

Clarity?
I'm putting this first only as time-line.

Is this sentence clear? To me it seems ... fractured:

"Patients (or their legal representatives) only have the right to refuse treatments in living wills; they cannot demand life saving treatments, or any treatments at all."

"Have the right to refuse" makes sense. But then "cannot demand life saving treatments or any treatments at all"? It's as though some conditional is missing.

==BenTrem (talk) 05:20, 5 November 2016 (UTC)

Law?
I was wondering if anyone knew the official law concerning terminal sedation. If anyone has any idea it would be greatly appreciated. —Preceding unsigned comment added by 141.233.8.152 (talk • contribs) 00:09, 8 April 2005


 * Terminal sedation, when used as a treatment response to terminal restlessness and agitation, should present no medico-legal problem. Using sedation inappropriately may lead to problems of professional misconduct. It would only be a problem if someone was over sedated with the intention of shortening life.


 * Rossodio - I note you comments re: subjectivity. However, "slow euthanasia" is unacceptable because it is not co-terminous with terminal sedation. It is itself a term that is subjective and misleading in this context. Terminal sedation is a legitimate clinical goal in all jurisprudences; euthanasia is the active shortening of life and is nothing to do with terminal sedation. Ravenswater 19:36, 30 January 2006 (UTC)

In most nhs hospitals in the UK, they put all elderly patients on codeine anyway, enter non existent 'pain' on their nursing records, then finish them off with midazolam and alfentanil to alleviate non existent agitation - no one checks their controlled drugs registers, although all uk police forces have a dedicated officer who is supposed to - most of them are married to nurses, so they dont have to give anyone they consider 'elderly' any of the treatments that a 30 year old would be entitled to - its licenced murder, the way the NHS practice it in this area - quite why you are even dressing this subject up with an 'ethical discussion' I can't fathom - its murder done with smoke and mirrors, the intention is murder - it avoids blocking up nhs beds with 'lives unworthy of life' - small matter of 'consent ' is conveniently circumvented by filling them up with morphine first, and saying the loss of conciousness is due to something like a stroke to their relatives - they rely on visitors knowing absolutely nothing about doseages and respiratory side effects of 'palliative care' drugs. Its rife - but as the 'attending doctor' is the one who writes the cause of death on the death certificate, no one questions it at all. —Preceding unsigned comment added by Thomaswilliamlofthouse (talk • contribs) 01:00, 13 April 2008 (UTC)

--> OMG, Do you have any reference for this? —Preceding unsigned comment added by 93.97.29.181 (talk) 18:35, 26 March 2009 (UTC)

With regards to the "License For Murder" link title: If there is a controversy regarding Terminal Sedation, a more appropriate tack would be to create a separate section with the controversy detailed in neutral POV terms, then cite the website.Dr. Scarabus (talk) 19:26, 16 April 2008 (UTC)

"Most patients die comfortably"
"Sedation is not routine in palliative and most patients die comfortably without the need for sedation."

Do you have any data to back this claim? I don't get how death is "comfortable". The outward signs may resemble sleep or comfort, but death is nothing like that as the body is violently shutting down. What if the patient is feeling extreme pain and distress, but cannot outwardly show this during their last moment due to paralysis or some other factor (ie the brain cells that receive pain input still work but those that send effector signals died off first)? It might also be extremely distressing
 * (who for ? the nurses injecting the stuff mainly?) —Preceding unsigned comment added by Thomaswilliamlofthouse (talk • contribs) 01:04, 13 April 2008

if the normal reflexes aren't working and the patient may feel like they are drowning (since they can't breath due to the loss of medullary function) but there may be no convulsions to indicate this due to the same reasons as above (loss of effector signals). Then again, it might not. We can't know for sure without data. —Preceding unsigned comment added by 64.12.116.5 (talk • contribs) 03:37, 20 April 2006


 * With midazolam and alfentanil iv, the synergistic effects knock out the ability to sense CO2 levels in the blood - so all voluntary respiration stops - its used in Intensive Care for people on mechanical ventilators to stop them fighting the machine, but is administered in the NHS on side wards mainly - CO2 just builds up in the blood, but the midazolam and morphine levels are so high, they dont twitch and upset the bitches of nurses who know exactly what they are doing when they inject this stuff, and dont really give a toss one way or the other. —Preceding unsigned comment added by Thomaswilliamlofthouse (talk • contribs) 01:04, 13 April 2008
 * Okay - I've assumed enough good faith. You've clearly read some article in the Daily Express or some other reactionary tabloid newspaper and taken its word as gospel. As a former NHS employee I can categorically state that I have NEVER seen this occur, and I am aware of dosages. All deaths in hospital are referred to the coroner and enough of these will result in a post-mortem examination which would include toxicology. Nobody would get away with this for long and it sure as hell isn't some unwritten NHS standard practice. Either start citing credible references or leave this article well alone. —Preceding unsigned comment added by 93.97.29.181 (talk) 18:41, 26 March 2009 (UTC)


 * The fact you have never seen this arising means..you have never seen this arising . The NHS have many types of 'employee', ranging from Consultants to cleaners, you don't state which you used to be. Plenty of qualified practitioners (which you clearly are not) have 'blown the whistle' in this regard - eg see Dr. Rita Pal's 'NHS Exposed' website - and the host of other fellow professionals who used to avoid giving the lethal injections of morphine they were ordered to administer to inconvenient elderly patients by injecting it into their pillows.   Thirdly, you ridiculously state 'all deaths in hospital are reported to the Coroner' - what rot!   Perhaps you should research the matter at the MDU or MPS (who give advice to members on what to avoid telling the Coroner), or a host of BMJ articles.  The only deaths in hospital referred to the Coroner have to be those the certifying doctor him/herself judges to be 'unexpected', or a death that takes place under an anaesthetic, or one the family reports to the coroner as suspicious or violent. Shipman didnt report the deaths of his patients to the Coroner as 'suspicious' did he???  Why dont you research Coronial Law at the Ministry of Justice before you post these ridiculous inaccuracies??  RE: Toxicology tests: you can kill someone by repeatedly infusing saline, under the guise of 'keeping the patient hydrated', you can kill with tabinsulin if a dipstick indicated to you they were 'hyperglycaemic' (theres no legal compunction to retain the dipstick to prove its administration was justified), you can kill someone with potassium suppositories  - none of these drugs or metabolits show up without specific, specialised tests, and since the Coroners' are funded by local Councils, most are in severe financial deficits by mid-year, and avoid havng to pay for as many tests as possible.  Most Coroner's appointed 'Ezperts' are usually retired GP's, and toxicology reports only show the drugs that the tests ordered are capable of showing (eg a basic alkaline gas screen of plasma will not reveal alfentanil or midazolam overdoseage).  RE: 'They wouldnt get away with it for long' - they 'get away with it ' for long enough - Shipman 'got away with it' for almost a decade.


 * Either start writing valid criticisms of peoples responses to your entry, or leave Wikipedia articles to qualified professionals who research a) medical aspects and b) legal aspects competently enough yourself to produce a page worthy of entry into an Encyclopedia.


 * ..and by the way, chum, I a) hold a Ph.D. in Physics, b) used to train Medics in Haematology (when I was a PostDoc), c) got my 'facts' from my encounters with the Coroner after watching my Father being drugged up to the gills in hospital as the ward he was on had 18 week RRT violations against it, which got the Managers in trouble with Monitor. Did you miss the Gosport War Memorial Inquest earlier this year???  90 families do not spend 10 years fighting for an inquest unless they witnessed the same as me -  —Preceding unsigned comment added by 79.77.85.35 (talk • contribs) 00:42, 20 June 2009

Hey guys, LOVE that "repeatedly ordered to give lethal morphine injection (to an opiate-tolerant person!), injected it into pillow" stuff, but last time I checked, that sounds more like some nurse getting caught red-handed for vast amounts of NHS morphine "disappearing" on their shift (and going into their pockets to sell or their veins to relax)... then coming up with a valid excuse AND trying to shift the blame over to her boss, probably the guy who caught her for the morphine. 208.127.80.59 (talk) 07:10, 8 September 2011 (UTC)

"Change of title of article to Palliative Sedation?"
I feel this article should be changed from terminal sedation to palliative sedation. The goal of sedation is the palliation of symptoms, not the ending of life (terminal). Calling it terminal sedation implies the goal is death. Palliative sedation can be stopped and reversed or used at different levels of sedation, therefore not always happening at the same time as death. I will await comments from others before changing.SpoticusKC 05:13, 30 June 2007 (UTC)


 * Is the above request for revision to 'palliate' your own concience? Lets call a spade a spade - its manslaughter by the back door - it was used to 'palliate' 70 elderly bed blockers in a Portsmouth hospital in the Uk, none of whom were in any pain at all, there were just insufficient funds for them to be supported by social services at home - all the district sherriff could say at the inquest was that it was the strangest form of 'pain relief' he had ever seen - if he'd expressed it any harder, the doctors threatened to sue him for defamation - its murder...do you do it as part of your job, Guber?  —Preceding unsigned comment added by Thomaswilliamlofthouse (talk • contribs) 01:08, 13 April 2008 (UTC)


 * District Sherriff (sic)?! Which country do you come from again? You claim to have extensive knowledge of this case so pray enlighten us with evidence. I must say, I missed the classes on institutionalised murder at medical school. Come to think of it, I don't even remember their being on the timetable!
 * 93.97.29.181 (talk) 15:02, 27 March 2009 (UTC)unsigned

No the request is that it more closely reflects the common medical language regarding this procedure, which you note has some controversy.SpoticusKC (talk) 11:26, 9 May 2008 (UTC)


 * If no one else has any objections, I will move again to rename this to palliative sedation as that is the term used by the AMA in the new ethical policy approved in June 2008. More research and articles are using the term palliative sedation then the older term terminal sedation.  The reasons for the different names could be expounded upon in the article.SpoticusKC (talk) 05:16, 5 August 2008 (UTC)


 * IT IS REFERRED TO AS 'TERMINAL SEDATION' IN THE 'WESSEX PALLIATIVE PHYSICIANS HANDBOOK' VOLUME 6, WHICH WAS USED AS A REFERENCE GUIDE BY THE 'DOCTORS' INVOLVED IN THE DEATHS OF 90 NON-TERMINALLY ILL SENIOR CITIZENS AT THE GOSPORT WAR MEMORIAL HOSPITAL. LEAVE IT AS 'TERMINAL SEDATION' - THE ONLY INSTANCES OF TRUE 'PALLIATIVE SEDATION' I CAN THINK OF ARE WHEN SOMEONE IS COMING ROUND AFTER A MAJOR OPERATION, OR IN AN INTENSIVE CARE UNIT.  UNLESS YOU FALL FOR THE 'EXISTENTIAL PAIN' GARBAGE THAT 'DOCTORS FEELING GUILTY' TRY TO FOOL THEMSELVES WITH?  —Preceding unsigned comment added by Sheriffspayne (talk • contribs) 15:21, 22 August 2008 (UTC)


 * Many textbooks (published years ago) may refer to 'terminal sedation' but many of the more recent journal articles as referenced on PubMed refer to 'palliative sedation.' And again there should be more discussion about the different 'terms' in the body of the article anyway.  The reference to Gosport War Memorial is a straw man argument since it does not describe the standards of palliative sedation set forth by the medical community.  Being a 'bed blocker' would not be an indication for palliative sedation.  I am not sure what the the last questions is referring to, since it does not seem to directly address the issue of title change.  Could you please clarify? Don't forget to sign any comments as well.SpoticusKC (talk) 03:38, 4 September 2008 (UTC)
 * (and please take off your caps lock.)SpoticusKC (talk) 03:38, 4 September 2008 (UTC)


 * Although 'Palliaitve Sedation' is not an ideal term, it is now the accepted term and certainly better then 'Terminal sedation'. So I fully support this change. What is the mechanism for changing a subject heading?
 * --Claud Regnard (talk) 21:57, 5 September 2008 (UTC)


 * Claude, should there be a differentiation between "palliative sedation" - which could occur, for many different reasons - drug effects, drug interactions, altered biochemistry, etc, - at any time, and the specific restlessness and agitation seen at the end of life?--MisterSensible (talk) 19:41, 14 September 2008 (UTC)


 * I am not sure as I am not a seasoned wikipedia contributor. Before changing it it may be best to flesh out a section on the alternate names and why there is a preference for one term over another so as to avoid confusion.SpoticusKC (talk) 05:12, 6 September 2008 (UTC)

Legal position
While the whole article is a little NPOV, this section reads more like an advocate's position and not a neutral, disspassionate encylopedia. I think its needs to be cleaned up to a NPOV standard. I'm sadly not able to take a stab at editing it right now, but I hope someone can look at it. Caelarch (talk) 23:22, 28 February 2009 (UTC)


 * It may read like an advocate, but isn't legally correct. Law's vary form country to country.  A "living will" is of doubtful legality in America, and of no effect elsewhere. Patients do have right to refuse treatment - this isn't limited to living wills.  Patients can demand life saving treatments. Whether they get it is another matter. Once a patient is no longer conscious, the clinical team cannot simply act in the patient's best interests. They must follow the directions of the legal next of kin, or any person with power of attorney for personal care.JohnC (talk) 03:18, 20 February 2011 (UTC)


 * What? So a person comes in with some minor injury, but noticeable bloodloss, with his heir&next of kin in tow, gets prepped for surgery and goes out... NOW the heir can fast-track himself to an inheritance and bullshit about the patient not believing in blood transfers for religious reasons or some crap like that? Or better yet just tell them to let the patient die, no need to give a reason? — Preceding unsigned comment added by 208.127.80.59 (talk) 07:15, 8 September 2011 (UTC)


 * Re: JohnC actually wrong in a large number of countries using UK medical models. Patients do have a right to refuse treatment, absolutely. There is however no medicolegal obligation to follow the directions of the next of kin nor power of attorney if it is not in the clinical interests of the patient outside, to my knowledge, of the US. This is best reflected in NFR/not for code status - in the USA doctors are often limited to continuing futile resuscitation events and cannot change a patient's resuscitation status without consent. In many other countries, there are protections in law (UK, AU, NZ etc) for a not-for-resuscitation order due to the senior clinician's judgment that a patient would not survive the attempt - IE, not in the patient's best interest; such as in the case of disseminated malignancy. You can trust me on the truth of this matter if you like - I sign these forms. --115.70.65.7 (talk) 02:26, 29 August 2015 (UTC)

NHS Bashing?!
I'm concerned by the use of quotes around 'best interests' in the risk assesment section. Partucularly their use in the following:

"'busy NHS teams can decide it is in their 'best interests' to withold all treatments, and this is common, particularly with elderly or disabled patients.'"

It seems to imply that under the NHS clinical staff will withhold treatment on cost grounds, or because docs/nurses are too lazy to care for their patients. It clearly has no place on wikipedia. Especially as no citations is given.

Worse still:

"'Sensible patients can therefore, under UK law, give a directive that they refuse 'Palliative Care' or 'Terminal Sedation', or 'any drug likely to supress my respiration' in a 'living will' or 'Advance Directive', and avoid being involuntarily euthenased, but it is imperative that these phrases are explicitly included in the advance directive.'"

--This is hardly encyclopaedic prose. I'm cleaning up this section post haste. —Preceding unsigned comment added by 93.97.29.181 (talk) 18:24, 26 March 2009 (UTC)

Foundations II 2020 Group 19 proposed edits
Our proposed edits include: - — Preceding unsigned comment added by Atrinh22 (talk • contribs) 21:57, 27 July 2020 (UTC)

- More statistics for US in the opening section (MS)

- Types of patients eligible for palliative care (such as disease states)(MS)

- Alternative care methods used prior to palliative sedation (TS)

- Find citations for sections on : "General practice", "Drugs used", "Sedation vs. euthanasia"(AT)

- Find alternative guidelines for statistics on palliative sedation outside of the UK (VT)

- Add more information to the "Policies" section (look up US guidelines)(VT)

- Add more information on the "hospice care movement" and expand on history of the movement, as well as the history of how palliative sedation came to be (TS)

- Organize into first line and second line drugs used and more details on the "Drugs Used" section (AT) Mau.Shin1 (talk) 20:57, 28 July 2020 (UTC)

Group 20 Peer Review
Do the group’s edits substantially improve the article as described in the Wikipedia peer review “Guiding framework”?
 * Yes, the edits have expanded the lead which makes it easy to understand and includes points of discussion that act as subsequent headings within the article. For example, the paragraph describing what palliative sedation provides acts a brief overview of the section on "General Practice". However, I believe the use of the word "patients" is not recommended as it makes it sound like one is writing to health professionals. T.Tsai,UCSF (talk) 21:46, 3 August 2020 (UTC)


 * Yes, the student editors expanded the topic of "palliative sedation" to encompass relevant areas of discussion within this topic. I like how they mentioned other terms that may be confused with "palliative sedation" and made its definition very clear. I also really liked how they added points that are relevant as student pharmacists, including the medications used in palliative sedation and their monitoring. Since this topic can be controversial, I think maybe expanding the discussion on policies and people's different stances on it will be a good addition, that is, if there is the material available. C. Do, Future UCSF Pharm.D. (talk) 22:02, 3 August 2020 (UTC)


 * The group substantially improved the article by adding various relevant sections such as “patient assessment and obtaining consent for palliative sedation” and “history of hospice.” The group also made significant expansions to the section on drugs used. C.Deng (talk) 22:00, 3 August 2020 (UTC)

Has the group achieved its overall goals for improvement?
 * Yes, the group has accomplished each of the previously listed goals. For the goal of "Add more information to the "Policies" section (look up US guidelines)", was more information intended to be added or was there insufficient sources? T.Tsai,UCSF (talk) 21:46, 3 August 2020 (UTC)


 * The group is in the process of achieving the goals that they have stated. I believe they still have to add citations under "General Practice" and add more information to "Policies". Their current edits are great and align with their goals. C. Do, Future UCSF Pharm.D. (talk) 22:06, 3 August 2020 (UTC)


 * The group achieved the goals for improvement outlined in the proposed edits. The “policies” section is the only area that does not appear to be edited yet. C.Deng (talk) 22:00, 3 August 2020 (UTC)

Does the draft submission reflect a neutral point of view? If not, specify…
 * Overall, there does not seem to be a particular bias for or against palliative sedation. However, I am unsure if use of phrases such as "greatest accomplishments made by the movement" and "This victor" in the "US Hospice Care Movement" creates a more positive bias for towards the subject. T.Tsai,UCSF (talk) 21:46, 3 August 2020 (UTC)

Is there any evidence of plagiarism or copyright violation?
 * There is no evidence of plagiarism and all points made were accompanied by proper citations. C.Deng (talk) 22:00, 3 August 2020 (UTC)

Are the edits formatted consistent with Wikipedia’s manual of style? If not, specify…
 * Yes, the editors added in elements of what is consistent with Wikipedia's suggested "content sections". Even though they mentioned the information in other parts of the article, it might be good to consider putting a section dedicated to risks and complications. C. Do, Future UCSF Pharm.D. (talk) 22:16, 3 August 2020 (UTC)

-The group's edits to the article do substantially add to the article by adding more information about palliative sedation itself but also some of the history relating to it and its prevalence in other countries. I also think it was very important that there was distinction between palliative sedation and euthanasia. Overall the structure of the article is very balanced and doesn't just focus on one area such as the drugs used for palliative sedation. I'm not sure if this group is done editing or not, but I would like to see a little bit more on the policies regarding this subject that have been approved and what about these policies makes it considered ethical.

-It looks like this group has achieved its overall goals for improving this page.

-The points on this page are cited and verifiable with the exception of like two sentences where there was a "citation" next to the information presented, although those particular edits were from someone outside of the group who had previously edited. I think this group has done a very good job at citing the sources they used to contribute to this article since there is a wide variety of sources that were used instead of only a couple articles per person.Dholston1 (talk) 21:48, 3 August 2020 (UTC)


 * Well I have never been so stunned in all my Wikipedia life as I have been by this group of students. I doubt you guys know that you are unique and rare.  In all my years of seeing (and deleting a lot of) student work which was a big time waste better spent on improving articles, out of the blue this happens.  Who are you guys, anyway?  Congrats on such fine work.    Gandydancer (talk) 00:58, 5 August 2020 (UTC)

Side effects
"Titrated sedation might speed up death, although death is considered a side effect and sedation does not equate with euthanasia. A survey of 663 physicians found half had an experience of their treatment being characterised as murder, euthanasia, or killing in the preceding five years with palliative sedation (along with stopping of hydration and nutrition) being the most common act in palliative care interpreted as killing."

To be clear, if death should happen as a mere "side effect" of sedation - it does not equated with and should not be interpreted as a killing?

So that's okay then? — Preceding unsigned comment added by 95.149.166.137 (talk) 10:36, 21 July 2023 (UTC)
 * Wikipedia's job is mostly to talk about what people say in other sources (which can be aided by an understanding of the topic). This will probably show up in ethics. Lots of issues that are normally cut-and-dry become more murky in life and death situations. An ethics text might well explore this at length, but some analogies would be to, say, a risky operation that might kill someone but also could improve their life greatly. For me the really murky issues here are more around consent - particularly when you sedate people so they can't consent - potentially in a procedural fashion. Tal pedia 12:31, 21 July 2023 (UTC)

Then again, while the use of powerfull drugs to end pain or life might be open to question, is not the end result of stopping all hydration and nutrition very cut and dry? — Preceding unsigned comment added by 91.110.75.17 (talk) 16:27, 21 July 2023 (UTC)
 * They tend to have an excuse for these things. The argument is that people are less able to digest food etc. But yeah, four hours is quite different from 3 days in this regard. My mother had a friend who deliberately starved herself to death as a form of euthanasia... so perhaps there can be some agency there. Tal pedia 16:54, 21 July 2023 (UTC)
 * I guess my question is what do you want wikipedia to do about it. Wikipedia summarizes the best literature in a nuanced and balanced way. This is a controversial issue - we can ensure that the coverage of the material is good. Most people don't know about palliative sedation, some people who do consider practices involuntary euthanasia, people who work in palliative care - perhaps understandably have excuses. I can say, yes, people agree with you. But to do anything on wikipedia you get to do is add reliable material in a balanced and complete fashion or encourage others to do so. Tal pedia 17:13, 21 July 2023 (UTC)