Sedative use in the last week of life and the implications for end-of-life decision making.
BACKGROUND
The use of sedation at the end of life has aroused ethical controversy, attracting accusations of hastening death by gradually increasing sedative doses. The doctrine of double effect has been introduced as an ethical defense. This study aimed to determine how sedative doses change at the end of life and how often the doctrine of double effect might be relevant.


METHODS
Case note review was performed of 237 consecutive patients who died in a specialist palliative care unit. Sedative dose changes during the last week of life were noted and survival from admission was compared between groups of patients receiving no sedation, sedation for 7 days, or a commencement of sedation in the last 48 hours of life. There was detailed review of notes from patients who received a marked increase in sedative dose to explore the applicability of the doctrine of double effect.


RESULTS
Sedation was given to 48% of patients. Of these, 13% received sedatives for 7 days or more, while 56% commenced sedative use only in the last 48 hours of life. The groups receiving no sedation or sedation for less than 48 hours had the shortest survival from admission (mean, 14.3 and 14.2 days), whereas the 7-day sedation group survived for a mean of 36.6 days (P<.001). Sedative use and dose increased toward the end of life, but the detailed case note review disclosed only 2 cases where the doctrine of double effect may have been implicated.


CONCLUSIONS
Sedative dose increases in the last hours of life were not associated with shortened survival overall, suggesting that the doctrine of double effect rarely has to be invoked to excuse sedative prescribing in end-stage care.
Sykes
Nigel
N
St Christopher's Hospice, Lawrie Park Road, London SE26 6DZ, England. n.sykes@stchristophers.org.uk
Thorns
Andrew
A
D000328:Adult; D000368:Aged; D000927:Anticonvulsants / Q000008:administration & dosage / Q000009:adverse effects; D003657:Decision Making; D003693:Delirium / Q000188:drug therapy; D034723:Double Effect Principle; D026690:Ethics, Clinical; D004992:Ethics, Medical; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage* / Q000009:adverse effects*; D008297:Male; D008728:Methotrimeprazine / Q000008:administration & dosage / Q000009:adverse effects; D008874:Midazolam / Q000008:administration & dosage / Q000009:adverse effects; D008875:Middle Aged; D010166:Palliative Care / Q000941:ethics* / Q000379:methods; D010634:Phenobarbital / Q000008:administration & dosage / Q000009:adverse effects; D015742:Propofol / Q000008:administration & dosage / Q000009:adverse effects; D013226:Status Epilepticus / Q000188:drug therapy; D016019:Survival Analysis; D013727:Terminal Care / Q000941:ethics* / Q000379:methods; D013997:Time Factors; D014481:United States
D000927:Anticonvulsants; D006993:Hypnotics and Sedatives; D008728:Methotrimeprazine; D008874:Midazolam; D015742:Propofol; D010634:Phenobarbital