title: European Association for Palliative Care (EAPC) framework for palliative sedation: an ethical discussion.
abstract: BACKGROUND
  The aim of this paper is to critically discuss some of the ethically controversial issues regarding continuous deep palliative sedation at the end of life that are addressed in the EAPC recommended framework for the use of sedation in palliative care.
  
  
  CONCLUSIONS
  We argue that the EAPC framework would have benefited from taking a clearer stand on the ethically controversial issues regarding intolerable suffering and refractory symptoms and regarding the relation between continuous deep palliative sedation at the end of life and euthanasia. It is unclear what constitutes refractory symptoms and what the relationship is between refractory symptoms and intolerable suffering, which in turn makes it difficult to determine what are necessary and sufficient criteria for palliative sedation at the end of life, and why. As regards the difference between palliative sedation at the end of life and so-called slow euthanasia, the rationale behind stressing the difference is insufficiently demonstrated, e.g. due to an overlooked ambiguity in the concept of intention. It is therefore unclear when palliative sedation at the end of life amounts to abuse and why.
  
  
  CONCLUSIONS
  The EAPC framework would have benefited from taking a clearer stand on some ethically controversial issues regarding intolerable suffering and refractory symptoms and regarding the relation between continuous deep palliative sedation at the end of life and euthanasia. In this text, we identify and discuss these issues in the hope that an ensuing discussion will clarify the EAPC's standpoint.
authors.affiliation: Karolinska institutet, Stockholm Centre for Healthcare Ethics (CHE), LIME, Berzelius väg 3, plan 4, 171 77 Stockholm, Sweden. niklas.juth@ki.se.
authors.forename: Niklas
authors.initials: N
authors.lastname: Juth
authors.forename: Anna
authors.initials: A
authors.lastname: Lindblad
authors.forename: Niels
authors.initials: N
authors.lastname: Lynöe
authors.forename: Manne
authors.initials: M
authors.lastname: Sjöstrand
authors.forename: Gert
authors.initials: G
authors.lastname: Helgesson