title: The ethical and clinical importance of measuring consciousness in continuously sedated patients.
abstract: Continuous sedation at the end of life is a practice that has attracted a great deal of attention. An increasing number of guidelines on the proposed correct performance of the practice have been drafted. All of the guidelines stress the importance of using sedation in proportion to the severity of the patient's symptoms, thus to reduce the patient's consciousness no more than is absolutely necessary. As different patients can have different experiences of suffering, the amount of suffering should, ideally, be assessed subjectively; that is, via communication with the patient. Continuously sedated patients are often unable to communicate, however, making subjective methods of pain assessment unusable. For these patients, the degree of consciousness is the sole available measure. It therefore seems important to adequately measure how deeply the patient is sedated, thereby allowing sedation to be increased when it is too light and decreased when it is too heavy. This is in accordance with the idea that reducing consciousness is not an ethically neutral act. Although consciousness measuring techniques are a hot topic in anesthesiology, almost no research exists on the use of such techniques in the context of continuous sedation at the end of life. This article aims to review existing techniques to measure consciousness and to evaluate their applicability, efficiency, and invasiveness for patients who are continuously sedated until death. Techniques commonly used to assess the depth of sedation in continuously sedated patients are basic clinical assessment and sedation scales, as they are often considered reliable and non-invasive. These techniques might not be very reliable, however, since it is known that some patients are nonresponsive and yet aware. Moreover, sedation scales require stimulation of the patient (for example prodding, shaking, or providing painful stimuli), and can thus be considered invasive of one's bodily integrity or dignity. Other techniques, such as EEG (electroencephalography) derivatives, may score better on reliability and invasiveness. Yet these have so far never been compared to sedation scale scores for patients receiving continuous sedation at the end of life. Therefore, we conclude that, for both clinical and ethical reasons, research into the efficiency and applicability of other techniques, such as derivatives of EEG, are urgently needed.
authors.affiliation: Blandijnberg 2, 9000 Gent, Belgium. kaspar.raus@UGhent.be.
authors.forename: Kaspar
authors.initials: K
authors.lastname: Raus
authors.affiliation: Ghent University Hospital, Gent, Belgium.
authors.forename: Martine
authors.initials: M
authors.lastname: de Laat
authors.affiliation: Ghent University Hospital, Gent, Belgium.
authors.forename: Eric
authors.initials: E
authors.lastname: Mortier
authors.affiliation: Ghent University, Ghent, Belgium.
authors.forename: Sigrid
authors.initials: S
authors.lastname: Sterckx
mesh_terms: D016292:Procedural Sedation; D003243:Consciousness; D054810:Deep Sedation; D004569:Electroencephalography; D026690:Ethics, Clinical; D004992:Ethics, Medical; D006801:Humans; D059408:Pain Management; D028723:Personhood; D015203:Reproducibility of Results; D013315:Stress, Psychological / Q000628:therapy*; D013727:Terminal Care / Q000941:ethics / Q000379:methods / Q000592:standards