Relación entre la base y el diámetro del ciclón

In the literature there is a general presupposition that death is hastened through the use of sedatives and opioids (Billings, 1996, Douglas, 2008, Jackson, 2002, Portenoy, 1996, Quill T. E., 1997, Quill et al., 2000a, Sykes, 2008). This is the case not only in medical literature but also amongst the general population (Portenoy et al., 2006, Sykes, 2008). Initial descriptions of the practice of ‘terminal sedation’ indeed asserted this as a feature of its use. Billings, for example, was clear about the nature of the use of terminal sedation as he described:

In a stuporous state the patient can no longer eat and drink, dehydrates to death, if it’s taking too long the morphine drip is increased until there is a quicker death (Billings, 1996).

It was clear to Billings and to others that sedation hastened death. The available evidence, however, does not support this assumption (Chiu et al., 2001, Fainsinger et al., 2000a, George and Regnard, 2007, Morita et al., 2001b, Rietjens et al., 2008, Sykes and Thorns, 2003a). Studies which have reported on the survival of patients after receiving sedation at the end of life have been carried out. These have been conducted using different methodologies and thus comparison between studies is difficult. In particular, interpretation of the term ‘sedation’ varies with some considering this to mean the use of sedative drug to induce unconsciousness, while others mean simply the use of sedative drugs, regardless of effect. Some studies have been retrospective and used an estimation of the prognosis of patients (Rietjens et al., 2004a), while others have looked at survival from admission in sedated and non-sedated patients (Sykes and Thorns, 2003a). None has demonstrated a significantly shorter survival in sedated

53 patients. Indeed the only study to demonstrate a statistically significant difference showed that patients who were sedated for a period longer than a week survived longer than those not sedated, and also longer than those who were only sedated for the last 48 hours of life (ibid). There were many variables in this retrospective study, including the drugs and doses used, and the condition of patients before having sedative drugs. While there are no studies which provide evidence that sedation hastens death, equally there are none which provide clear evidence, which can account for variables, that sedation does not hasten death. Nonetheless, some descriptions of practice in the literature do suggest that sedation may hasten death (Anquinet et al., 2011, Claessens et al., 2011, Rietjens et al., 2004b). Once again, different practices of using sedation abound, with widespread international variation (Fainsinger et al., 2000b, Rietjens et al., 2004a, Sykes and Thorns, 2003b). It appears that certain practices of using sedation, such as CDS, may hasten death, while others may not. The answer to the question of whether or not sedation hastens death depends on which practice of sedation is being considered. Perhaps the more nuanced question of whether sedation may hasten death allows a more useful account of the moral nature of sedation at the end of life.

Sedation at the end of life may be considered to hasten death when artificial nutrition and hydration (ANH) are, as part of the normal practice of sedation, withheld or

withdrawn. While there may be a separate decision that this is the appropriate action to take, the automatic withholding or withdrawal of ANH may be considered to cause a patient to dehydrate or starve to death (Craig, 2004, de Graeff and Dean, 2007). This has been addressed in guidelines advising that the decision to use ANH ought to be independent of the decision to use sedation (Cherny et al., 2009, Dean et al., 2012, de Graeff and Dean, 2007, Verkerk et al., 2007). An interesting distinction is found in the Dutch national guidelines for the use of palliative sedation. This suggests that ‘in general’ fluids should not be given to a deeply sedated patient (Verkerk et al., 2007). This is based upon the expectation that a patient who is deeply sedated should have no more than two weeks left of life, and that by the time they are deeply sedated they would naturally have stopped drinking; thus they are not considered to have dehydrated to death as a direct cause of the withholding or withdrawing of ANH (Verkerk et al., 2007). While this forms part of the Dutch national guidelines, international guidelines consider the decisions to use sedation and to use ANH at the end of life to be separate decisions (Cherny et al., 2009, de Graeff and Dean, 2007).

54 Even when the decision to withhold or withdraw ANH is considered separately to the decision to use sedation, there remains a concern about the possibility of hastening death through the use of drugs which may remove consciousness. A distinction is established between those who intend to hasten death and those who do not. Those who intend to hasten death through the use of sedation, when voluntary, may be considered to practice euthanasia. Euthanasia may be defined as:

A doctor intentionally killing a person by the administration of drugs, at that person’s voluntary and competent request (Materstvedt et al., 2003).

When sedation is used with the intention of hastening death in the absence of a patient’s ‘voluntary and competent request’, the practice is either non-voluntary euthanasia (when a patient is unable to consent, and this is recognised to be a valid distinction), or murder. It is not the intention or within the scope of this thesis to consider further the question of euthanasia, rather to consider in outline the moral nature of sedation based upon definition and exploration of terms. This is in order to set out the position of the practices of sedation when considering the results of the study of sedation in a UK hospice.