TERMINAL SEDATION:
DYING IN YOUR SLEEP
GUARANTEED

SYNOPSIS: 

    Modern medical care has quietly developed a new way to manage dying:
It is now possible, legal, & ethical to make the patient unconscious
for the duration of the dying process.
This is especially appropriate when the patient has uncontrollable suffering.

    The patient is dying under medical care
in a hospital, nursing home, hospice, or even at home.
Everyone involved knows that this patient is inevitably dying.
All reasonable attempts to cure the patient have already been tried.
And now, clearly, the patient is on the downward pathway towards death.

    But, instead of forcing the patient to suffer thru the last few days of life,
everyone agrees that it would be more merciful to induce deep sleep.
Drugs are given to create permanent unconsciousness.

    And all forms of life-support are also withdrawn or withheld. 
Even food and water provided by any means are discontinued.
Life-supports would only needlessly prolong the dying process.
Terminal sedation is a life-ending decision.


OUTLINE:

1.  TERMINAL SEDATION MEANS INDUCING PERMANENT SLEEP.

2.  USING THE BEST NAME FOR TERMINAL SEDATION.

3.  WHEN TERMINAL SEDATION EMERGED IN MEDICAL PRACTICE.

4.  GETTING PATIENT AND FAMILY COOPERATION FOR DEEP SLEEP.

5.  THE CAUSE OF DEATH IS ALWAYS THE UNDERLYING CONDITION.

6.  SAFEGUARDS FOR CHOOSING TERMINAL SEDATION.

7.  FRANCE AVOIDS THE USUAL RIGHT-TO-DIE CONTROVERSIES
            BY OFFICIALLY AUTHORIZING TERMINAL SEDATION.

8.  HOW COMMON IS TERMINAL SEDATION IN THE UNITED STATES?

RESULT:

   
For readers who have never heard of terminal sedation,
this chapter explains how deep sleep can be used
as a medical method of managing dying.
Because the dying patient is completely and permanently asleep,
there is no possibility of any form of suffering.




TERMINAL SEDATION:
DYING IN YOUR SLEEPGUARANTEED

by James Leonard Park


1.  TERMINAL SEDATION MEANS INDUCING PERMANENT SLEEP.

    One common hope of people when they think about their own deaths
is that they will "die in their sleep".
This means they will become unconscious one night and never wake up.
And death does come for a few people while they are asleep:
Some element of their dying process renders their brains unconscious:
They never again experience a single thought or feeling.
Thereafter, they are completely oblivious to the dying process.

    Dying on the operating table is one medically-induced way this can happen:
Before the beginning of the operation,
the patient is given sedative drugs that put the patient into sleep so deep
that even radical cutting into his or her body causes no pain.
Anesthesia creates deep unconsciousness.
The drugs used during surgery make all forms of suffering impossible.

    Surgical anesthesia prevents the patient from feeling anything
while something is removed or repaired in his or her body.
Anesthesiology can guarantee no suffering during surgery.

    And if the surgical operation is not successful
if the repair does not work,
if the medical condition is much worse than expected

the doctors might decide never to allow this patient to awaken.
It would only cause unnecessary and meaningless suffering
for this patient to become conscious again
only to learn that he or she is inevitably dying.
Therefore, to spare everyone concerned,
the drugs are maintained until death is declared.
The operation did not save this patient
and the patient "never regained consciousness".
This patient died on the operating table or in the 'recovery' room
while under a medically-induced state of deep sleep.

    Sometimes heavy sedation is used to keep the patient asleep
while some recovery process is still being attempted.
This might be called a "medically-induced coma".
The patient would suffer so terribly if awake
that it is obviously best to keep him or her deeply asleep
until the hoped-for healing can take place.
If the patient's body does recover sufficiently,
then the sedation can be lifted gradually.
The patient will emerge from drug-induced sleep.
Some mechanical supports might still be necessary
until all normal functions of the patient's body are restored.

    Such heavy sedation is completely different from terminal sedation.
The sedation used during a surgical operation and the recovery period
is very carefully controlled by the anesthesiologist.
Everyone is hoping and planning for this patient to recover.
Careful attention is paid to keeping the patient breathing.
Perhaps a heart-lung machine will be used
to keep the patient's blood circulating and oxygenated.
Nutrition and hydration are also carefully maintained.
All forms of life-support that this patient might need
are carefully kept in place and functioning correctly.
Heavy sedation is a temporary measure,
intended to help the patient thru a difficult phase of medical treatment,
which is expected to result in the patient returning to ordinary life.

    In contrast, terminal sedation is a declared part of the dying process.
No one should be under any illusions that this patient will ever recover.
All forms of medical treatment and support are also withdrawn
since they would only delay the inevitable death.
This patient will never return to his or her ordinary life.
This sedation is called "terminal" because the doctor has ordered
that the drugs be given continuously until death comes.
All efforts at cure are abandoned.
Besides turning off the ventilator and the feeding tube
which are obvious means of life-support
terminal sedation also includes giving up antibiotics
and any other forms of chemical support for the body.
And because this patient's brain will never have another feeling,
even drugs to control uncomfortable symptoms are routinely withdrawn.
Because this patient will be in a deep sleep until death comes,
the drugs to induce permanent sleep are sufficient
to prevent any and all forms of possible suffering.

    When terminal sedation is ordered by the doctor,
this patient will be kept permanently unconscious until death comes.
In other words, this terminal care guarantees
that this patient will die is his or her sleep.




2.  USING THE BEST NAME FOR TERMINAL SEDATION.

    This medical practice has been known by some other names:
"Palliative sedation" or "terminal palliative sedation".
As long as the word "terminal" is included,
there should be less confusion with other uses of anesthesia.
When terminal sedation is ordered by the doctor,
the clear intention is to keep the patient asleep until death comes.
If the patient shows any signs of suffering, even while unconscious,
the amount of the sedative drug is increased
so that there is not even the slightest hint to any observer
that this patient might be suffering any pain or discomfort.

    "Palliative sedation" has been preferred by some advocates,
because it does not seem so stark an expression.
"Palliative medical care" refers to the medical support at the end of life.
But the expression "palliative sedation" is redundant.
All sedation is given for the purpose of alleviating symptoms.
And when the patient and/or family agrees to "palliative sedation",
do they fully understand that they are making a life-ending decision?
Some might be misled by this expression to believe
that these drugs are being given to prevent suffering for a few days
after which the patient will recover.
But, as explained above, terminal sedation is the medical decision
that this patient's life is completely and permanently over.
Nothing further will be attempted to save this patient from death.
Rather, the dying process has now been set on a downward path,
with no plan and no chance ever to reverse the dying process.

    Increasing pain-medication is also a valid end-of-life medical treatment.
And frequently these medications will also shorten the process of dying.
But under comfort care, the patient will be awake from time to time.
The level of symptom-control will be governed by what the patient wants.
Even tho this use of drugs takes place near the end of life,
comfort care should never be called "terminal sedation".

    Some doctors blur the difference between
comfort care and terminal sedation.
The change in medical orders can be very gradual:
More morphine is given.
The patient has less and less consciousness
until eventually there is no consciousness at all.
But if the patient will be kept unconscious until death,
this should be clearly acknowledged as a life-ending decision.
Safeguards for life-ending decisions should be used, as noted below.
Let it be clear to everyone: This life is over.  Death is coming.

    Here are a few alternative expressions for terminal sedation:
"sedation to unconsciousness",
"continuous sedation to unconsciousness",
"keeping the patient asleep until natural death",
"continuous deep sedation", &
"continuous palliative sedation".




3.  WHEN TERMINAL SEDATION EMERGED IN MEDICAL PRACTICE.

    Modern medicine has used terminal sedation since before the year 2000.
This can be confirmed by noting the dates of articles about terminal sedation.
One survey in the United Kingdom found that terminal sedation
was used in 16.5 % of all deaths in the years 2007-2008.
The Royal Dutch Medical Association created its guidelines
for terminal sedation in 2005, which were updated and clarified in 2009.
And in 2008 the American Medical Association
Council on Ethical and Judicial Affairs approved this method of dying.

    No major shift in thinking either by doctors or laypersons
was required to accept using drugs to relieve all suffering at the end of life.
Because doctors understood the observed suffering of their dying patients,
they compassionately used the means at their disposal
to limit and then to eliminate all needless and useless suffering.

    No changes of law were required.
Doctors already had all the authority needed
to order more sedatives for their dying patients.
Perhaps it was first referred to as "keeping the patient comfortable".
But later, it was acknowledged as keeping the patient unconscious.

    By carefully adjusting the sedative drugs used,
the doctors and nurses could be very confident
that the dying patient would never again experience
even one moment of pain or discomfort.
And they often considered the psychological stress of dying as well:
The patient and the family know that death is coming.
So then the question can be asked:
"Should the patient be awake or asleep during this process of dying?"

    And if no further purposes could be achieved by being awake,
the choice was made to keep the patient continuously unconscious
until the natural processes of dying had run their course.
Terminal sedation usually lasts only a few days.




4.  GETTING PATIENT AND FAMILY COOPERATION FOR DEEP SLEEP.

    Once everyone has acknowledge that this patient is actively dying,
and that there are no further curative treatments that might be tried,
then it is usually no problem to get agreement from everyone involved
that the patient will be better off sleeping thru the last few days
rather than having to awaken occasionally only to suffer more.

    Frequently the problem arises earlier in the process,
when the patient and some family members are not ready to 'give up'
on trying yet one more medical treatment
that has some remote possibility of saving the patient.

    Because the doctor has seen similar cases before,
he or she might be more ready to accept death than the patient and family.
So the doctor might be the first person to suggest terminal sedation
as a way of saving the patient from further meaningless suffering.

    How does the patient and the family want to handle this death?
It might take them a few days to accept that death is coming.
But having observed the suffering of the dying patient,
and having been convinced that further attempts at cure are useless,
they might agree that terminal sedation is the best way to meet death.

    When terminal sedation is the planned pathway towards death, 
then everyone should say good-bye before terminal sedation begins.
This patient will never have another moment of consciousness.
And from some perspectives, the last moment of consciousness
might be remembered as the last day of this patient's life.




5.  THE CAUSE OF DEATH IS ALWAYS THE UNDERLYING CONDITION.

    After the death has occurred and been officially declared,
the doctor in charge will complete the death-certificate,
which will always name the major cause of death
perhaps with some other notes about contributing factors,
such as other diseases or conditions that the patient had.
But almost never will the certificate of death say anything
about the specific drugs and their amounts used at the end of life.
Such facts of terminal care will be duly recorded in the medical record,
but there little reason to include such data on the death-certificate.

    Everyone who was present for the last few days
will know whether the patient was awake or asleep.
And the decision-makers will know whether terminal sedation
was ever ordered and perhaps begun.

    Statistics collected about the causes of death
will not be changed by the fact of terminal sedation.
Each death was caused by cancer, heart disease,
breathing problems, degenerative conditions, etc.
And the fact that the patient was kept unconscious at the end
is not relevant for keeping statistics of the causes of death.

    However, if and when the medical methods of managing dying
are added to the certificates of death,
then terminal sedation might be put on that additional line
for life-ending decisions or medical methods of managing dying.




6.  SAFEGUARDS FOR CHOOSING TERMINAL SEDATION.

    Usually the overwhelming reason for choosing terminal sedation
is the fact that this patient is already actively dying.
And terminal sedation was the major comfort measure used at the end.
But it will do not harm to list all of the possible safeguards
that might be relevant for any life-ending decisions.

    These safeguards can be used as a check-list
by any group of people considering terminal sedation
for a particular patient at a particular time.
Which safeguards are most relevant for this dying-process?
Which have already been fulfilled?

    Each of the following safeguards is fully explained on the Internet.
Following this list of 26 safeguards,
each safeguard is specifically applied to using terminal sedation.

A. ADVANCE DIRECTIVE FOR MEDICAL CARE

B. REQUESTS FOR DEATH FROM THE PATIENT

C. PSYCHOLOGICAL CONSULTANT EVALUATES
            THE PATIENT'S ABILITY TO MAKE MEDICAL DECISIONS


D. PHYSICIAN'S STATEMENT OF CONDITION AND PROGNOSIS

E. INDEPENDENT PHYSICIAN
            REVIEWS THE CONDITION AND PROGNOSIS


F. CERTIFICATION OF TERMINAL ILLNESS OR INCURABLE CONDITION

G. UNBEARABLE SUFFERING

H. UNBEARABLE PSYCHOLOGICAL SUFFERING

I.   PALLIATIVE CARE TRIAL

J. INFORMED CONSENT FROM THE PATIENT

K. REQUESTS FOR DEATH FROM THE PROXIES

L. ENROLLMENT IN A HOSPITAL OR HOSPICE

M. STATEMENTS FROM HOSPITAL OR HOSPICE STAFF MEMBERS

N. STATEMENTS FROM FAMILY MEMBERS
            AFFIRMING OR QUESTIONING CHOOSING DEATH


O. A MEMBER OF THE CLERGY
            APPROVES OR QUESTIONS CHOOSING DEATH


P. RELIGIOUS OR OTHER MORAL PRINCIPLES
            APPLIED TO THIS LIFE-ENDING DECISION

Q. AN INSTITUTIONAL ETHICS COMMITTEE
            REVIEWS THE PLANS FOR DEATH


R. STATEMENTS FROM ADVOCATES FOR DISADVANTAGED GROUPS
             IF INVITED BY THE PATIENT AND/OR THE PROXIES

S. REVIEW BY THE PROSECUTOR (OR OTHER LAWYER)
            BEFORE THE DEATH TAKES PLACE

T. CIVIL AND CRIMINAL PENALTIES FOR CAUSING PREMATURE DEATH

U. WAITING PERIODS FOR REFLECTION

V. OPPORTUNITIES FOR THE PATIENT TO RESCIND OR POSTPONE
            ANY LIFE-ENDING DECISIONS


W. PHYSICIANS REVIEW THE COMPLETE DEATH-PLANNING RECORDS

X. COMPLETE RECORDING AND SHARING
            OF ALL MATERIAL FACTS AND OPINIONS


Y. THE PATIENT MUST BE CONSCIOUS AND ABLE TO ACHIEVE DEATH

Z. THE DEATH-PLANNING COORDINATOR ORGANIZES THE SAFEGUARDS




A. ADVANCE DIRECTIVE FOR MEDICAL CARE

    Did this patient have the foresight to create an Advance Directive?
If so, does it support the use of terminal sedation?
Is terminal sedation explicitly mentioned?
Are there any conditions or limitations that might be relevant?

B. REQUESTS FOR DEATH FROM THE PATIENT

    How deeply is this patient able to participate in planning death?
Has this patient explicitly asked for death?
Would terminal sedation be a reasonable method of managing dying?

C. PSYCHOLOGICAL CONSULTANT EVALUATES
            THE PATIENT'S ABILITY TO MAKE MEDICAL DECISIONS

   
Did this patient consult a psychological professional?
If so, did the psychologist or psychiatrist agree with the plans for death?
Will this professional testify that the life-ending decision was reasonable,
given all of the medical facts and professional recommendations?

D. PHYSICIAN'S STATEMENT OF CONDITION AND PROGNOSIS

    The physician's written statement of the patient's medical situation
will be the most important document created
for the process of authorizing terminal sedation.
Does the physician agree that the patient is actively dying?
Is the patient suffering physically and/or psychologically?
Would terminal sedation be a wise end-of-life choice?

E. INDEPENDENT PHYSICIAN
            REVIEWS THE CONDITION AND PROGNOSIS

    Because choosing death is so final and irrevocable,
a second professional opinion should be sought from another doctor.
Does a specialist agree that this death cannot be avoided?
Does this second doctor endorse terminal sedation
as a good medical method of managing dying?

F. CERTIFICATION OF TERMINAL ILLNESS OR INCURABLE CONDITION

    Probably separate from the full medical record,
have the doctors issued an official statement
declaring that this patient is likely to die within six months?

G. UNBEARABLE SUFFERING

    The basic reason for choosing terminal sedation
is that the patient will suffer unnecessarily without these drugs.
Does everyone agree it is better to keep the patient asleep?

H. UNBEARABLE PSYCHOLOGICAL SUFFERING

    Sometimes the fear of death is worse than the actual process of dying.
Thus, if this patient would otherwise endure terrible psychological trauma,
it might be best to give drugs to keep the patient unconscious until death.

I.   PALLIATIVE CARE TRIAL

    In almost all cases of choosing terminal sedation,
there has been some period of using less drugs
to see if that will alleviate the symptoms sufficiently
to make this a meaningful process of dying.
But if such efforts do not yield an acceptable level of existence,
then permanent and continuous sedation into deep sleep might be better.

J. INFORMED CONSENT FROM THE PATIENT

    Before terminal sedation is begun,
it is sometimes possible to ask the patient himself or herself
whether he or she wants to be kept asleep until death.
Has the patient been given enough time to consider this alternative?
If so, has the patient given fully-informed agreement
to following this pathway towards death?

K. REQUESTS FOR DEATH FROM THE PROXIES

    And if the patient is already too far gone to give informed consent,
do the proxies now agree that terminal sedation is the best option?
Do the proxies want the patient kept asleep until death comes?

L. ENROLLMENT IN A HOSPITAL OR HOSPICE

    This safeguard has probably already been fulfilled:
When terminal sedation becomes a reasonable end-of-life choice,
the patient is already actively dying
under some forms of professional medical care.
Does this hospital or hospice-program have any reasons
to question the choice of terminal sedation for this patient?

M. STATEMENTS FROM HOSPITAL OR HOSPICE STAFF MEMBERS

    Do the doctors and nurses connected with this terminal-care setting
have any views about using terminal sedation for this patient?
Since they have some experience with this method of dying,
do they regard terminal sedation as a wise choice for this patient?

N. STATEMENTS FROM FAMILY MEMBERS
            AFFIRMING OR QUESTIONING CHOOSING DEATH

    Also, family members might be asked for their written opinions.
Second only to the dying patient,
these are the people who will be most deeply affected
by whatever pathway toward death is chosen
or not chosen.
Do family members understand the full implications of terminal sedation?
And do they prefer this method of managing dying
rather than the patient being awake from time to time?

O. A MEMBER OF THE CLERGY
            APPROVES OR QUESTIONS CHOOSING DEATH

    If the patient and/or family has any connections with organized religion,
they might ask for a professional opinion from their preferred religious leader.
Has this clergy-person been brought 'up to speed'
with respect to all the medical facts and professional recommendations?
Once fully-informed, does this minister, priest, rabbi, or other religious leader
agree that terminal sedation would be a good pathway towards death?

P. RELIGIOUS OR OTHER MORAL PRINCIPLES
            APPLIED TO THIS LIFE-ENDING DECISION

    And if terminal sedation seems a new option for this religious tradition,
has anyone written a statement of principles covering this method of dying?
Terminal sedation will become an ever-more-common end-of-life choice.
Thus, organized religious group might discuss this pathway towards death
and issue official statements about how to handle terminal sedation.

Q. AN INSTITUTIONAL ETHICS COMMITTEE REVIEWS THE PLANS FOR DEATH

    Each medical institution that takes care of patients who are dying
will also face the pros and cons of choosing death by terminal sedation.
If there is an official medical ethics committee,
have they been consulted about this particular proposed death?
And do they endorse keeping the patient continuously asleep until death?

R. STATEMENTS FROM ADVOCATES FOR DISADVANTAGED GROUPS
             IF INVITED BY THE PATIENT AND/OR THE PROXIES

    If this patient belongs to any group sometimes disfavored by society,
would it be reasonable to ask some representative of that group
to review the plans for terminal sedation at the end of this patient's life?
If this advocate selected especially to protect a vulnerable patient
also agrees that death under continuous, deep sedation would be wise,
then other members of the same minority group
should be assured that no lower level of medical care was provided
because of the group-identity of this particular dying patient.

S. REVIEW BY THE PROSECUTOR (OR OTHER LAWYER)
            BEFORE THE DEATH TAKES PLACE

    If most of the other safeguards have already been fulfilled,
then it might not be necessary to do an additional legal review.
But if the case is especially complicated
and if there are differences of opinion about using terminal sedation,
then the full record can be presented to someone well-versed in the law. 
Does this public prosecutor or private attorney agree
that terminal sedation is completely reasonable
given all of the medical facts and family opinions?
Such a legal review should assure everyone involved
that there will be no legal complications after this death occurs.

T. CIVIL AND CRIMINAL PENALTIES FOR CAUSING PREMATURE DEATH

    However, if someone has manipulated the data or concealed some facts,
then the justice system in that location
should still have the authority to investigate this death by terminal sedation.
If some patient was put to death before it would have been reasonable,
then a crime or a civil violation has occurred.
And the most appropriate system of justice can then be applied
with the possibility of imposing severe penalties
on anyone who has done anything to harm the dying patient.

U. WAITING PERIODS FOR REFLECTION

    Because of the many days and months already devoted to terminal care,
it might not be reasonable to require any additional waiting periods.
But, if it will not make much difference to anyone involved
for instance, if the patient has already been in PVS for a few months
then it will do no harm to declare a 'time-out for reconsideration'.
Terminal sedation will be the last decision made for this patient.
Has everyone concerned taken enough time to review this choice?

V. OPPORTUNITIES FOR THE PATIENT TO RESCIND OR POSTPONE
            ANY LIFE-ENDING DECISIONS

    When the patient has become a candidate for terminal sedation,
then no one is likely to rescind or overturn this whole process.
But are there reasons to postpone the terminal sedation?
Both the patient and others involved in this life-ending decision
can consider what would be the very best time to say 'good night'.
Or the drugs for terminal sedation can be held close at hand,
to be given only when some medical catastrophe occurs.

W. PHYSICIANS REVIEW THE COMPLETE DEATH-PLANNING RECORDS

    As a final review before starting terminal sedation,
the physician most in charge of this patient's terminal care
could read thru all of the safeguard-documents already created.
Should any aspect of this plan for death be reconsidered?
If all plans point in the same direction,
this physician can issue the official order to begin terminal sedation.

X. COMPLETE RECORDING AND SHARING
            OF ALL MATERIAL FACTS AND OPINIONS

    Because ordering terminal sedation is a final life-ending decision,
have all the relevant facts and recommendations been gathered?
Perhaps one person has taken responsibility
to make certain that everyone who has a right to know
about this process of planning death
has been informed of each step towards death.
If everything has been completely shared beforehand,
there will be no second-guesing after this patient's death.

Y. THE PATIENT MUST BE CONSCIOUS AND ABLE TO ACHIEVE DEATH

    Philosophically, it is correct to make certain that the patient
understands the full implications of beginning terminal sedation.
But, obviously, if the patient is asleep for the last week of life,
he or she cannot authorize or act to achieve death at the end.
And this safeguard should never prevent
proxies from authorizing terminal sedation
if the patient has already passed the point
of making wise end-of-life medical choices.
Probably the patient has endorsed this plan for death beforehand.
And now the duly-authorized proxies are responsible
for carrying forward the settled wishes of the patient.

Z. THE DEATH-PLANNING COORDINATOR ORGANIZES THE SAFEGUARDS

    Once terminal sedation has been selected for this patient,
then the record-keeping person should complete the process
of gathering all of the records
concerning this life-ending process into one permanent place
just in case there might ever be (at some future time)
a need to review the decisions that led to this patient's death.




7.  FRANCE AVOIDS THE USUAL RIGHT-TO-DIE CONTROVERSIES
            BY OFFICIALLY AUTHORIZING TERMINAL SEDATION.


    The President of France and the French National Assembly
might now have achieved by a simple new law (2016)
what other countries have struggled with for decades.
With remarkably little public controversy,
the right-to-die might have been achieved for France
simply by endorsing medical practices already well established.

    French doctors have long been helping their dying patients 
to avoid the last few days of meaningless suffering
by ordering (with the permission of the patient and/or the proxies)
that the dying patient by kept completely unconscious until death comes.
French law now officially authorizes
"deep, continuos sedation until death".

    Probably no new law was actually required,
but it will be reassuring to everyone to know
that French doctors are now officially and legally authorized
to prevent suffering at the end of life by ordering terminal sedation.

    90% of the French people favor this method of choosing death.
These are the provisions of the new law authorizing terminal sedation:
1. Normal pain-relief has been found not sufficient.  (palliative care trial)
2. The patient must be terminally ill to be granted terminal sedation.
3. The patient must request terminal sedation.
4. If the patient can no longer request terminal sedation,
it can still be ordered by the physician.
5. If the patient is no longer able to request terminal sedation,
a prior authorization (such as in an Advance Directive) can be honored.
6. Other provisions of an Advance Directive are enforceable.
7. The physician can also withdraw all medical treatments
and life-support measures.
8. Artifically-provided food and water are defined as medical treatments.
These can be stopped (or never started)
at the request of the patient and/or the proxies.

    The opposition came mainly in the form of re-labeling:
Those who do not approve of terminal sedation
want to call it "slow euthanasia".
This condemnation depends on the negative connotations of "euthanasia".

    But terminal sedation differs from euthanasia is these four ways: 
(1) Euthanasia causes death immediately.
Terminal sedation continues for a few days
(2) Choosing euthanasia means taking the gentle poison only once.
Terminal sedation means the flow of anesthetic is continuous for days.
(3) In euthanasia, the direct cause of death is the lethal injection or death pill.
In terminal sedation, the direct cause of death is the medical condition.
(4) The stated purpose of euthanasia is to bring the patient's life to an end.
Terminal sedation is instituted to save the patient from further suffering.

    Several near-by European countries already do have right-to-die laws
that authorize 'euthanasia' and 'physician-assisted suicide'.
But even where these methods of choosing death are legal,
doctors are increasingly turning to terminal sedation
because keeping the patient asleep until death
does not require any application to a government agency
nor does it require as much paperwork after the death has taken place.
And terminal sedation is sometimes easier for the family than euthanasia,
because it gives them a few days in which to adjust to the coming death.

    Dutch doctors say that terminal sedation is a normal part of medical care.
Therefore, there are no special requirements for reporting such deaths.
The death-certificate always says that the patient died of natural causes.
Sedatives used at the end of life are not mentioned on the death-certificate.

    Thus, France now has legal authority for their doctors to do likewise:
As a normal part of medical practice,
they can order whatever levels of sedation
they find appropriate for each particular dying patient.

    The percentage of French deaths using terminal sedation
was probably about 10% of all deaths before this new legislation.
And it could easily jump to 20% of all deaths
or even higher
now that terminal sedation has become the law of France.
And some part of any such increase will result from more honest reporting.
French doctors have been quietly helping to ease the dying process
by giving their dying patients all of the sedatives found necessary.
And now they can extend the practice of terminal sedation
to more patients and acknowledge this method of dying more openly.

    See more information about France's right-to-die law:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/RTD-FR.html




8.  HOW COMMON IS TERMINAL SEDATION IN THE UNITED STATES?

    Because terminal sedation is seldom mentioned on death-certificates,
there is no easy way to gather statistics about the number of deaths
that take place while the patient was kept unconscious by drugs.
The most reasonable way to gather such numbers
would be to ask the people who were at the bedside
both the doctors who were in charge of the dying process
and the laypersons who observed everything.

    Another chapter of this book
Four Medical Methods of Managing Dying
estimates that only 5-10% of all deaths in the USA include terminal sedation.
But as the decades unfold, such numbers are certain to rise.
As noted earlier, in the UK in 2007-2008, one study found
that terminal sedation was used in 16.5% of all deaths.

    As laypersons learn more about this method of managing dying,
they will more readily accept this recommendation from their doctors.
And sometimes the patient and/or the family will ask for terminal sedation.
If everyone already agrees that this death cannot be avoided,
then the only remaining question is:
"How shall we manage this process of dying?"

    There is no logical or medical reason why termination sedation
could not be used in all managed deaths
in hospitals, nursing homes, and even at home.
Terminal sedation, probably combined with giving up food and water,
is one of the most obvious choices for avoiding further suffering.
Dying is already a terrible prospect for everyone.
But terminal sedation can make dying easier.



Created March 21, 2015; Revised; 3-26-2015; 4-1-2015; 4-2-2015; 4-3-2015; 4-18-2015; 4-23-2015;
5-1-2015; 7-10-2015; 10-8-2015; 10-27-2015; 12-8-2015; 12-23-2015;
9-15-2016; 11-27-2017; 2-20-2018;


AUTHOR:

    James Leonard Park is an advocate of
the right-to-die with very careful safeguards.
His 26 recommended safeguards are applied
to the method of terminal sedation in this chapter.
(See Section 6 above.)

    This whole essays is also a chapter of:
How to Die:
Safeguards for Life-Ending Decisions


    And terminal sedation is also included in:
Right-to-Die Hospice




Could permanent sleep become a good method of dying?

    Did you originally think that being drugged-to-death was intolerable?
Would you now approve sleeping-into-death as a good method of dying?
Did you previously believe that giving drugs to aid in dying was not legal?
When the most relevant safeguards are fulfilled,
is continuous sedation an appropriate pathway towards death?
Would you approve terminal sedation for someone you love who is dying?
Would you choose terminal sedation for yourself at the end of your life?




TERMINAL SEDATION LINKS

"Responding to Intractable Terminal Suffering:
The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids"
by Timothy E. Quill, MD & Ira R. Byock, MD
Annals of Internal Medicine, Volume 132, Number 5, 7 March 2000, p. 408-414.
http://www.acponline.org/clinical_information/resources/end_of_life_care/intractable_suffering.pdf


"Putting the Right-to-Die into Health-Care Laws and Regulations:
Authorized Methods of Dying,
Safeguards for Life-Ending Decisions"
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-HCLAWS.html

This essay includes terminal sedation as one of five possible methods of dying.

"Suicide-Model Right-to-Die vs. Medical Model Right-to-Die"
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-SM-MM.html
Terminal sedation is one of the medical methods of managing dying
when the right-to-die is being affirmed as a normal part of medical practice.





The above exploration of terminal sedation as a method of choosing death
  is also Chapter 40 of How to Die: Safeguards for Life-Ending Decisions:
"Terminal Sedation: Dying in Your SleepGuaranteed".

Would you like to join a world-wide Facebook Seminar discussing this book-being-revised?

See the complete description for this first-readers book-club:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/ED-HTD.html

Join our Facebook Group called: Safeguards for Life-Ending Decisions: http://www.facebook.com/home.php#!/groups/107513822718270/



WOULD YOU LIKE TO MEET OTHER SUPPORTERS
OF RIGHT-TO-DIE HOSPICE?

If you agree with using terminal sedation as a method of managing death,
consider joining a Facebook Group and Seminar called Right-to-Die Hospice.

The essay above exploring all dimensions of terminal sedation
has become Chapter 6 of Right-to-Die Hospice.

Here is a complete description of this on-line gathering of advocates of the right-to-die:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/ED-RTDH.html

And here is the direct link to our Facebook Group:
Right-to-Die Hospice:
https://www.facebook.com/groups/145796889119091/




    Closely related chapters and on-line essays:

Four Medical Methods of Managing Dying


Methods of Choosing Death in a Right-to-Die Hospice

VDD:
Why Giving Up Water is Better than other Means of Voluntary Death

Voluntary Death by Dehydration:
Safeguards to Make Sure it is a Wise Choice

The One-Month-Less Club:
Live Well Now, Omit the Last Month

Choosing Your Date of Death:
How to Achieve a Timely Death
Not too Soon, Not too Late

Losing the Marks of Personhood:
Discussing Degrees of Mental Decline

Advance Directives for Medical Care:
24 Important Questions to Answer

Fifteen Safeguards for Life-Ending Decisions

Will this Death be an "Irrational Suicide" or a "Voluntary Death"?

Will this Death be a "Mercy-Killing" or a "Merciful Death"?




    Further Reading:

Best Books on Terminal Care (from the Doctor's Point of View)

Books on Hospice Care

Terminal Medical Care from the Consumer's Point of View

Books on Advance Directives for Medical Care
 

Best Books on Voluntary Death

Best Books on Preparing for Death

Books on Terminal Care


Medical Methods of Managing Dying

Books on Helping Patients to Die

Books Supporting the Right-to-Die

Books Opposing the Right-to-Die



Go to the Right-to-Die Portal.


Go to the Book Review Index
to discover 350 reviews
organized into 60 bibliographies.


Return to the DEATH page.


Go to the Medical Ethics index page.


Read other free books on the Internet.


Go to other on-line essays by James Park,
organized into 10 subject-areas.


Go to the beginning of this website
James Leonard Park—Free Library