NHPCO response to NY Times article of 12/26/09

December 30, 2009

Whenever the media focuses on issues involving end-of-life care, there are sure to be different points of view, nowhere is this better understood than within the hospice and palliative care provider community. When such an article appears in the press, there is always value in the conversations that follow among individuals and families, and between healthcare providers.

That said, there is concern regarding The New York Times article by Anemona Hartcollis, “Hard Choices for a Comfortable Death: Sedation” (12/26/09). While the large majority of the nearly 500 responses posted to the New York Times Web site in response to this article reflect favorably on hospice care and the personal experiences of many readers, there is concern that others may draw inaccurate conclusions about hospice and care of the dying.

As Ms. Hartcollis points out, intractable pain at the end of life is never a simple issue. A decision to use sedation near the end of life should be made carefully and thoughtfully, with adequate support from knowledgeable and skilled healthcare providers.

Research showing that patients at the very end of life who receive palliative sedation do not die more quickly than patients who are not sedated has been published in such peer reviewed professional journals as Annals of Oncology, Journal of Palliative Medicine, Journal of Pain and Symptom Management, Archives of Internal Medicine, and Palliative Medicine. (A bibliography of these articles is available from NHPCO.)

National Hospice and Palliative Care Organization would like to offer some important points about hospice care that may help those confused by this article. 

The goal of hospice is to provide compassionate, effective care that is consistent with the needs and goals of patients and family caregivers—the goal is not to hasten death. A hospice team works to maximize quality of life and minimize suffering for those they serve.

Hospice typically involves a wide range of interventions to control physical suffering in addition to meeting the emotional, spiritual, and social needs of the patient and family. Provided by an interdisciplinary team of professionals, hospice services can include counseling, complementary therapy (such as massage, music, and physical therapy), and medications. In the vast majority of cases, a combination of medical and non-medical therapies can reduce physical suffering to a level that is comfortable for the patient.

On the rare occasion when treatments for pain or other forms of physical suffering are not able to help the patient reach an acceptable level of comfort, hospice providers may discuss the option of palliative sedation. The benefits and risks should be discussed carefully with the patient and his or her family. The patient and family are always at the heart of all decisions that are made and every patient’s care plan is individualized and unique to him or her.

NHPCO—in alignment with the world's leading experts on palliative sedation—believes that palliative sedation should be used only when other therapies that do not compromise patient consciousness have failed.

Above all, any discussion about sedation should begin early. Rushed decisions by patients and families in crisis are often not ideal. Instead, patients are best able to make decisions when they have time to discuss and reflect. Advance care planning and good hospice care should therefore pay attention to patients' goals and fears about suffering, and should anticipate the need for sedation so that decisions can be made with the care that they require.

The NY Times article makes reference to the term “slow euthanasia.” Palliative sedation is medically, ethically, and legally separate from euthanasia. It is not administered with the intent to cause death; it is not administered with the foreseen outcome of causing death; and, when administered successfully, it does not cause death.

The National Hospice and Palliative Care Organization along with the American Medical Association, the American Association of Hospice and Palliative Medicine, and the United States Supreme Court believes that palliative sedation can be a safe and appropriate intervention at the end of life. Importantly, NHPCO does not believe—nor do any of the aforementioned institutions—that palliative sedation, when practiced safely by qualified clinicians using evidence-based protocols, is a form of “slow euthanasia” or euthanasia of any kind.

The recently published European Association for Palliative Care recommended framework for the use of sedation in palliative care is another important source of guidance surrounding this issue that healthcare professionals may find as a valuable resource. It is available online at www.eapcnet.org/projects/Sedation.html.

For members of the public looking to learn more about care at the end of life, please visit NHPCO’s Caring Connections at www.caringinfo.org.

National Hospice and Palliative Care Organization
Alexandria, VA

Inquiries may be directed to: Jon Radulovic, Vice President of Communications, jradulovic@nhpco.org or 703-837-3139.

NHPCO is the oldest and largest nonprofit membership organization representing hospice and palliative care programs and professionals in the United States. NHPCO’s mission is to lead and mobilize social change for improved care at the end of life.