The use of continuous deep sedation for patients nearing death in the Netherlands is increasing, while cases of euthanasia have declined, according to a study published on bmj.com today.
Although the exact cause of this trend is unclear, there are indications that continuous deep sedation may in some cases be being used as a substitute for euthanasia.
Patients nearing death often experience distressing symptoms and sedating drugs can be used as an option of last resort. Sedation can be used intermittently or continuously until death, and the depth of sedation can vary from a lowered state of consciousness to unconsciousness.
The most extreme use of sedation is continuous deep sedation until death, but there is a lack of large scale research on its use.
In 2001, a large study in six European countries showed that continuous deep sedation was used in up to 8.5% of all deaths, among patients with cancer and other diseases, and provided in as well as outside hospital.
In 2005, researchers repeated this study using a random sample of over 6,500 deaths that occurred in the Netherlands between August and November 2005. Physicians were surveyed about their medical decisions for the non-sudden deaths.
The use of continuous deep sedation increased from 5.6% of deaths in 2001 to 7.1% in 2005 (an increase of 1800 cases). The increase occurred mostly in patients with cancer who were treated by a general practitioner. In contrast, the use of euthanasia decreased from 2.6% of all deaths in 2001 to 1.7% of all deaths in 2005 (a decrease of 1200 cases).
In about four out of five of cases, sedation was induced by benzodiazepines, and in 94% patients were sedated for less than one week until death. Only 9% of physicians consulted a palliative expert.
About one in ten patients who received continuous deep sedation had previously requested euthanasia or assisted suicide but it had not been granted.
Possible explanations for these trends include increased knowledge and media attention about continuous deep sedation, say the authors. Their findings suggest that continuous deep sedation is increasingly considered part of regular medical practice in the Netherlands.
They call for future research to focus on the underlying reasons for the use of continuous deep sedation.
This study provides some insight into end of life management of patients with intractable suffering, say researchers in an accompanying editorial.
They believe that further research must incorporate the perspectives of patients and families, as well as professionals from health care, spiritual care, social services, law and ethics. And they call for informed public debate about ethical and effective ways to alleviate persistent suffering at the end of life.
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