From Our 2008 Archives

Deep Sedation Becoming More Common for Dying Patients in Holland

By Steven Reinberg
HealthDay Reporter

FRIDAY, March 21 (HealthDay News) — Continuous deep sedation is becoming more common than euthanasia in the Netherlands when treating terminally ill patients who are nearing death, Dutch researchers report.

Euthanasia is legal in the Netherlands, but it's not clear from the study whether continuous deep sedation is being used as a substitute for euthanasia, or whether it's proving to be a better way to care for the terminally ill who would otherwise suffer an uncomfortable death.

Deep sedation is often used when other methods of controlling pain or discomfort fail. The technique can be used intermittently or continuously until death occurs. The level of sedation can vary from a lowered state of consciousness to unconsciousness. Patients are often kept in deep sedation for several days before they die, the researchers noted.

"The increased use of continuous deep sedation for patients nearing death in the Netherlands suggests that this practice is increasingly considered as part of regular medical practice," said lead researcher Judith Rietjens, a postdoctoral researcher in the Department of Public Health at Erasmus University Medical Center in Rotterdam.

The increase in the use of continuous deep sedation may be explained by increased knowledge and media attention about the technique, Rietjens said. "Also, the use of continuous deep sedation may in some situations be a relevant alternative to the use of euthanasia for patients," she added.

An earlier study done in 2001 in six European countries found that deep sedation was used in 8.5 percent of all deaths in patients with cancer and other diseases. The technique was used both in and out of the hospital, researchers found.

For the new study, Rietjens's team collected data on 6,860 deaths that occurred between August and November 2005 in the Netherlands. The researchers found that the use of continuous deep sedation rose from 5.6 percent of all deaths in 2001 to 7.1 percent of deaths in 2005 — an increase of 1,800 cases, the researchers noted.

The increase was mostly among patients with cancer treated by general practitioners. During the same period, the use of euthanasia dropped from 2.6 percent of deaths to 1.7 percent, a decrease of 1,200 cases, the report found.

"Of the physicians who used continuous deep sedation, 15 percent used morphine and no benzodiazepines and 91 percent did not consult a palliative-care expert," Rietjens said.

Among patients who opted for continuous deep sedation, 94 percent had less than a week to live. For 47 percent of the patients, continuous deep sedation was started in the last 24 hours before they died. In addition, about one in 10 of these patients had requested euthanasia, but their request had not been approved, the researchers reported.

The findings were published Friday in the online edition of the British Medical Journal.

Dr. Ira Byock is an end-of-life-care expert and director of palliative medicine at Dartmouth Medical School, who co-authored an accompanying editorial in the journal. He said he's not sure why there's been an increase in the use of continuous deep sedation in the Netherlands, and he questions whether other methods of controlling pain and discomfort shouldn't be used instead.

"We don't know if continuous deep sedation is being used as a substitute for euthanasia or whether it is indicative of better care for people who would otherwise die in distress," Byock said.

If deep sedation is being used as a substitute for euthanasia, then there are troubling clinical and ethical implications, Byock said. "We want to know if deep sedation is being used to avoid the procedural safeguards for euthanasia or whether it is being used appropriately to address symptoms such as pain or breathlessness that would otherwise be uncontrolled," he said.

In the United States, where euthanasia is not legal, deep sedation is used as a last resort when pain or discomfort is no longer controllable by other methods, Byock said. The decision to use deep sedation is also made in consultation with the patient or the family, he added.

"Even in the United States, there is concern that these practices [deep sedation] not be used too readily as a substitute for the meticulous, painstaking treatment of people's physical distress," Byock said. "There is no distress you're going to have that I cannot alleviate with medications, but we don't want that to be a substitute for good, comprehensive medical care."

SOURCES: Judith Rietjens, Ph.D., postdoctoral researcher, Department of Public Health,Erasmus University Medical Center, Rotterdam, the Netherlands; Ira Byock, M.D., director, palliative medicine, Dartmouth Medical School, Hanover, N.H.; March 1, 2008, online British Medical Journal

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