In face-to-face interviews with 410 physicians in the Netherlands, 52 percent said that in the previous two years they had administered sedating medications while withholding fluids and nutrition for patients nearing death.

So-called “terminal sedation” was most commonly used to relieve severe pain (51 percent), agitation (38 percent), breathlessness (38 percent) and anxiety (11 percent). Hastening death was partly the intention of the physician in 47 percent of the terminal sedation cases and the explicit intention for 17 percent.

However, less extreme measures might have helped these patients, a U.S. physician suggests.

According to their report in the Annals of Internal Medicine, Dr. Judith A. C. Rietjens from Erasmus Medical Center in Amsterdam, and colleagues, found that physicians discussed the use of terminal sedation with the patient in 59 percent of cases and with patients’ relatives 93 percent of instances. The decision to forgo food and water was discussed with the patient in only 34 percent of cases.

While physicians surveyed “almost always” discussed the use of terminal sedation with relatives, Rietjens and colleagues found it “remarkable” that general practitioners often did not consult other physicians or caregivers and rarely sought the advice of specialists in palliative care or pain management.

This concerns Dr. Muriel R. Gillick from Harvard Medical School in Boston, who notes in an editorial that “although state-of-the-art palliative care should substantially control pain in 90 percent of cases,” pain was the most common reason for turning to terminal sedation.

“That the Dutch physicians seldom used palliative care consultation underscores the concern that they may have used terminal sedation when a less drastic approach existed,” Gillick writes.

She feels that the experience in the Netherlands “should lead the medical profession as a whole to conclude that we need to control the use of terminal sedation by developing and implementing practice guidelines.”

SOURCE: Annals of Internal Medicine, August 3, 2004.