The newly revised HPNA Position Statement on Palliative Sedation brings to the fore important considerations regarding the use of palliative sedation for terminally ill patients with refractory symptoms. This view highlights some of the important aspects of palliative sedation as an intervention of last resort for patients with intractable suffering.

Palliative sedation is one of many approaches to relief of suffering. It is an approach of last resort for refractory suffering when other interventions have failed. It is, however, more frequently surrounded by controversy than other forms of palliative interventions. Some nurses and other practitioners are uncomfortable with sedation because the patient may die while sedated, which may raise the question as to whether the intent of the sedation was to cause death rather than to alleviate the patient's suffering. As noted in the position statement, palliative sedation is "intended to induce varying degrees of unconsciousness, but not death, for relief of refractory and unendurable symptoms in imminently dying patents."^(p1-9) This intent to relieve suffering is further supported by the ANA's Code of Ethics for Nurses.

The ethical principle of double effect allows for an action that has a known adverse effect when the intent is relief of suffering and when the benefit to the patient outweighs the risk. In 1997, the US Supreme Court upheld a patient's right to relief of suffering even if it can be foreseen to also cause death. In other words, as long as the intent of the professional is to relieve suffering and not to directly end the patient's life, there is no inherent ethical or legal controversy for the use of palliative sedation.1-3

For some nurses, another reason for the discomfort may be that it is used only for refractory symptoms of suffering that cannot be alleviated with interventions that are effective for most other patients. Because suffering is subjective in nature, it is difficult to assess the refractory suffering of others. One of the greatest areas of difficulty comes with patients who express refractory existential suffering. Although existential suffering may have physical components, it is an underlying distress of nonphysical origin that remains the cause of the suffering. The source of this discomfort for nurses is likely a reflection of unease regarding our ability to assess this suffering, in particular nonphysical, existential suffering. Tools for assessment of physical symptoms are more readily available and widely used. When suffering is of a nonphysical nature, we have limited tools for objective assessment of what is essentially a subjective experience. Yet it remains a tenet of good patient care and an ethical imperative to provide the informed patient (or assigned surrogate) sufficient intervention to relieve the unacceptable (according to the patient) suffering when other interventions prove ineffective.

Although primarily a medical decision, an interdisciplinary approach to requests for relief of refractory suffering, including existential suffering, through palliative sedation is essential to help address the ethical concerns of some professionals related to intent and proportionality of palliative interventions. It also helps to ensure that the patient's autonomy rights and the right to relief of suffering as upheld by the courts are met with due diligence and beneficence. Having policies and procedures to help with a consistently applied approach also benefits patients and professionals. Few, if any, would argue with the ethical imperative of nurses to act as advocates for their patients. Because of the intimate and interpersonal nature of nursing practice and the nurse-patient relationship, nurses are implicitly and explicitly required to act as advocates for their patients. The HPNA Position Statement on Palliative Sedation should help guide nurses in their responsibility to advocate for the relief of refractory suffering of their patients and help guide one's own conscience in our efforts to relieve the suffering of our patients within an ethical and legal framework.

Pam Dalinis, MA, BSN, RN

Board of Directors

Hospice and Palliative Nurses Association

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