PALLIATIVE OPTIONS OF LAST RESORT - A COMPARISON OF VOLUNTARILY STOPPING EATING AND DRINKING, TERMINAL SEDATION, PHYSICIAN-ASSISTED SUICIDE, AND VOLUNTARY ACTIVE EUTHANASIA

Palliative care is generally agreed to be the standard of care for the dying, but there remain some patients for whom intolerable suffering persists, In the face of ethical and legal controversy about the accep tability of physician-assisted suicide and voluntary active euthanasia , voluntarily stopping eating and drinking and terminal sedation have been proposed as ethically superior responses of last resort that do n ot require changes in professional standards or the law, The clinical and ethical differences and similarities between these 4 practices are critically compared in light of the doctrine of double effect, the ac tive/passive distinction, patient voluntariness, proportionality betwe en risks and benefits, and the physician's potential conflict of dutie s, Terminal sedation and voluntarily stopping eating and drinking woul d allow clinicians to remain responsive to a wide range of patient suf fering, but they are ethically and clinically more complex and closer to physician-assisted suicide and voluntary active euthanasia than is ordinarily acknowledged, Safeguards are presented for any medical acti on that may hasten death, including determining that palliative care i s ineffective, obtaining informed consent, ensuring diagnostic and pro gnostic clarity, obtaining an independent second opinion, and implemen ting reporting and monitoring processes, Explicit public policy about which of these practices are permissible would reassure the many patie nts who fear a bad death in their future and allow for a predictable r esponse for the few whose suffering becomes intolerable in spite of op timal palliative care.