Responding to intractable terminal suffering: The role of terminal sedation and voluntary refusal of food and fluids

When provided by a skilled, multidisciplinary team, palliative care is high ly effective at addressing the physical, psychological, social, and spiritu al needs of dying patients and their families. However, some patients who h ave witnessed harsh death want reassurance that they can escape if their su ffering becomes intolerable. In addition, a small percentage of terminally ill patients receiving comprehensive care reach a point at which their suff ering becomes severe and unacceptable despite unrestrained palliative effor ts; some of these patients request that death be hastened. This paper prese nts terminal sedation and voluntary refusal of hydration and nutrition as p otential last resorts that can be used to address the needs of such patient s. These two practices allow clinicians to address a much wider range of in tractable end-of-life suffering than physician-assisted suicide (even if it were legal) and can also provide alternatives for patients, families, and clinicians who are morally opposed to physician-assisted suicide. This pape r will define the two practices, distinguish them from more standard pallia tive care interventions and from physician-assisted suicide, illustrate the m with a real clinical scenario, provide potential guidelines and practical ities, and explore their moral and legal status. Although medicine cannot s anitize dying or provide perfect answers for all challenging end-of-life cl inical problems, terminal sedation and voluntary refusal of hydration and n utrition substantially increase patients' choices at this inherently challe nging time.