Managing Cases of Terminal Sedation: “Doctor, I’m Troubled by this Prescription”

Situations such as the one that pharmacist Ed Patch has encountered are now a reality of professional pharmacy practice, so much so that the phrases “pharmaceutically mediated death” and “pharmaceutically assisted death” have been added to the medical lexicon. These enigmatic phrases embody a range of clinical activities, including terminal sedation, and are important to profession of pharmacy because they highlight the role pharmacists play in these cases. Moreover, these phrases underscore the importance of decisions made by pharmacists as they struggle to meet their obligations in providing quality pharmaceutical care. Indeed, some authors argue that the failure of effective pharmaceutical care is a necessary condition for pharmaceutically mediated death [1]. There is no universally accepted definition of terminal sedation; however, most clinicians describe the effort as: 1) intentionally producing and maintaining deep sleep, but not deliberately causing death, and 2) entering into an agreement with the patient stating that when the patient reaches a point at which his or her condition is intractable or refractory to standard palliative treatment and is in a deep sleep, the patient will no longer receive any further supportive treatment, allowing death to occur. Some clinicians prefer to name this procedure “palliative sedation” or “sedation in the imminently dying [2,3]. This case presents challenges on many fronts. Traditionally, pharmacists have recognized a moral, even legal, duty to fill valid prescriptions; at present, some pharmacists question their right of refusal to fill prescriptions on the grounds of conscience. Ed will first have to settle that issue and in so doing will need to more completely examine the circumstances of the case. Ed will need to ascertain the intention of the physician in proposing terminal sedation; he also will need to be satisfied that the explicit intention of the prescribed sedative is for the relief of suffering and not the hastening of death. Furthermore, Ed will need to confirm that the patient made a voluntary and informed choice for sedation and refusal of food and fluids. Once these facts are confirmed, Ed can decide whether or not he wants to cooperate by preparing the medication. In making his decision, Ed will probably be torn between two widely held principles of moral behavior: the avoidance of killing and autonomy.

Although the principle of avoidance of killing is not specifically addressed in the Code of Ethics for Pharmacists, it seems apparent to Ed that killing is just inherently wrong, even if the patients who die are better off than if they had lived. While Dr. Menninger has assured Ed that the intent of the sedative was not the death of the Mr. Durkheim, Ed realizes what the ultimate outcome will be. At the same time, Ed recognizes and fully supports the respect for patient autonomy statement in the Code of Ethics for Pharmacists and concludes that Mr. Durkheim has the right to decide such an outcome for himself. In order to resolve this matter, Ed will need to carefully examine these principles and decide if one principle has priority over the other, whether the principles need to be balanced against each other, or whether they can be combined for a final resolution to the challenge.

In recent years, Biofield Energy Treatment was reported in several scientific reports and clinical trials for the useful effects in case of cervical cancer patients [14], massage therapy [15], and many more. Complementary and Alternative Medicine (CAM) therapies have been reported that Biofield Therapies (or Healing Modalities) as one of the best preferred models of treatment with several benefits to enhance physical, mental and emotional human wellness. National Centre of Complementary and Integrative Health (NCCIH) has been recognized and accepted Biofield Energy Healing as a CAM along with other therapies such as deep breathing, yoga, Tai Chi, Qi Gong, chiropractic/osteopathic manipulation, meditation, massage, special diets, homeopathy, progressive relaxation, guided imagery, acupressure, acupuncture, relaxation techniques, hypnotherapy, healing touch, movement therapy, pilates, Ayurvedic medicine, traditional Chinese herbs and medicines, naturopathy, essential oils, aromatherapy, Reiki, and cranial sacral therapy. Human Biofield Energy has subtle energy that has the capacity to work in an effective manner [16,17]. Biofield Energy Healing Treatment/Blessing (the Trivedi Effect^®) results has been published in numerous peer-reviewed science journals with significant outcomes in many scientific fields on various models in the metal science [18,19], agriculture science [20], microbiology [21,22], biotechnology [23,24], and improved bioavailability of various compounds [25,26], skin health [27,28], nutraceuticals [29], cancer research [30], bone health [31-33], overall human health and wellness. The present study was designed to study the mechanistic biomarkers such endothelin-1 and nitric oxide in kidney, lungs, and artery using ELISA assay in male Sprague Dawley rats in presence of VDD diet and novel test formulation.

1. Kathleen MD, Karen LK (1998) Longing for mercy, requesting death: pharmaceutical care and pharmaceutically assisted death. American Journal of Health System Pharmacy 55(6): 578-585.
2. Tatsuya M, Satoro T, Yasuo S (2001) Proposed definitions for terminal sedation. Lancet 358(9278): 335-336.
3. Daniel P, Sulmasy, Wayne AU, Judith CA, Mark Siegler, et al. (2000) Publication of papers on assisted suicide and terminal sedation. Ann Intern Med 133(7): 564-566.