The doctrine of double effect—that a harmful effect of treatment is permissible if it occurs unintentionally as a side effect of a beneficial action—is “almost completely irrelevant” in the case of sedatives given in palliative end-of-life care, according to a case study from St. Christopher’s Hospice in London.
After reviewing information about 237 patients who died in the 62-bed hospice, the researchers concluded that most episodes of sedative use were brief, with no evidence that they had precipitated death. Instead, the episodes were a response to features of a dying process that had already begun. The sedatives were intended not to produce unconsciousness but to relieve symptoms such as agitation and restlessness that were associated with the final stages of terminal illness.
Many of the patients (52%) received no significant sedation at any stage during the last week of their lives. Indeed, more than half of the patients (56%) who took the drugs had received them only in the last 48 hours of their lives, and most of those patients had taken them only in the last 24 hours.
The patients who received no sedation and those who received sedation for less than 48 hours had the shortest survival from admission (14 days). The patients who received sedatives for the last week of their lives survived for an average of 37 days. However, the reason might be because they may have been admitted for delirium, rather than terminal restlessness, and were thus more fit physically.
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Only two cases might have justified the doctrine of double effect, the researchers say. One patient was a man with an astrocytoma whose condition was deteriorating before an acute onset of violent agitation and paranoia. His physician considered that sedation might have shortened his life because of an already poor prognosis. The second patient, a 70-year-old woman with lung cancer and a history of schizophrenia, was admitted for a generally deteriorating condition. She was given a series of sedating drugs for delusions and continuing agitation.
The researchers suggest that sedation might have allowed pneumonia to develop in the presence of lung disease. A characteristic of the clinical picture in both of these types of cases is death, usually within 24 to 72 hours.