Terminal sedation vs voluntary assisted dying

Peter Beahan / 14 August 2020

Terminal sedation and voluntary assisted dying (VAD) are different approaches to the management of the approximately 5% of dying patients who experience overwhelming suffering. Terminal sedation is also known as palliative sedation.

Opponents of VAD often say that such dying patients can be provided with terminal sedation. However, we believe that terminal sedation can be an inferior option to VAD for patients who are able to choose between them. The differences are summarised in the table below.

Terminal SedationVoluntary Assisted Dying
Dying can be prolonged and uncertainDying is quick and certain
The decision is most often made by the doctorThe decision is made by the patient
Death is often experienced by loved ones as undignified and harrowingDeath is experienced with reverence, thankfulness, and a sense of release
The time of death is indeterminate; patients sometimes die alone, to the distress of familyThe time of death is chosen by the patient
Deep sedation may remove both consciousness and all semblance of personhoodConsciousness is preserved. Death is induced by fast acting and effective medication
Documentation may be cryptic, and clouded in secrecyDocumentation is regulated, transparent and subject to official scrutiny
Doctor accountability for process and outcome is not clearly definedDoctor accountability is fully and clearly defined
Legal protections for the doctor (criminal homicide), and the patient (abuse) are minimalThe doctor and the patient are well protected by the law
Access depends on the doctor’s attitude, including religious beliefsAccess is legally available, provided the patient is eligible
Neither capacity to consent, nor consent itself, is necessary, even from the familyBoth capacity, and consent from the patient are required
No beneficial effect on
Beneficial effect on bereavement compared with death from natural causes (Swarfe et al, 2003)

With terminal sedation, dying can take many days, and the time to death is unpredictable. The patient may linger in a semi-comatose state, dehydrated and deteriorating. This can be distressing to loved ones, who are not able to communicate with the dying person or help in any meaningful way. With VAD, the person has capacity and awareness, plus the ability to communicate and to initiate the process.

With terminal sedation, the decision to administer continuous sedative medication is often that of the doctor. The patient may not be able to indicate consent. With VAD, the dying person makes the decision while dignity and purpose are intact. This is both a rational and a mentally healthy choice, for those who take that option.

With terminal sedation, death can be a trial for all concerned.  It can be remembered with guilt and horror. With VAD, the patient chooses the timing and the arrangements. Death is dignified and peaceful. It is often described as a ‘good death’ – a fitting end that complements and rounds off a person’s life experiences and achievements (Reid, 2018).

With terminal sedation, sedative and analgesic medications are relied on to control the dying process and associated suffering. Even so, fluctuating levels of response mean that complete control of suffering cannot be guaranteed. With VAD, the dying process is brought to a conclusion by the administration of medication that is the same as, or similar to, that used for general anaesthesia. This can be self-administered by mouth, or given intravenously. The latter can be given by the doctor or arranged for self-activated administration by the patient. Communication channels remain open up to the last minutes of life. The most important loved ones are usually present or close by.

With terminal sedation, documentation may be incomplete and statistical information impossible to collect. There is no regulatory framework. With VAD, documentation is clear, frank and open to scrutiny.

Finally, there are some characteristics that terminal sedation and VAD have in common. In both, the primary aim of the doctor is the relief of suffering. In both, the patient is in the process of dying, and will inevitably die. In each case, the intent is the same, and the outcome (death) is the same (Lipuma, 2013).

VAD will not be acceptable to some dying people, nor will it be available to some others. Terminal sedation will continue to be a valuable intervention for such people if they experience refractory suffering. It can be well accepted, where there is accountability, and good communication and care directed toward family members (Bruinsma, 2015).

Dr Beahan is a retired anaesthetist from Perth. He is a member of Doctors for Assisted Dying Choice.
Dr Lugg is an Environmental Health Consultant from Perth. He is convenor of Doctors for Assisted Dying Choice (WA).

All the more reason.