COMMENTS AND RESPONSES Justifying Different Levels of Palliative Sedation

TO THE EDITOR: We read with great interest the article by Quill and colleagues (1), which presented and discussed 3 categories of palliative sedation: ordinary sedation, proportionate palliative sedation (PPS), and palliative sedation to unconsciousness (PSU). One notion shared by these practices, and by all attempts to justify sedation, is that the degree of sedation should match the symptoms— proportionality. The prominence of proportionality in this and other discussions of palliative sedation suggests a simpler and ethically clearer classification. Instead of “ordinary,” “proportionate,” and “unconscious” sedation, we suggest that all palliative sedation be classified as PPS. This is not a confusion of types of palliative sedation, as Quill and colleagues suggest, but a helpful reconception. Under the notion of proportionality, all types of palliative sedation are given only to the extent demanded by symptoms. Low demands imply minimal sedation, and higher demands imply greater sedation. In this way, prognosis does not change the rationale or the practice of sedation, but it places limits on the degree of acceptable sedation. The closer the patient is to death, the higher the level and duration of acceptable sedation (although low levels of sedation will sometimes still be sufficient). The classification presented by Quill and colleagues is reasonable and helpful, but our amendment improves simplicity and ethical clarity. Considering all palliative sedation as PPS avoids the inevitable difficulties of distinguishing among ordinary, proportionate, and unconscious sedation, particularly when palliative sedation is titrated to the point of near or total unconsciousness. Classifying some sedation as PSU also risks blurring the importance of intention to the practice of palliative sedation (2). Considering all palliative sedation as proportionate underscores the ethical imperative that the intention in using sedation is to palliate and not to hasten death.