IN HIS commentary last Saturday, senior writer Andy Ho implied that practitioners of terminal sedation kill their patients stealthily through dehydration, under the guise of deep, continuous sedation of the terminally ill ("Terminal sedation is stealthy euthanasia").
Confusion regarding appropriate levels of fluids required to avoid dehydration is commonplace in end-of-life care, as one tends to extrapolate the requirement for water in health with that in disease.
In patients dying from the underlying medical condition and not from dehydration, over-hydration creates discomfort and complications through symptoms of body swelling and fluid accumulation in lungs and other body cavities, which may even hasten death.
In palliative care, hydration is given or withheld judiciously, taking into consideration fluid losses like diarrhoea or vomiting, the ability to ingest, and heart or kidney function.
Keeping the mouth moist and clean is also a must, irrespective of the hydration status.
The decision to employ palliative sedation is rarely made.
It is considered only when intractable symptoms are highly distressing and cannot be ameliorated to a level acceptable to the patient, despite all that modern medicine can offer, augmented by psychological, emotional and spiritual support.
Even then, the decision must be reviewed by a multi-disciplinary team and discussed extensively with patient and family; a joint decision has to be made that there are no other options in the patient's best interest before proceeding.
Being a matter of life and death, it is not an intervention that can be carried out in stealth, nor on demand ("No stealth in terminal sedation" by Dr Cynthia Goh; yesterday).
Lalit Kumar Radha Krishna (Dr) Senior Consultant
Department of Palliative Medicine National Cancer Centre Singapore
Angeline Seah Soek Tian (Dr)
Chairman
Chapter of Palliative Medicine Physicians
Academy of Medicine Singapore
Ramaswamy Akhileswaran (Dr)
Chairman
Singapore Hospice Council
Confusion regarding appropriate levels of fluids required to avoid dehydration is commonplace in end-of-life care, as one tends to extrapolate the requirement for water in health with that in disease.
In patients dying from the underlying medical condition and not from dehydration, over-hydration creates discomfort and complications through symptoms of body swelling and fluid accumulation in lungs and other body cavities, which may even hasten death.
In palliative care, hydration is given or withheld judiciously, taking into consideration fluid losses like diarrhoea or vomiting, the ability to ingest, and heart or kidney function.
Keeping the mouth moist and clean is also a must, irrespective of the hydration status.
The decision to employ palliative sedation is rarely made.
It is considered only when intractable symptoms are highly distressing and cannot be ameliorated to a level acceptable to the patient, despite all that modern medicine can offer, augmented by psychological, emotional and spiritual support.
Even then, the decision must be reviewed by a multi-disciplinary team and discussed extensively with patient and family; a joint decision has to be made that there are no other options in the patient's best interest before proceeding.
Being a matter of life and death, it is not an intervention that can be carried out in stealth, nor on demand ("No stealth in terminal sedation" by Dr Cynthia Goh; yesterday).
Lalit Kumar Radha Krishna (Dr) Senior Consultant
Department of Palliative Medicine National Cancer Centre Singapore
Angeline Seah Soek Tian (Dr)
Chairman
Chapter of Palliative Medicine Physicians
Academy of Medicine Singapore
Ramaswamy Akhileswaran (Dr)
Chairman
Singapore Hospice Council
