What Is Palliative Sedation?

Near the end of life, a very small number of people have symptoms that nothing else controls, such as severe breathlessness, agitation, or pain. For those situations, doctors have a last-resort option called palliative sedation. It is often confused with medical aid in dying, so it’s worth being clear about what it is and isn’t.

What is palliative sedation?

The American Academy of Hospice and Palliative Medicine (AAHPM) defines palliative sedation as “the intentional lowering of awareness towards, and including, unconsciousness” for patients with severe and refractory symptoms. “Refractory” means the symptoms haven’t responded to other treatments. The Hospice and Palliative Nurses Association describes it as monitored use of medication meant to bring varying degrees of unconsciousness, but not death, to relieve refractory, unendurable symptoms in people who are imminently dying.

Other names include “terminal sedation,” “total sedation,” “controlled sedation,” and “proportional sedation,” and the medical literature notes that the variety of terms can cause confusion. The amount of sedation can range from light to deep, and a common approach today, according to one hospice provider’s description, is to use the lightest level that allows the patient to tolerate the symptom.

When is it used?

AAHPM says palliative sedation is reserved for extreme situations. The National Hospice and Palliative Care Organization (NHPCO) supports making it available, delivered by highly trained professionals, for the small number of imminently dying patients whose suffering is intolerable and refractory. An informal NHPCO review found that many institutional policies require a patient to be imminently dying, meaning within hours to days, before it is considered.

It comes after other measures have been tried. Hospice and palliative teams have many ways to control pain, breathlessness, nausea, and anxiety; see comfort care. Sedation is considered only when those aren’t enough.

What is the intent, and does it hasten death?

The defining feature is intent. AAHPM says practitioners should be clear in their intent to relieve symptoms and not to shorten survival, and that in clinical practice palliative sedation usually doesn’t alter the timing or mechanism of a patient’s death, because refractory symptoms most often occur with very advanced illness. NHPCO states that, properly administered to imminently dying patients, it isn’t the proximate cause of death, and death isn’t used as a means to relieve symptoms. Both statements emphasize proportionality: using no more sedation than is needed to relieve the symptoms.

Death may be a foreseeable consequence of a patient’s illness during sedation, but ethicists describe the intent as relieving suffering while the patient remains alive.

How is it different from medical aid in dying and euthanasia?

	Palliative sedation	Medical aid in dying	Euthanasia
Purpose	Relieve symptoms that can’t otherwise be controlled	A patient’s choice to end their life	A person’s life is intentionally ended by someone else
Who decides and acts	Patient or surrogate decides with the care team; clinicians administer sedation	The patient requests, and must take the medication themselves	Someone other than the patient administers the drug
Typical timing	Near the very end of life	Any time the patient qualifies and chooses	Not applicable
Legal status	Accepted clinical practice	Legal in 13 states and D.C. under specific laws	Not authorized by U.S. state laws

See what is medical aid in dying. Federal law also draws this line: the Assisted Suicide Funding Restriction Act bars federal funds for items or services meant to cause death, but CMS says it doesn’t apply to items or services given to relieve pain or discomfort, even if they may increase the risk of death, as long as they aren’t also given to cause death. Professional groups disagree about aid in dying, but they treat palliative sedation as a distinct practice.

What do families see?

Clinical teaching materials describe the main points families should know:

• The patient becomes less aware or unconscious and often won’t talk or respond. AAHPM notes that because people receiving palliative sedation are typically close to death, most no longer want to eat or drink; see changes in eating, drinking, and comfort
• It may be intermittent or continuous. Clinicians should talk with families about how long it is expected to last, whether it will stop once a symptom resolves, or continue until death. It can be given at home in some circumstances
• It isn’t prescribed to hasten death, and families should be told that
• The care team keeps monitoring comfort and adjusting care

Some families worry that sedation “caused” the death or that they gave up too soon. The professional statements say sedation usually doesn’t change the timing of death, but each person’s situation is different, so ask the team directly what to expect. See being with someone at the moment of death.

Where do professionals disagree?

• Existential suffering. NHPCO acknowledges deep disagreement among skilled palliative care specialists about using sedation for suffering that is primarily nonphysical, such as distress about meaning or dying. AAHPM says that if it is used for truly refractory existential suffering, it shouldn’t shorten survival, as with physical symptoms. Some ethicists argue that proportionality and intent are hard to satisfy in that case, and that other forms of support should be tried first
• Who should offer it, and when. Policies and availability vary among hospices and facilities, and NHPCO calls for it to be delivered by highly trained professionals

How do I ask about it?

• “Are there symptoms we can’t control now? What else could we try?”
• “Is palliative sedation an option? What would it look like for us?”
• “Who will make the decision, and what will you monitor?”
• “How long would the sedation last? Would it stop and start, or continue?”
• “How will you keep my loved one comfortable, and what should we expect?”

If you are struggling with hopelessness or thoughts of harming yourself, please call or text 988, or call 911 in an emergency.

Practices and policies vary. This is general information, not medical advice; the palliative care or hospice team can tell you what’s appropriate for your situation.