[Distress during end-of-life: Ethical questions about sedation]

Distress and suffering are words currently used in the medical vocabulary, the first carrying a more acute and dramatic feature, while suffering is more subjective. They may concern the somatic, psychic, social, and spiritual domains, with interactions such as excrutiating and unrelieved pain causing psychological distress. Distress during the end of life is induced by the threatening of an unavoidable death, more or less foreseen by the patient. It may correspond to an existential distress, with loss of the meaning of life, and of the social role, along with metaphysical anxiety. Patient's next of kin and carers can also be involved by the distress, either by empathic transmission, or due to specific factors. Palliative care and anticipation should allow to prevent or relieve distress and suffering. This imply to ask for palliative care on due time, and to anticipate the foreseeable situations, trying meanwhile to identify the patient's preferences. Pharmacologic sedation is becoming a frequent practice during terminal phase of diseases, raising ethical questioning on its motives and aims. Deep continuous sedation maintained until death may be viewed as a psychic and social euthanasia, ethically questionable, and should be foreseen only in case of intractable distress. A controlled and reversible sedation, when needed, should be preferred, always with the agreement of the patient or his/her proxy. Existential distress by itself should not justify a deep continuous sedation.