Palliative Sedation, Compassionate Extubation, and the Principle of Double Effect: An Ethical Analysis

Palliative sedation is a well-recognized and commonly used medical practice at the end of life for patients who are experiencing refractory symptoms that cannot be controlled by other means of medical management. Given concerns about potentially hastening death by suppressing patients' respiratory drive, traditionally this medical practice has been considered ethically justifiable via application of the ethical doctrine known as the Principle of Double Effect. And even though most recent evidence suggests that palliative sedation is a safe and effective practice that does not hasten death when the sedative medications are properly titrated, the Principle of Double Effect is still commonly utilized to justify the practice of palliative sedation and any risk-however small-it may entail of hastening the death of patients. One less common clinical scenario where the Principle of Double Effect may still be appropriate ethical justification for palliative sedation is when the practice of palliative sedation is pursued concurrently with the active withdrawal of life-sustaining treatment-particularly the practice of compassionate extubation. This case study then describes an unconventional case of palliative sedation with concurrent compassionate extubation where Principle of Double Effect reasoning was effectively employed to ethically justify continuing to palliatively sedate a patient during compassionate extubation.