Establishing a Health System Policy for Proportionate Palliative Sedation

Proportionate palliative sedation (PPS) is an important therapeutic option for patients at the end of life who experience intractable suffering despite use of all conventional interventions. Clinical guidelines for PPS differ between institutions, often tailored to local practice patterns and the regulatory environment. While professional organizations encourage institutions to develop tailored PPS guidelines, the literature lacks robust discussion of the development process. In this article, we present two cases from Yale New Haven Hospital, and explore the associated practical and ethical challenges, in the absence of clear institutional guidelines. We then describe the policy development process that followed these cases and discuss how defined PPS guidelines not only ensure patient comfort and autonomy but also mitigate decisional fatigue and moral distress among clinicians. As further guidance, we offer an ethical analysis and our own institution's PPS policy, available upon request. We encourage other institutions that are similarly committed to patient-centered care and the moral support of clinicians and caregivers to develop PPS guidelines.