Palliative Care and Ethical Considerations

Palliative Care is the ethical commitment of a society that is sensitive to the suffering of its citizens.

When medicine has failed to prevent or cure a disease, the physician must commit to caring for and supporting the person suffering from the disease in order to alleviate their suffering. It is then that we must adopt an ethical perspective on care, guided by the five ethical imperatives of palliative care:

1.- Respect the patient’s wishes and values. Listening is the best tool for understanding their final wishes and values, thereby honoring their preferences regarding their care. We can maintain an ongoing dialogue with the patient or rely on an advance directive for situations where they are unable to express their wishes personally.

2.– Do not abandon the patient or their family. Although we may not always realize it, we can abandon the patient in various ways: through insufficient medication dosages (what we call “therapeutic abandonment”), due to a lack of training in palliative care and not knowing what to offer to alleviate their suffering, or by failing to dedicate the time they need to share their concerns with us.

However, the most irresponsible and empathy-devoid way to abandon the patient and their family is with the phrase “there is nothing more to be done.” It would be different if we said, “We cannot cure the illness, but there is still much we can do to continue caring for the patient.”

3.- Relieve and treat symptoms that cause suffering. Preventing the suffering caused by symptoms is the fundamental goal of palliative care. If we focus on pain—the most prominent symptom in the advanced stage of an illness—we must bear in mind that controlling it is not a matter of choice for the physician; it is a legal and ethical obligation.

Patients have the right to have their pain relieved, and we have a duty to relieve it. The patient himself will be the one to tell us how effective the pain relief is when he says, “Doctor, I’m no longer in pain.”

4.- Tailor diagnostic and therapeutic efforts. In the case of a terminal illness, diagnostic tests and treatments that would be futile in that situation—and would undoubtedly prolong an unnecessary dying process—must be avoided.

A treatment that is indicated and mandatory in curative medicine—such as cardiopulmonary resuscitation—may be contraindicated in palliative care.

5.- Administer sedation in cases of refractory symptoms. There are patients who, despite all the treatments used, continue to experience one or more symptoms that are refractory to treatment and cause them unbearable suffering. This compels the physician to lower the patient’s level of consciousness to ensure a peaceful death.

When a doctor sedates a terminally ill patient who is suffering—acting in accordance with clinical and ethical criteria— he is not causing the patient’s death; he is preventing suffering while the patient dies.

Palliative sedation neither shortens life nor delays death; it merely reduces the patient’s level of consciousness to relieve suffering until death occurs naturally, while the progression of the illness continues its course. Sedation is simply another therapeutic measure—and is therefore ethically neutral.

What makes it ethically acceptable or reprehensible is the purpose it serves and the circumstances in which it is applied; the aim we seek to achieve through sedation is the standard by which the act is judged to be ethical.

To conclude this article, I would like to remember that palliative care does not aim to hasten death, nor to prolong unnecessary agony, but rather to accompany the patient to alleviate their suffering until death arrives.

And that this kind of care provides the best setting for experiencing the end of life, because palliative care helps people live, improves their quality of life during the dying process, and, furthermore, strengthens bonds of affection with loved ones and helps give meaning to life.