Norlander (2008), suggests resolving ethical dilemmas using four bioethical principles framework that include; beneficence which is providing the best intervention given the situation, nonmaleficence which is vowing to do no harm, autonomy which is to respect the patient’s right to self-determination and incase of incapacitation it would mean respecting the patient’s wishes and finally justice which means being fair given the situation at hand. To resolve the moral component on palliative sedation for me the first question to ask is does the patient require it? I must keep in mind that I am an advocate for the patient and not a decision maker for the patient. If the patient is alert, I would talk to the patient about available options and where I have no answer, I would refer the issue to a doctor, social worker, clergy etc. In my personal experience with hospice patients since most are in severe pain palliative sedation works the best and other complimentary therapies are only good if the patient had prior exposure to such therapies. Most times palliative sedation works faster in relieving symptoms than any other therapy but has unintended consequence of the principle of double effect, in this case applying the ethical framework should help resolve any ambiguity in providing palliative sedation. Allmark, Cobb, Liddle and Tod (2010) add that “a diagnosis of dying allows clinicians to focus on good dying and not to worry about whether their intervention affects the time of death”.


Allmark, P., Cobb, M., Liddle, B. J., & Tod, A. M. (2010). Is the doctrine of double effect irrelevant in end-of-life decision making? Nursing Philosophy: An International Journal for Healthcare Professionals, 11(3), 170-177. doi:10.1111/j.1466-769X.2009.00430.x

Norlander, L. (2008). To comfort always: A Nurse’s Guide to End-of-Life Care.

Indianapolis, Indiana: Sigma Theta Tau International.

#2: I do not have ethical concerns with palliative sedation. My belief is, even if limitations exist, people should have the option to enjoy life. However, people have different views on this topic. As a nurse, you might find yourself in a situation where advocating for the patient conflicts with the advice of another healthcare professional (Norlander, 2014). Some healthcare professionals might be morally disturbed by the notion of assistive suicide. When killing the patient or hastening the patient’s death is the intention or co-intention, what is done is not palliative sedation but slow euthanasia (Broeckaert, 2011). Norlander’s four principles on healthcare ethics framework are essential when evaluating the practice of palliative sedation.

The notion of quality of life, in my opinion, goes hand in hand with beneficence. In end-of-life care this means looking at the benefits and burdens of a particular action or treatment (Norlander, 2014). My initial question is always, what does the patient want? If that information is not available, the next question is, how will the patient benefit from this? While taking those factors into consideration, the next principle of nonmaleficence comes into play. Is the treatment going to prolong the patient’s dying without increasing quality or comfort? (Norlander, 2014). Will the patient be able to enjoy their final days with their family? Will they experience some type of joy? The point of palliative sedation is not to reach a certain level of consciousness (e.g., coma); its point is finding a solution for a refractory symptom and therefore lowering the level of consciousness only as much as needed (Broeckaert, 2011).

Norlander’s third principle, autonomy, is one that I find has the biggest issue. Autonomy, in end-of-life care, the right to choose also means the right to refuse treatment (Norlander, 2014). Some people may not understand this concept when it comes to making end of life decisions. I personally, would not want to live on a vent or consider treatment for a terminal illness. Not only do I believe there would be no quality of life, I would not want my family to suffer. Often the most important role you can play involves guiding patients and families to make decisions that are consistent with their values and beliefs (Norlander, 2014). My belief is if we respect and carry out a person’s decision in end of life care, we will achieve justice, which “encompasses fair and equitable treatments” (Norlander, 2014). In the case of palliative sedation, ter- minally ill patients die as result of their illness; nobody is killing or is being killed, not at the level of intention, nor at the level of the action itself, nor at the level of its results (Broeckaert, 2011).


Broeckaert, B. (2011). Palliative sedation, Physician-Assisted Suicide, and Euthanasia: “Same, same but different”?. The American Journal of Bioethics, 11(6), 62-64.

Norlander, L. (2014). To comfort always: A nurse’s guide to end-of-life care (2nd ed.). Indianapolis: Sigma Theta Tau International.


Palliative sedation refers to the deliberate administration of sedative medications that cause unconsciousness while reducing distress from unendurable and refractory symptoms (Broeckaert, 2011; HPNA, 2016). Refractory symptoms refer to symptoms that have been thoroughly assessed and determined that there is no other possible treatment except palliative sedation (HPNA, 2016). The aim of palliative sedation is not to accelerate death, but to reduce suffering in terminally ill patients (HPNA, 2016; Maltoni et al., 2009). As such, I do not have any ethical concern with this practice as long as it is conducted within the scope of normal medical practice that involves informed consent from patients and collaboration among palliative care specialists, patients, and patients’ families.

Some nurses and other healthcare professionals might be morally disturbed by palliative sedation because they tend to link it with existential and psychological distress. Specifically, as illustrated by Maltoni et al. (2009), some healthcare professionals link palliative sedation with hopelessness and even reduced quality of palliative care. They also tend to believe that this practice is open to abuse and some healthcare professionals ostensibly administer sedative drugs to reduce symptoms, but to secretly hasten the death of patients. Some also link palliative sedation to lower survival rate, and sometimes even call it terminal sedation or ‘slow euthanasia’ (Maltoni et al., 2009).

However, the healthcare professions who are ethically disturbed by palliative sedation need to know that this practice does not hasten death when utilized to reduce refractory symptoms (Broeckaert, 2011; Maltoni et al., 2009). Terminally sick patients are dying because of their conditions; nobody is being killed or is killing, not at the point of the action itself, results, or intention (Broeckaert, 2011). Actually, when the four principles of healthcare ethics – justice, autonomy, nonmaleficence, and beneficence – described by Norlander (2014) are considered, palliative sedation conducted within the scope of normal medical practice is a morally acceptable practice that reduce the suffering of patients with intractable symptoms and pain (HPNA, 2016). Whereas justice includes equitable and fair treatment, autonomy is based on the right of an individual to independently make a choice (Norlander, 2014). Also, nonmaleficence is the duty to “do no harm,” while beneficence is the duty to act in a way that benefits another person (Norlander, 2014). Palliative sedation conducted within the scope of standard medical intervention is fair, independently chosen by patients, their families, or significant others, and does not harm patients, but benefits them in relieving their refractory symptoms.


Broeckaert, B. (2011). Palliative sedation, physician-assisted suicide, and euthanasia: “Same, same but different”?. The American Journal of Bioethics, 11(6), 62-64. doi: 10.1080/15265161.2011.577518

HPNA (Hospice and Palliative Nurses Association). (2016). HPNA position statement: Palliative sedation.

Maltoni, M., Pittureri, C., Scarpi, E., Piccinini, L., Martini, F., & Turci, P. et al. (2009). Palliative sedation therapy does not hasten death: Results from a prospective multicenter study. Annals of Oncology, 20(7), 1163-1169. doi: 10.1093/annonc/mdp048

Norlander, L. (2014). To comfort always: A nurse’s guide to end-of-life care (2nd ed.). Indianapolis: Sigma Theta Tau International.