Guidelines of the Norwegian Medical Association on Palliative Sedation
1. By palliative sedation for the dying is meant pharmacological depression of the level of consciousness in order to alleviate suffering that cannot be relieved in any other way.
2. Palliative sedation should be an extraordinary measure initiated as a response to intolerable suffering that stems from, and is dominated by, physical symptoms. Mental suffering alone is not an indication for palliative sedation.
3. Palliative sedation for the dying may only be given to patients with a life expectancy of a few days.
4. The causes of the patient´s suffering must have been appropriately diagnosed. All other treatments of individual symptoms must have been tried, or at least have been carefully considered and found to be futile. If the ward lacks resources to help the patient, the patient should be referred for specialist palliative care, or the ward should seek the assistance of such expertise. Palliative sedation should not be opted for because it is apparent that lack of resources prevents optimal alternative treatment and care. In such a case, the doctor in charge should notify his or her superiors or the Health Authorities.
5. The ward chief physician is formally responsible for initiating and carrying out palliative sedation of the dying. The decision must be based on an overall medical assessment of the patient´s situation, and be made after consultation with the nursing staff and with other doctors familiar with the patient, or others who are qualified to contribute.
6. If the patient is capable of doing so, he or she must give express consent to the treatment. The patient should be informed of his or her state of health and prognosis, what palliative sedation would involve (including information about the level and duration of the sedation), the risks associated with sedation as well as alternatives to sedation. If the patient is not competent to give consent, palliative sedation may still be given if, all things considered, it is assumed to be in the patient´s best interests
7. The patient´s next-of-kin should also be informed and involved in the decision-making process, provided the patient is not opposed to this. The next-of-kin have the right to be informed, but cannot be assigned the ultimate responsibility for initialization of the treatment.
8. Patients should only be sedated sufficiently deeply to alleviate suffering.
9. Although sedation of some patients is most likely to be continued until death occurs, raising the level of the patient´s consciousness must be considered and attempted. If it becomes clear during the wakening process that the patient´s situation is still intolerable, it is justifiable to increase sedation without the patient regaining consciousness.
10. The patient should be adequately monitored with respect to level of consciousness, maintenance of an unrestricted respiratory passage and the efficacy of the treatment. Possible side effects of the treatment must also be monitored, so that these can be dealt with.
11. Patients who have stopped drinking on their own need not be given fluids intravenously. If the patient is still capable of drinking significant amounts, and the sedation renders him or her incapable of this, intravenous fluids should be administered. If the administration of intravenous fluids was started before palliative sedation, it should be continued.
12. The treatment must be documented in the medical records. The following must be emphasized: the grounds for concluding that sedation was necessary; how the decision to sedate was reached; information to the patient and next-of-kin and their views regarding the treatment; how the treatment was carried out and monitored.
Originally printed in Førde R, Materstvedt LJ, Syse A. (2008) "Scandinavia". Chap. 14 in: Griffiths J, Weyers H, Adams M, Euthanasia and Law in Europe. Oxford: Hart Publishing.