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Terminal Sedation: Palliative Care for Intractable Pain, Post Glucksberg and Quill

Published online by Cambridge University Press:  06 January 2021

Rob McStay
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Extract

In 1997, the U.S. Supreme Court tacitly endorsed terminal sedation as an alternative to physician-assisted suicide, thus intensifying a debate in the legal and medical communities as to the propriety of terminal sedation and setting the stage for a new battleground in the “right to die” controversy. Terminal sedation is the induction of an unconscious state to relieve otherwise intractable distress, and is frequently accompanied by the withdrawal of any life-sustaining intervention, such as hydration and nutrition. This practice is a clinical option of “last resort” when less aggressive palliative care measures have failed. Terminal sedation has also been described as “the compromise in the furor over physician-assisted suicide.”

Medical literature suggests that terminal sedation was a palliative care option long before the Supreme Court considered the constitutional implications of physician-assisted suicide. Terminal sedation has been used for three related but distinct purposes: (1) to relieve physical pain; (2) to produce an unconscious state before the withdrawal of artificial life support; and (3) to relieve non-physical suffering.

Type
Research Article
Information
American Journal of Law & Medicine , Volume 29 , Issue 1 , March 2003 , pp. 45 - 76
Copyright
Copyright © American Society of Law, Medicine and Ethics and Boston University 2003

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Footnotes

†

Senior Business Practices Analyst, The Methodist Hospital, Houston, Texas. B.A., University of Texas, 1991; J.D., Texas Tech University, 1995; LL.M., University of Houston, 2002.

References

1 See Washington v. Glucksberg, 521 U.S. 702 (1997); Vacco v. Quill, 521 U.S. 793 (1997); see also infra Part II.

2 See Cantor, Norman L. & Thomas, George C., III, The Legal Bounds of Physician Conduct Hastening Death, 48 BUFF. L. REV. 83 (2000)Google Scholar; Hallenbeck, James, Terminal Sedation for Intractable Distress, 171 W. J. MED. 222 (1999)Google Scholar; Quill, Timothy et al., Palliative Options of Last Resort: A Comparison of Voluntarily Stopping Eating and Drinking, Physician-Assisted Suicide, and Voluntary Active Euthanasia, 278 JAMA 2099 (1997)Google Scholar [hereinafter Palliative Options]; Rousseau, Paul, Terminal Sedation in the Care of Dying Patients, 156 ARCHIVES INTERNAL MED. 1785 (1996)Google Scholar; Truog, Robert D. et al., Barbiturates in the Care of the Terminally Ill, 327 NEW ENG. J. MED. 1678 (1992)Google Scholar. Although the term “terminal sedation” has been used to describe sedation of non-terminal patients who are expected to fully recover, for the purposes of this paper, terminal sedation refers to patients who are on a “terminal” trajectory. See Quill, Timothy & Byock, Ira, Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids, 132 ANNALS INTERNAL MED. 408 (2000)Google Scholar.

3 Palliative Options, supra note 2; see also Cherny, Nathan I. & Portenoy, Russell K., Sedation in the Management of Refractory Symptoms: Guidelines for Evaluation and Treatment, 10 J. PALLIATIVE CARE 31 (1994)Google Scholar.

4 Trafford, Abigail, Second Opinion; At Last, an Alternative to Painful Death, WASH. POST, Oct. 10, 2000, at Z08Google Scholar.

5 See generally Truog et al., supra note 2.

6 Id.

7 Stone, Patrick et al., A Comparison of the Use of Sedatives in Hospital Support Team and in a Hospice, 11 PALLIATIVE MED. 140 (1997)Google Scholar (citing a group that consisted of 115 hospital and hospice patients in the United Kingdom). For the hospice patients, the prevalence of sedation was thirty-one percent and the hospital patients were sedated at a rate of twenty-one percent, with the overall average being twenty-six percent. Id.

8 Vitorio Ventrafida, Symptom Prevalence and Control During Cancer Patients Last Days of Life, 6 J. PALLIATIVE CARE 7 (citing a study group consisting of 120 advanced-stage cancer patients).

9 Morita, Tatsuya et al., Sedation for Symptom Control in Japan: The Importance of Intermittent Use and Communication with Family Members, 12 J. PAIN SYMPTOM MGMT. 32 (1996)Google Scholar (citing a study group that consisted of 143 palliative care patients in a Japanese hospice).

10 Stone et al., supra note 7, at 140.

11 Fainsinger, Robin L. et al., Sedation for Uncontrolled Symptoms in a South African Hospice, 16 J. PAIN SYMPTOM MGMT. 145 (1998)Google Scholar (citing a study group that consisted of seventy-three palliative care patients in a South African hospice).

12 Id. The studies referred to in this article were not performed in the United States. Consequently, cultural differences call into question the applicability of the numbers to palliative care patients in the United States.

13 See discussion infra Parts II.A-B.

14 Cruzan v. Dir., Mo. Dep't of Health, 497 U.S. 261, 269 (1990).

15 Id. at 270.

16 In re Quinlan, 355 A.2d 647, 663-64 (N.J. 1976), cert. denied sub. nom. Garger v. New Jersey, 429 U.S. 922 (1976).

17 See, e.g., Rasmussen v. Fleming, 741 P.2d 674, 691 (Ariz. 1987); Bouvia v. Superior Court, 225 Cal. Rptr. 297 (Cal. Ct. App. 1986); In re Stevens, 425 A.2d 156, 158 (Del. 1980); In re Guardianship of Browning, 568 So.2d 4, 9 (Fla. 1990); In re Estate of Longway, 549 N.E.2d 292, 296 (Ill. 1990); In re Gardner, 534 A.2d 947, 951 (Me. 1987); Mack v. Mack, 618 A.2d 744, 755 (Md. 1992); Superintendent of Belchertown v. Saikwicz, 370 N.E.2d 417, 424 (Mass. 1977); In re Rosebush, 491 N.W.2d 633, 635 (Mich. Ct. App. 1992); Cruzan v. Harmon, 760 S.W.2d 408, 425 (Mo. 1988), aff’d sub nom. Cruzan v. Dir., Mo. Dep't of Health, 497 U.S. 261 (1990); In re Storar, 420 N.E.2d 64, 70 (N.Y 1981), cert. denied, 454 U.S. 858; San Juan-Torregosa v. Garcia, 80 S.W.3d 539, 541 (Tenn. Ct. App. 2002); Norwood Hospital v. Munoz, 564 N.E.2d 1017 (Mass. 1991); In re Colyer, 660 P.2d 738, 742 (Wa. 1983).

18 See, e.g., In re Storar, 420 N.E.2d at 70 (declining to extend a federal constitutional right to privacy to the refusal of medical treatment but recognizing a common law interest in doing so); In re Gardner, 534 A.2d at 951 (declaring that the “personal right to refuse life-sustaining treatment is now firmly anchored in the common law doctrine of informed consent”).

19 See, e.g., San Juan-Torregosa, 80 S.W.3d at 541; Mack, 618 A.2d at 755-56 (describing state holdings).

20 See, e.g., Bouvia, 225 Cal. Rptr. at 302.

21 See, e.g., In re Conroy, 486 A.2d 1209 (N.J. 1985); Mack, 618 A.2d at 755 n.7.

22 See Brophy v. New England Sinai Hosp., Inc., 497 N.E.2d 626, 634 (Mass. 1986); Mack, 618 A.2d at 755, n.7.

23 Cruzan v. Director, Mo. Dep't of Health, 497 U.S. 261, 283-84 (1990).

24 Washington v. Glucksberg, 521 U.S. 702, 735 (1997).

25 Vacco v. Quill, 521 U.S. 793, 807-09 (1997).

26 497 U.S. 261 (1990).

27 Id. at 266.

28 Id. at 267.

29 Id. at 268.

30 Id.

31 Id.

32 Id.

33 Id.

34 Id. at 269 (quoting Cruzan v. Harmon, 760 S.W.2d 408, 425 (Miss. 1988)).

35 Id.

36 Id. at 286-87.

37 Id. at 270.

38 Id. at 278. These prior decisions included Jacobson v. Massachusetts, 197 U.S. 11 (1905) (balancing an individual's liberty interest in declining an unwanted smallpox vaccine against the State's interest in preventing the disease); Washington v. Harper, 494 U.S. 210 (1990) (recognizing “a significant liberty interest in avoiding the unwanted administration of antipsychotic drugs under the Due Process Clause of the Fourteenth Amendment”); Vitek v. Jones, 445 U.S. 480 (1980) (noting that transferring a patient to a mental hospital coupled with mandatory behavior modification treatment implicates liberty interests); Parham v. J.R., 442 U.S. 584 (1979) (recognizing a substantial liberty interest in not being confined unnecessarily for medical treatment).

39 Cruzan, 497 U.S. at 279.

40 Id.

41 Id. at 281-82.

42 521 U.S. 702 (1997).

43 521 U.S. 793 (1997). Vacco and Glucksberg were argued and decided on the same day.

44 Glucksberg, 521 U.S. at 707-08.

45 Quill, 521 U.S. at 796-97.

46 Glucksberg, 521 U.S. at 708.

47 Compassion in Dying v. Washington, 850 F. Supp. 1454, 1459-62 (W.D. Wa. 1994).

48 Id. at 1466.

49 Compassion in Dying v. Washington, 49 F.3d 586, 591 (9th Cir. 1995); see also Glucksberg, 521 U.S. at 708-09.

50 Compassion in Dying v. Washington, 79 F.3d 790, 798 (9th Cir. 1996).

51 Id.; see also Glucksberg, 521 U.S. at 709.

52 Glucksberg, 521 U.S. at 706.

53 Id. at 706-16.

54 Id. at 711.

55 Id. at 720-23 (citing Cruzan, 497 U.S. at 278-79).

56 Glucksberg, 521 U.S. at 720-23 (internal citation and quotation marks omitted).

57 Id. at 725.

58 Id. at 728. The Court's reasoning is somewhat vague about why an analysis of the state's interests was constitutionally necessary when no constitutional right was found. A reasonable inference from the opinion is that, while the Court declined to find a “fundamental” liberty interest, its holding from Cruzan at least raised the possibility that some liberty interest was at least implicated.

59 Id. at 728-33.

60 Id. at 733.

61 521 U.S. 793 (1997).

62 Id. at 797.

63 Id. at 797-98.

64 Quill v. Koppell, 870 F. Supp. 78, 84-85 (S.D.N.Y. 1994).

65 Quill v. Koppell, 80 F.3d 716, 731.

66 Id. at 729.

67 Quill, 521 U.S. at 809.

68 Id. at 800-01.

69 Id. at 801.

70 Id.

71 Id. at 801-02.

72 Id.

73 Id. at 802-03.

74 Id. at 808.

75 Id. at 807 n.11.

76 Id.

77 Glucksberg, 521 U.S. at 736.

78 Id.

79 Id. at 736-37.

80 Id. at 790-91.

81 Id.

82 Id. at 791.

83 Id. at 791-92.

84 Id. at 792.

85 See infra Part III.

86 See Palliative Options, supra note 2; see also Quill, 521 U.S. at 801-02 & n.11.

87 Quill, Timothy et al., The Rule of Double Effect—A Critique of Its Role in End-of-Life Decision Making, 337 NEW ENG. J. MED. 1768 (1997)Google Scholar [hereinafter Double Effect]; Nuccetelli, Susana & Seay, Gary, Relieving Pain and Foreseeing Death: A Paradox about Accountability and Blame, 28 J.L. MED. & ETHICS 19, 20 (2000)Google Scholar.

88 See Brody, Howard, Commentary on Billings and Block's “Slow Euthanasia”, 12 J. PALLIATIVE CARE 38 (1996)Google Scholar; Portenoy, Russell K., Morphine Infusions at the End of Life: The Pitfalls in Reasoning from Anecdote, 12 J. PALLIATIVE CARE 44 (1996)Google Scholar.

89 See, e.g., Double Effect, supra note 87; Andrew Billings, J. & Block, Susan D., Slow Euthanasia, 12 J. PALLIATIVE CARE 21 (1996)Google Scholar.

90 Double Effect, supra note 87, at 1770.

91 Id.

92 Id.

93 Id.

94 Id.

95 See infra Part IV.A.

96 See Glucksberg, 521 U.S. at 710-20; see also infra notes 272-277 and accompanying text.

97 Id. at 718.

98 See Cherny & Portenoy, supra note 3, at 31 (contending that “[s]ome patients … experience symptoms or an overall level of suffering that may be termed ‘refractory’”); Smith, George P., II, Terminal Sedation as Palliative Care: Revalidating the Right to a Good Death, 7 CAMBRIDGE Q. HEALTHCARE ETHICS 382, 382 (1998)Google Scholar (reporting that fifty percent of patients with terminal cancer have physical suffering during the last days of their life that can be controlled only by sedation).

99 The U.S. Constitution demands that juries perform this task by giving criminal defendants the right to have a jury determine guilt. U.S. CONST. amend. VI.

100 See, e.g., State v. Naramore, 965 P.2d 211, 213 (Kan. Ct. App. 1998); see also, Alpers, Ann, Criminal Act or Palliative Care? Prosecutions Involving the Care of the Dying, 26 J.L. MED. & ETHICS 308, 319 (1998)Google Scholar (commenting that a pattern in criminal cases involving caregivers indicates that prosecutors and the public are influenced by a physician's motive).

101 See infra Part IV.A.

102 For a discussion on the “reasonable person,” see PROSSER AND KEETON ON THE LAW OF TORTS § 32 (W. Page Keeton et al. eds., 5th ed. 1984) [hereinafter KEETON].

103 See Enck, Robert E., Drug-Induced Terminal Sedation for Symptom Control, AM. J. HOSPICE & PALLIATIVE CARE 3 (1991)Google Scholar; Kenny, Nuala P. & Frager, Gerry I., Refractory Symptoms and Terminal Sedation of Children: Ethical Issues and Practical Management, 12 J. PALLIATIVE CARE 40 (1996)Google Scholar; Truog et al., supra note 2; Cherny & Portenoy, supra note 3.

104 Glucksberg, 521 U.S. at 706; Quill, 521 U.S. at 796.

105 See Oregon v. Ashcroft, 192 F.Supp.2d 1077 (Or. 2002); see also infra Part IV.B.

106 521 U.S. 793 (1997).

107 Quill, Timothy, The Ambiguity of Clinical Intentions, 329 NEW ENG. J. MED. 1039, 1040 (1993)Google Scholar.

108 See infra Part IV.

109 Quill, supra note 107, at 1040.

110 See United States v. McClatchey, 217 F.3d 823 (10th Cir. 2000) (distinguishing “hope” and “expectation” from “purpose” with respect to criminal liability).

111 See id. Legal fictions, however, have their benefits. For instance, the “presumption of innocence” is essentially a legal fiction to ensure procedural fairness to an accused and protect persons’ liberty interests against the government. Similarly, the Fourth Amendment exclusion doctrine requires fact finders to ignore evidence of guilt obtained in an unconstitutional manner. See Weeks v. United States, 232 U.S. 383 (1914). Additionally, the civil liability “reasonable person” standard requires that juries consider evidence from the vantage point of an artificially created third party. See KEETON, supra note 102, § 32.

112 Cherny & Portenoy, supra note 3, at 36.

113 See, e.g., Cantor & Thomas, supra note 2, at 149.

114 Id.

115 Cruzan v. Dir., Mo. Dep't of Health, 497 U.S. 261, 286 (1990).

116 See id.; see also Bouvia v. Superior Court, 225 Cal. Rptr. 297, 303-04 (Cal. Ct. App. 1986); In re Requena, 517 A.2d 886, 892, (N.J. Super. Ct. Ch. Div. 1986), aff’d, 517 A.2d 869 (N.J. Super. Ct. App. Div. 1986); Cantor & Thomas, supra note 2.

117 See Cruzan, 497 U.S. at 294-98 (Scalia, J., concurring); Cantor & Thomas, supra note 2, at 98.

118 Cantor & Thomas, supra note 2, at 101.

119 See supra Part II.C.

120 Id. The term “passively” is in quotation marks because the argument has been made that the distinction between active and passive suicide is arbitrary. See Cruzan, 497 U.S. at 296-97 (Scalia, J., concurring).

121 See Orentlicher, David, The Supreme Court and Terminal Sedation: Rejecting Assisted Suicide, Embracing Euthanasia, 24 HASTINGS CONST. L. Q. 947 (1997)Google Scholar.

122 Id. at 948.

123 Id.

124 Id. at 956-60.

125 Id. at 956.

126 Id. at 957.

127 Id.

128 Id.

129 Id. at 958-59.

130 Id.

131 Id.

132 Id.

133 Id. at 959.

134 Id. at 960.

135 Id.

136 Id.

137 Id. at 961.

138 Id. at 962-63.

139 Id. at 963.

140 Id. at 965-66.

141 Id. at 967.

142 Washington v. Glucksberg, 521 U.S. 702, 710 (1997).

143 Id. at 720-21 (internal quotations and citations omitted).

144 This is true except when the term is used to refer to a practice that is actually a form of euthanasia. See Billings & Block, supra note 89.

145 See, e.g., Rosseau, supra note 2; Truog et al., supra note 2.

146 See supra Part II.A-B.

147 Id.

148 Id.

149 Cantor, Norman, Twenty-Five Years After Quinlan: A Review of the Jurisprudence of Death and Dying, 29 J.L. MED. & ETHICS 182, 187 (2001)Google Scholar.

150 Id. However, given that the majority specifically addressed the practice of “induc[ing] a barbiturate coma and then starv[ing] [a patient] to death,” it seems likely that the Court was fully aware of the components of terminal sedation. See Vacco v. Quill, 521 U.S. 792, 808 n.11 (1997).

151 Cantor & Thomas, supra note 2, at 139.

152 Id. at 142-44.

153 Id. at 145.

154 Id. at 147.

155 Id. at 148-49.

156 Id. at 149.

157 Id.

158 Id. at 149-50.

159 Id. at 150.

160 See supra note 17 and Part II.A-B.

161 Smith, supra note 98, at 382.

162 Id.

163 Id. at 382-85.

164 Id. at 383.

165 Palliative Options, supra note 2, at 2101.

166 Id. at 2101-02.

167 Id.

168 Id.

169 Billings & Block, supra note 89, at 21.

170 Id.

171 Id.

172 Id.

173 Id. at 22.

174 Id. The authors do not indicate whether the same physicians who conceded they were engaging in euthanasia also attempted to justify the practice based upon “double effect.”

175 Id. at 22-23.

176 Id. at 26.

177 See, e.g., Brody, Howard, Commentary on Billings and Block's “Slow Euthanasia”, 12 J. PALLIATIVE CARE 38Google Scholar; Hallenbeck, supra note 2; Mount, Balfour, Morphine Drips, Terminal Sedation, and Slow Euthanasia: Definitions and Facts, Not Anecdotes, 12 J. PALLIATIVE CARE 31Google Scholar; Portenoy, Russel K., Morphine Infusions at the End of Life: The Pitfalls in Reasoning from Anecdote, 12 J. PALLIATIVE CARE 45Google Scholar.

178 Hallenbeck, supra note 2, at 23.

179 Id.

180 Id.

181 Some practitioners advocate the use of drugs other than opioids, such as barbituates or benzodiazepines, as more efficacious for achieving deep sedation. See, e.g., Hallenbeck, supra note 2; Truog et al., supra note 2.

182 Hallenbeck, supra note 2, at 24.

183 Id. at 27.

184 Id. at 25.

185 See supra note 177.

186 Mount, supra note 177, at 31.

187 Id. at 35.

188 Id.

189 Id.

190 Portenoy, supra note 177, at 45.

191 Id.

192 Id. at 46.

193 Brody, supra note 177, at 39.

194 Id.

195 Id. at 40.

196 Hallenbeck, supra note 2, at 222.

197 See supra Part II.

198 Barber v. Superior Court, 195 Cal. Rptr. 484, 486 (Cal. Ct. App. 1983).

199 See Roy, David J., Need They Sleep Before They Die?, 6 J. PALLIATIVE CARE 3 (1990)Google Scholar.

200 State v. Naramore, 965 P.2d 211, 213 (Kan. Ct. App. 1998). Naramore was also indicted for the premeditated first degree murder of Chris Willt because he withdrew life-support after providing Willt with a paralytic drug. Only the Leach case implicates issues involved with terminal sedation. Id. at 213-18.

201 Id. at 213.

202 Id.

203 Id.

204 Id.

205 Id. at 215.

206 Id.

207 Id.

208 Id.

209 Id.

210 Id.

211 Id.

212 Id. at 220-21.

213 Id. at 223. Naramore's conviction for the murder of Chis Willt was also reversed. Id.

214 Id. at 223-24.

215 See, e.g., United States v. Wood, 207 F.3d 1222, 1229 (10th Cir. 2000) (finding insufficient evidence to find “malice aforethought” in a murder prosecution against a physician for the death of a patient under his care); Barber v. Superior Court, 195 Cal. Rptr. 484, 486 (Cal. Ct. App. 1983) (noting that the trial court refused to find evidence supporting murder charges against two physicians who withdrew life-support from a comatose patient in accordance with the families’ wishes).

216 See Barber, 195 Cal. Rptr. at 484.

217 MODEL PENAL CODE § 210.1(1) (Proposed Official Draft 1962) [hereinafter MPC].

218 Id. § 210.1(2).

219 Id. § 210.5(1).

220 Id. § 2.02(2)(a)(i).

221 Id. § 2.02(2)(a)(ii).

222 Id. § 2.02(2)(b)(i).

223 Id. § 2.02(2)(b)(ii).

224 Id. § 2.02(2)(c).

225 Id. § 2.02(2)(d).

226 Id. § 210.2. If the homicide is committed under the influence of “extreme mental or emotional disturbance for which there is a reasonable explanation or excuse,” the offense may constitute manslaughter rather than murder. Id. § 210.3.

227 MPC, supra note 217, at § 210.3(1).

228 Id. § 210.4

229 See, e.g., State v. LaMar, 767 N.E.2d 166 (Ohio 2002); Edwards v. Shumate, 468 S.E.2d 23 (Ga. 1996); People v. Cox, 228 P.2d 163 (Co. 1951); Hopkins v. Commonwealth, 202 S.W.2d 634 (Ks. 1947).

230 A practitioner acting intentionally, but for compassionate reasons, may have ethical arguments to support her conduct, but a straightforward application of the MPC murder statute does not allow for this distinction.

231 MPC, supra note 217, at § 210.2.

232 Id. § 210.3

233 Id. §§ 210.4, 2.02.

234 Id. § 2.02 (commentary).

235 Id.

236 See infra Part V.

237 Cantor & Thomas, supra note 2, at 117.

238 See Hoover v. Agency for Health Care Admin., 676 So.2d 1380 (Fl. Dist. Ct. App. 1996); In re DiLeo, 661 So.2d 162 (La. Ct. App. 1995).

239 In re DiLeo, 661 So.2d at 164-65.

240 Id. at 165.

241 Id. at 166.

242 Id.

243 Id.

244 Id.

245 Id.

246 Id.

247 Id. at 167-68.

248 Hoover v. Agency for Health Care Admin., 676 So.2d 1380 (Fl. Dist. Ct. App. 1996).

249 Id.

250 Id. at 1381.

251 Id.

252 Id. at 1382.

253 Id.

254 Id.

255 Id.

256 Id. at 1384-85.

257 Pain Relief Promotion Act, S. 272, 106th Cong. (1999); H.R. 2260, 106th Cong. (1999).

258 H.R. 2260.

259 21 U.S.C.A. §§ 801-971 (West 1999).

260 H.R. 2260.

261 21 U.S.C.A. § 841. The term “dispense” includes the prescription and administration of controlled substances by a practitioner. Id. § 802(10).

262 21 U.S.C.A. § 812; see Cherny & Portenoy, supra note 3, at 35.

263 21 U.S.C.A. § 824.

264 H.R. 2260 § 101.

265 Id.

266 See Diebold, Beth A., The Pain Relief Promotion Act of 1999: Whose Pain Does it Relieve?, 12 LOY. CONSUMER L. REV. 356 (2000)Google Scholar.

267 H.R. 2260.

268 Diebold, supra note 266, at 362. The investigation would be conducted by the DEA, which raises questions as to the ability of the DEA to distinguish between pain management treatment and actions designed to hasten death. Id. at 363.

269 Diebold, supra note 266, at 360-61.

270 66 Fed. Reg. 56,607 (Nov. 9, 2001).

271 Id.; see also Oregon v. Ashcroft, 192 F.Supp.2d 1077 (D. Or. 2002).

272 OR. REV. STAT. § 127.800-897 (2001); see also Ashcroft, 192. F.Supp.2d at 1081.

273 Ashcroft, 192 F.Supp.2d at 1082.

274 Washington v. Glucksberg, 521 U.S. 702, 735 (1997); see also Ashcroft, 192 F.Supp.2d at 1079 (commenting on the Supreme Court's language regarding this national debate, and describing the Glucksberg opinion as “thoughtful”).

275 Ashcroft, 192 F.Supp.2d at 1079.

276 Id. at 1092-93.

277 Id. at 1092.

278 Id.

279 Id. § 821 (1999).

280 Id. §§ 823(f), 824(a)(4).

281 Palliative Options, supra note 2, at 2103.

282 Id.

283 Quill & Byock, supra note 2, at 408. The guidelines apply regardless of whether the sedation is accompanied by the withdrawal or removal of life-sustaining medical intervention.

284 Id. at Table 1.

285 Id.

286 Id.

287 Id.

288 Id.

289 Id.

290 Cherny & Portenoy, supra note 3, at 35.

291 Id.