ABSTRACTThe Belgian Euthanasia Act of 2002 (The Act), amended in 2014 to include the Minor Act (The Minor Act), has drawn international criticisms for its liberal laws and practices regarding Euthanasia. This paper is a response to allegations that the liberal laws on Euthanasia has encouraged doctors to adopt a paternalistic 2 approach towards their patients by terminating their lives without their explicit consent, i.e. engaging in Involuntary Euthanasia.3, 4, 5Although in theory, only Voluntary Euthanasia (explicit patient request and therefore consent) is permitted in Belgium 6 the allegations implied that in practice, Involuntary Euthanasia (no explicit patient request and therefore consent is given) is practiced, especially in the Intensive Care Units (ICU) in Belgium.This paper attempted to make distinctions between Terminal Sedation and Euthanasia based on current dominant discourse in Bioethics and argued that it is not Involuntary Euthanasia that is practiced in the ICU but Non-Voluntary Euthanasia or Terminal Sedation (explicit patient request and therefore consent is unavailable) is practiced based on the intent of the doctor. In presenting its arguments, this paper focused specifically on the reports it procured from its qualitative research. Finally, in order to understand if doctors in the ICU are Gods or Monsters, the paper attempted to answer four questions namely:1. Are doctors in Belgium Gods, who help end lives?2. Or are they Monsters, who help end lives?3. Or are they pre-hippocratic doctors, historically called Witch-Doctors, who are“for hire” to either “cure or to kill” with no loyalty to the Hippocratic Oath?4. Or are they mutated witch-doctors pressured to practice Euthanasia in a countrywhere the laws are perhaps fatally flawed? / Doctorat en Philosophie / info:eu-repo/semantics/nonPublished

This dissertation will support full ethical endorsement of terminal sedation for those most urgently in crisis and need of beneficence, those who are dying and in the final hours or days and suffering. To clarify the practice I first detail ethical differences between euthanasia, physician assisted suicide and terminal sedation. Moreover, I identify new areas where harms and benefits need to be evaluated as affecting not only patients, but also families and caregivers. I evaluate the current practice to allow the development of ethical guidelines and greater consensus on deciding the hard cases. This work may also serve to assist those looking to enlarge the practice in the future with ETS for those with debilitating diseases or disability, but they are not my primary goal. Below is the standard I propose for moral allowability for the use of terminal sedation. I will refer to it often in the pages that follow simply as my standard . Terminal sedation is the appropriate and intentional use of medications (benzodiazepines and/or narcotics) to produce ongoing, deep unconsciousness upon 1) a terminal patient’s (or surrogates) request due to 2) suffering intractable pain or other distressing clinical symptoms intolerable to the patient when 3) death is expected within hours or days (less than two weeks) due to the terminal illness, injury, or disease. I offer two versions of initial guidelines for development of hospital policy. The first version outlines minimal guidelines that ought to be utilized to allow TS for patients who fit my standard. The minimal guideline is based upon the recommendations of the American Medical Association with some modifications. The guideline is admittedly restrictive in hopes of gaining wider societal support for a currently controversial practice. Secondly, I offer more moderate guidelines for policy that could become a standard in the future. It maintains the restrictive focus of the minimal guidelines and offers additional education and support to others which has yet to be broadly provided. The moderate guidelines would mark an important step forward for allowing more choices in dying and offering additional supports to those involved with dying patients.

Bakgrund: Palliativ sedering avser en avsiktlig sänkning av medvetandegraden hos en patient som befinner sig i livets slutskede och har outhärdliga symtom. Behandlingen ges av ett multiprofessionellt team där sjuksköterskornas uppgift är att iordningställa och administrera ordinerade läkemedel samt utvärdera effekt och upplevelse av behandlingen. Förutom de praktiska kraven som ställs på sjuksköterskorna medför palliativ sedering även krav på förmåga till reflektion och kritiskt såväl som etiskt tänkande. Syfte: Syftet med denna litteraturöversikt var att undersöka sjuksköterskors erfarenheter av palliativ sedering. Metod: En litteraturöversikt genomfördes och tio vetenskapliga artiklar valdes ut till analys efter litteratursökningar i databaserna CINAHL Complete och PubMed. Resultat: Tre teman med underteman identifierades. God palliativ vård inkluderade att ge palliativ sedering för att erbjuda patient, närstående och personal ett fridfullt avslut och för att uppfylla patientens önskningar. Palliativ sedering och eutanasi kunde vara svåra att skilja från varandra och sjuksköterskorna hade en känsla av att palliativ sedering påskyndande patientens död. Att arbeta i team var en viktig faktor för hur sjuksköterskor upplevde arbetet med palliativ sedering. Det underlättade om beslut om sedering togs gemensamt och olika former av stöd från teamet var betydelsefullt för sjuksköterskor under arbetet med palliativ sedering. Diskussion: Resultaten diskuterades utifrån Jean Watsons omvårdnadsteori om mänsklig omsorg och tre av hennes caritasprocesser Ett kärleksfullt och omsorgsfullt sinnelag, Utrymme för känslor och Hjälpsamma och tillitsfulla omsorgsrelationer. / Background: Palliative sedation refers to an intentional lowering of consciousness of a patient in the end of life who is suffering from unbearable symptoms. The care is performed by a multi-professional team where the nurses’ duties are to prepare, administer and evaluate prescribed pharmaceuticals. In addition to the practical skills required by the nurses, this treatment also requires ability to reflect as well as critical and ethical thinking. Aim: The aim of this literature review was to explore nurses’ experiences of palliative sedation. Method: A literature review was conducted and ten scientific articles were chosen for analysis. Literature searches were made in the databases CINAHL Complete and PubMed. Results: Three themes with subthemes were identified. Good palliative care included giving palliative sedation to offer patients, families and the staff a peaceful ending and to meet the patient’s wishes. Palliative sedation and euthanasia could be difficult to separate and there was a sense that palliative sedation hastened the patient’s death. Teamwork was an important factor for how nurses experienced working with palliative sedation. It was easier if the decision to sedate was taken jointly and support within the team was meaningful to nurses during their work with palliative sedation. Discussion: The results were discussed in relation to Jean Watson’s Theory of Human Caring and the three caritas processes The practice of loving kindness and equanimity, Promotion and acceptance of the expression of positive and negative feelings and Developing and sustaining a helping-trusting caring relationship.