Palliative Care and End-of-Life Accompaniment in Oncology in Algeria: Ethical Reflection, Challenges of Palliative Sedation, and the Imperative of Interdisciplinary Collaboration

In Algeria progress is being made in the way cancer is treated at the same time as there is an increasing demand for organized palliative care services. Yet end-of-life care encounters cultural, legal and institutional obstacles, especially when it comes to the use of palliative sedation for symptoms that are no longer responsive to treatment. This kind of clinical practice is either not present or not formally established and is frequently mistakenly regarded as being equivalent to euthanasia. The best way of handling such critical cases depends on having a multidisciplinary level of expertise, with the key element being cooperation between medical oncologists and anesthesiologists or intensivists. The present paper offers a cross-sectional analysis of the sociocultural particularities, the clinical difficulties, internationally validated pharmacological protocols, and the necessity of training healthcare professionals in palliative care and in providing end-of-life support.

Introduction

Cancer is still one of the main causes of illness and death in Algeria, there being about 75,000 new cases and more than 37,000 deaths each year (1). Even though the network of the Cancer Care Center has been expanded and access to innovative systemic treatments has improved, a large number of patients still see their disease progress beyond the point where curative treatment is possible. When patients reach this terminal stage, the physician has to shift the aim of treatment to include improvements in quality of life, better control of symptoms, and the maintenance of the patient’s dignity.

Although conventional methods of pain relief have made great progress, the handling of end-of-life cases and what is known as “refractory” suffering (that is, refractory pain, acute respiratory distress, severe anxiety, and intractable delirium) is still a weak area. Palliative sedation—which is described as the appropriate use of sedative drugs to lower the patient’s level of consciousness in order to alleviate a refractory symptom—still remains an exceptional practice and is affected by cultural, religious, and social taboos. The aim of this paper is to offer an ethical and clinical consideration of the features of terminal cancer care in Algeria and to identify the conditions necessary for effective cooperation between oncologists and anesthesiologists-intensivists.

The sociocultural and ethical aspects of end-of-life care in Algeria

The Arabs’ and Muslims’ view of suffering and the end of life

In Algeria, the relationship with illness and dying is deeply intertwined with spiritual and community representations:

People often see physical illness and pain as a divine trial by means of which the believer can purify themselves of their sins (2). It is for this reason that some patients or their families may want to remain fully conscious right up to the end, so that they can recite the declaration of faith (Shahada) or carry out their spiritual obligations.

The family unit plays a dominant role in Algeria’s medical decision-making process. The family surrounds the person who is terminally ill and often takes on the role of guardian, at times asking that the prognosis not be disclosed (this reflects a cultural attitude aimed at preventing diagnostic shock). The patient is almost never the one who makes the main decisions about their end-of-life course; even if they wish to die peacefully at home among their family, the relatives tend to rehospitalise them in order to obtain further treatments, due to their denial of death.

Conceptual Confusion: The difference between palliative sedation and euthanasia

Euthanasia is strictly prohibited by both medical law and Islamic bioethics (3), although there remains a persistent confusion regarding:

Euthanasia refers to the intentional ending of a person’s life to relieve suffering. It must be distinguished from withholding or withdrawing life-sustaining treatment, which may be ethically and legally appropriate under specific circumstances and does not, in itself, constitute euthanasia.

Palliative sedation: the use of sedatives in a proportional or deep way which is meant solely to alleviate a symptom that is unbearable and has not responded to normal treatments, with a decreased level of consciousness accepted as a side effect or as a necessary measure (4) (this is known as the principle of double effect).

According to the SFAP and the HAS, palliative sedation for distress in the terminal phase is the pursuit, by pharmacological means, of a reduction in vigilance that may extend to loss of consciousness. Its aim is to reduce or abolish the patient’s perception of a situation experienced as unbearable, when all the means available and appropriate to that situation have been offered and/or implemented without achieving the expected relief (4). This definition makes the relief of a perceived, refractory suffering the sole purpose of the act, which is what fundamentally distinguishes palliative sedation from euthanasia, whose purpose is to cause death.

In this context, it is important to clarify the intentionality of the act of sedation, as well as the modalities and consequences of sedative practices with the patient, the relatives and the caregivers (4). Making explicit why, how and for how long the patient is sedated, and what can be expected as a result, is essential to dispel the confusion with euthanasia, to respect the family’s spiritual expectations, and to protect the professionals involved.

In the absence of clearly established institutional protocols specifically addressing palliative sedation, clinicians may hesitate to initiate sedation because of concerns about legal consequences or disapproval from patients’ families(5).

The international protocols relating to palliative sedation and accompaniment (in Europe and the United States)

In order to standardise practice and guarantee both clinical and ethical safety, medical societies in Europe (the EAPC, the SFAP and the HAS) and in America (the NCCN and the AAHPM) have set out guidelines relating to the indications, the assessment, and the administration of drugs in the case of palliative sedation (4, 6, 7).

At the European level, the EAPC framework on palliative sedation, first issued in 2009, has been replaced by a revised version developed through an international Delphi process, which yielded 42 consensus statements. The revised framework introduces the principle of proportionality into the definition of palliative sedation, proposes a stepwise pharmacological approach, and provides guidance on decision-making about hydration (6).

The framework for making decisions and the process of evaluation

Prior to initiating palliative sedation:
The refractory symptoms—namely respiratory distress, hyperactive delirium or agitation, intractable pain, and severe existential or psychological distress—have to be assessed by a multidisciplinary team as being beyond what can be achieved through conventional interventions without causing excessive alteration of consciousness.

When assessing sedation level, validated tools such as the Rudkin scale or the RASS-PAL (Richmond Agitation-Sedation Scale in Palliative Care) should be used in order to adjust the level of effect (i.e. distinguish between mild and transient sedation and deep and continuous sedation until death).

Sedation does not take the place of analgesia and the opioid regimes used for pain relief must be kept at effective doses to avoid experiencing a painful awakening.

To describe precisely the intention behind a sedative practice, the SEDAPALL typology developed by the SFAP can be used as a teaching, documentation and research tool (8). It characterises each sedative practice along three axes: its duration (D1, transient and reversible; D2, of undetermined duration and potentially reversible; D3, maintained until death and irreversible), its depth (P1, proportionate sedation; P2, deep sedation from the outset) and the patient’s consent (C0, absence of consent; C1, consent given in advance; C2, consent; C3, request for sedation). Defining and recording these three parameters (D, P and C) before starting sedation supports the collegial decision and the information given to the patient, the relatives and the team (8).

The key yet underused role of the anesthesiologist-intensivist

Anesthesiologist-intensivists play a pivotal yet underused role in palliative sedation, as they master the centrally acting agents involved (midazolam, propofol, neuroleptics), can titrate doses precisely, and can manage adverse effects such as inadvertent respiratory depression and paradoxical agitation. In Algeria, however, clinicians trained in acute sedation generally lack specific training in the care of patients with terminal cancer. Moreover, the specialty has historically focused on perioperative medicine, trauma, and the resuscitation of acute organ failure, so shifting from an interventional, curative model to one centered on supportive accompaniment and acceptance of biological finitude constitutes a major paradigm change. This transition is further hindered by postgraduate curricula that offer very little teaching on palliative medicine, end-of-life communication, or the ethics of withholding and withdrawing life-sustaining treatment.

Recommendations

To establish an ethically grounded and clinically rigorous end-of-life care system for oncology patients in Algeria, several key initiatives must be implemented:

Integration of Palliative Medicine into Curricula: Set up specialized certification courses (C.E.S.), Specialized Medical Studies Diplomas (DEMS), or compulsory interdisciplinary modules in palliative care for residents in medical oncology, anesthesiology-intensive care, and medical reanimation, with a focus on palliative sedation protocols and the management of end-of-life care.

Regulatory Clarification and National Consensus: Encourage a consensus that is multidisciplinary and involves the Ministry of Health, various professional societies, and experts in bioethics in order to establish a definite legal and procedural framework for protecting the practice of palliative sedation in cases of refractory symptoms.

Institutionalization of Interdisciplinary Collaboration: Introduce Palliative Care Multidisciplinary Team Meetings (MDTs) in hospital centres by bringing together medical oncologists, anesthesiologists, psychologists, and specialist palliative care nurses.

Structured Family Communication and Dialogue: When dealing with family members in the later stages of disease, use clear and compassionate communication methods so as to explain the aims of care, correct any misunderstandings about palliative sedation, and make sure that everyone’s expectations are aligned.

Conclusion

The provision of end-of-life care in the field of oncology goes beyond just managing physical pain; it needs to involve a thorough attention to the patient’s suffering. In Algeria, implementing validated international protocols for palliative sedation (specifically those based on midazolam) is an important move towards humanizing end-of-life care without compromising the country’s cultural and spiritual values. Making this kind of progress will depend on eliminating the conceptual stigma and on establishing a sustainable collaboration between medical oncologists and anesthesiologists-intensivists through proper education, open communication, and a steadfast dedication to human dignity.

References

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