Reflection on Palliative Sedation for Existential Distress. It is Possible to Tolerate the Incomprehensible?

The difficulty of making decisions in end of life is the subject of these reflections through two clinical cases. We considered the question of palliative sedation for existential distress through a phenomenological approach, focusing the relationship between a patient’s clinical history and the reactions of the care team to the existential distress of the patients. We chose to introduce a concept, dynamic projective identifications, which is a powerful mechanism for communication between human beings. The hypothesis is that projective identification works as a powerful mechanism of emotional contagion between people facing death, families, and their health workers. In the cases, however, the use of this therapeutic tool is not oriented to provide psychotherapeutic methods of supporting dying patients but to sustain the awareness of the care team in the decision-making process. The psychological pressure on the care team may lead physicians to act considering “what you already know”. Being aware of these mechanisms can help physicians to understand the phenomena that are happening. Even if palliative sedation is the best therapy, the care team must clarify the meaning of the projective identification and enter them into the flow of communication with the patients and their families