might speed up death, although death is considered a side effect and sedation does not equate with euthanasia. a survey of 663 physicians found half had an experience of their treatment being characterised as murder, euthanasia, or killing in the preceding five years with palliative sedation (along with stopping of hydration and nutrition) being the most common act in palliative care interpreted as killing. the primary difference between palliative sedation, relief of severe pain and symptoms, and euthanasia (the intentional ending of a person's life) is both their intent and their outcome. at the end of life sedation is only used if the individuals perceives their distress to be unbearable, and there are no other means of relieving that distress. the intended goal is to provide them some relief of their suffering through the use of benzodiazepines and other agents which inadvertently may increase the risk of death. studies have been conducted however, showing that the risk of death through palliative sedation is much lower than earlier perceived. this has raised the argument that palliative sedation does not cause or hasten death and that an individual's death following palliative sedation is more likely to be due to their disease - the measure of success of palliative sedation remains relief of a person's symptoms until their end of life. on the other hand, euthanasia is performed with the intent to permanently relieve the person of their pain through death - the measure of success being their death. in palliative care, the doses of sedatives are titrated (i.e., varied) to keep the individual comfortable without compromising respiration or hastening death. death typically results from the underlying medical condition. people (or their legal representatives) only have the right to refuse treatments in living wills; however the demand of life saving treatments, or any treatments at all is controversial among states and heavily depends on each specific situation. however, once unconsciousness begins, as the person is no longer able to decide to stop the sedation or to request food or water, the clinical team can make decisions for the individual. a living will made when competent, can, under uk law, give a directive that the person refuses "palliative care" or "terminal sedation", or "any drug likely to suppress my respiration." the use of sedation for palliative care in the uk was considered as part of an independent review of the liverpool care pathway for the dying patient. families of patients in some instances said that they thought the doses of sedatives prevented patients from asking for water leading to death from dehydration,: 1.66 there were many accounts of subcutaneous infusions being started as a matter of course rather than to control a specific symptom, there were many reports of patients being left alone for a short-period of time by their families only to find that sedation had been administered leaving them unable to speak to their relatives;: 1.69 relatives and carers reported instances where they felt that the administration of morphine had directly lead to the death of a patient.: 1.68 physician-assisted suicide as of 2022, assisted suicide in the united states, otherwise known as medical aid in dying, is legal in ten jurisdictions (california, colorado, district of columbia, hawaii, maine, montana, new jersey, oregon, vermont, and washington). epidemiology prevalence in a review of research articles on various aspects of palliative care, the prevalence of palliative sedation was reported as highly varied. in palliative care units or hospice, the prevalence ranged from 3.1%-51%. in the home care setting, two italian studies reported a prevalence of 25% and 52.5%. hospital-based palliative support teams vary in prevalence, with reports of 1.33% and also 26%. different countries also report large differences in prevalence of palliative sedation: country prevalence netherlands 10% belgium 8.2% italy 8.5% denmark 2.5% switzerland 4.8% sweden 3% a 2009 survey of almost 4000 u.k. people whose care had followed the liverpool care pathway for the dying patient found that while 31% had received low doses of medication to control distress from agitation or restlessness, only 4% had required higher doses. almost half of the studies reviewed differentiated intermittent versus continuous palliative sedation. the prevalence of intermittent sedation was 30% -67% of cases and continuous sedation was 14-68% of cases. people starting intermittent sedation may progress to use of continuous sedation in 10 - 27% of cases. the prevalence of mild versus deep sedation was also reported: one study reported 51% of cases used mild sedation and 49% deep sedation; a second study reported 80% of cases used mild sedation and 20% deep sedation. survival there are reports that after initiation of palliative sedation, 38% of people died within 24 hours and 96% of people died within one week. other studies report a survival time of < 3 weeks in 94% of people after starting palliative sedation. some physicians estimate that this practice shortens life by ≤24 hours for 40% of people and > 1 week for 27% of people. another study reported people receiving sedation in their last week of life survived longer than those who did not receive sedation, or only received sedation during last 48 hours of life. according to 2009 research, 16.5% of all deaths in the united kingdom during 2007–2008 took place after continuous deep sedation. history of hospice u.s. hospice care movement hospice care emphasizes palliative, rather than curative, treatment to support individuals during end-of-life care when all other alternatives have been exhausted. it differs vastly from other forms of healthcare because both the person and the family are included in all decision-making and aims to treat the individual, not the disease. the hospice care movement began in the united states during the 1960s and was influenced heavily on the model published by st. christopher's hospice of london located in great britain. despite differing setting, services, and staffing, the u.s. hospice care movement still sought to maintain the goals and philosophy of st. christopher's model which centered on symptom control to allow the person to die with freedom, rather than attempting curative treatment. the first hospice in the united states, connecticut hospice, was founded by florence wald and opened in 1974. supporters of the movement faced many challenges early on, the biggest being the lack of insurance coverage for hospice care services. initiatives to increase public awareness of the movement were created to combat this obstacle and supply the movement with public funding in order to maintain their services. one of the greatest accomplishments made by the movement was in the inclusion of hospice care in services covered under medicare in 1982. this victory prompted the creation of national hospice week by president reagan to take place from november 7–14 as a form of recognition to the vital impact nurses and caregivers have on these individuals and their families. less than five decades after the first hospice program began, there are now over 4,000 programs in place under the umbrella of a multi-billion dollar industry. the cumulative budget for hospice programs nationwide increased from 10 million in the late 1970s, to 2.8 billion dollars in 1995, and 10 billion in 2008. policies united states in 2008, the american medical association council on ethical and judicial affairs approved an ethical policy regarding the practice of palliative sedation. there is no specific law in barring the practice of palliative sedation, and the u.s. conference of catholic bishops is reported to accept the practice of keeping people pain free at end of life. sweden in october 2010 svenska läkaresällskapets, an association of physicians in sweden, published guidelines which allowed for palliative sedation to be administered even with the intent of the terminally ill person not to reawaken.