Palliative Sedation for the Terminally Ill Patient
- 161 Downloads
Palliative sedation (PS) is performed in the terminally ill patient to manage one or more refractory symptoms. Proportional PS, which means that drugs can be titrated to the minimum effective dose, is the form most widely used. From a quarter to a third of all terminally ill patients undergo PS, with a quarter of these requiring continuous deep sedation. The prevalence of PS varies according to the care setting and case mix. The most frequent refractory physical symptoms are delirium and dyspnea, but PS is also considered for existential suffering or psychological distress, which is an extremely difficult and delicate issue to deal with. Active consensus from the patient and advanced care planning is recommended for PS. The decision-making process concerning the continuation or withdrawal of other treatments is not the same as that used for PS. The practice differs totally from euthanasia in its intentions, procedures, and results. The most widely used drugs are midazolam and haloperidol for refractory delirium, but chlorpromazine and other neuroleptics are also effective. In conclusion, some patients experience refractory symptoms during the last hours or days of life and PS is a medical intervention aimed at managing this unbearable suffering. It does not have a detrimental effect on survival.
The authors thank Gráinne Tierney for editorial assistance.
Compliance with Ethical Standards
No sources of funding were used in the preparation of this paper.
Conflict of interest
Ferdinando Garetto, Ferdinando Cancelli, Romina Rossi and Marco Maltoni have no conflicts of interest to declare for this paper.
Ethical approval and informed consent
Given the nature of this paper, ethical approval and informed consent were not required.
- 1.Byock I. Palliative care and the right to die. In: The 2015 Quality of death index. Ranking palliative care across the world. The Economist Intelligence Unit. 2018. https://www.eiuperspectives.economist.com/sites/default/files/2015%20EIU%20Quality%20of%20Death%20Index%20Oct%2029%20FINAL.pdf. Accessed 19 May 2018.
- 10.Schur S, Weixler D, Gabl C, Kreye G, Likar R, Masel EK, et al. AUPACS (Austrian Palliative Care Study) Group. Sedation at the end of life - a nation-wide study in palliative care units in Austria. BMC Palliat Care. 2016;14(15):50.Google Scholar
- 17.Rudkin GE, Osborne GA, Curtis NJ. Intra-opertaivepatient-controlledsedation. Anesthesia. 1991;46:90–2.Google Scholar
- 25.Claessens P, Menten J, Schotsmans P, Broeckaert B. Level of consciousnessin dying patients. The role of palliative sedation: a longitudinal prospectivestudy. Am J HospPalliat Care. 2012;29:195–200.Google Scholar
- 44.Caraceni A, Speranza R, Spoldi E, Ambroset CS, Canestrari S, Marinari M, et al. Italian Society of Palliative Care Study Group on Palliative Sedation. Palliative sedation in terminal cancer patients admitted to hospice or home care programs: does the setting matter? Results from a national multicenter observational study in adult cancer patients. J Pain Symptom Manage. 2018;13:30133–7.Google Scholar
- 49.Trees AR, Ohs JE, Murray MC. Family communication about end-of-life decisions and the enactment of the decision maker role. BehavSci (Basel). 2017;7:pii E36.Google Scholar
- 59.Ferrari L, Caraceni A. Pharmacology of sedation. In: Grassi L, Riba M, editors. Psychopharmacology in oncology and palliative care. Berlin: Springer-Verlag; 2014. p. 375.Google Scholar
- 61.Cheng C, Roemer-Becuwe C, Pereira J. When midazolam fails. J Symptom Manage. 2002;23:256–65.Google Scholar
- 65.Doyle D, Hanks GWC, MacDonald N, editors. Oxford textbook of palliative medicine. 1st ed. Oxford: Oxford University Press; 1993.Google Scholar
- 69.Shrikant Kulkarni N. Antipsychotics worsen symptoms in patients with delirium who receive palliative care. Am Fam Physician. 2017;95:396B.Google Scholar
- 71.Kayhart B, Lapid MI, Nelson S, Cunningham JL, Thompson VH, Leung JG. A lack of systemic absorption following the repeated application of topical quetiapine in healthy adults. Am J HospPalliat Care. 2018;35:1076–80.Google Scholar
- 83.Covarrubias-Gómez A, LópezCollada-Estrada M. Propofol-based palliative sedation to treat antipsychotic-resistant agitated delirium. J Pain Palliat Care Pharmacother. 2017;16:1–5.Google Scholar
- 99.Rietjens JA, van Delden JJ, van der Heide A. Palliative sedation: the end of heated debate? Palliat Med. 2018;269216318762708. (Epub ahead of print).Google Scholar
- 101.Maltoni M, Scarpi E, Dall’Agata M, Schiavon S, Biasini C, Codecà C, et al. Early Palliative Care Italian Study Group (EPCISG). Systematic versus on-demand early palliative care: a randomised clinical trial assessing quality of care and treatment aggressiveness near the end of life. Eur J Cancer. 2016;69:110–8.PubMedGoogle Scholar
- 102.Hoerger M, Greer JA, Jackson VA, Park ER, Pirl WF, El-Jawahri A, et al. Defining the elements of early palliative care that are associated with patient-reported outcomes and the delivery of end-of-life care. J ClinOncol. 2018;36:1096–102.Google Scholar