Palliative sedation in advanced cancer patients hospitalized in a specialized palliative care unit

  • Santiago Parra Palacio
  • Clara Elisa Giraldo Hoyos
  • Camilo Arias Rodríguez
  • Daniel Mejía Arrieta
  • John Jairo Vargas Gómez
  • Alicia Krikorian
Original Article

Abstract

Purpose

To describe the practice of palliative sedation (PS) in patients with advanced cancer in a specialized palliative care (PC) unit in Colombia.

Methods

Descriptive prospective study including all adults with cancer hospitalized under PS in a cancer institute between January and July 2015 in Colombia. Variables examined were diagnosis, physical functioning, symptoms at the start of sedation, medications and dosages used, and type, level, and time of sedation. Descriptive and correlational statistics were obtained.

Results

Sixty-six patients were included, 70% of which were women. The patients had an average age of 61 years (range 24–87), and 74% had a Karnofsky Index (KI) of 50% or less. The most frequent diagnosis was breast cancer (22%), and 82% had metastatic cancer. The prevalence of palliative sedation was 2% and the most common symptoms indicating it were dyspnea (59%), delirium (45%), and pain (32%). All patients received midazolam as a sedative. The average time between the interval start and culmination of sedation was 44 h. There was a significant and inverse relationship between functionality and time under sedation.

Conclusions

Palliative sedation is a valid therapeutic option for refractory symptoms causing suffering. The results correspond to international reports and guidelines, which suggests that PS is tailored to the needs of the individual patient while maintaining a high scientific standard, even in a context where PC is under development. However, further development of strategies and clear indications towards the use of PS in Colombia are needed, given its still scarce use.

Keywords

Palliative care Terminal care Deep sedation Evaluation of symptoms Neoplasia Cancer 

Notes

Acknowledgements

We thank the Instituto de Cancerología, Clínica Las Américas (IDC) in Medellin, Colombia, for allowing us to develop our study at their institution and Carolina Palacio for her contributions in the analysis of the data.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Formal consent was not required.

References

  1. 1.
    Zas Tabares V, Rodríguez Rodríguez JR, Silva JE (2013) El dolor y su manejo en los cuidados paliativos. Panorama Cuba y Salud 8(2):41–48Google Scholar
  2. 2.
    Astudillo Alarcón W, Díaz-Albo E, García Calleja JM, Mendinueta C, Granja P, De la Fuente Hontañón C et al (2009) Cuidados paliativos y tratamiento del dolor en la solidaridad internacional. Rev Soc Esp Dolor 16(4):246–255CrossRefGoogle Scholar
  3. 3.
    World Health Organization (2004) Palliative care: symptom management and end-of-life care. OMS, GinebraGoogle Scholar
  4. 4.
    Morrison LJ, Morrison RS (2006) Palliative care and pain management. Med Clin North Am 90(5):983–1004CrossRefPubMedGoogle Scholar
  5. 5.
    Soriano García JL, Lima Pérez M, Batista Albuerne N, Febles Cabrera R, Morales Morgado D (2011) Midazolam en la sedación paliativa terminal de pacientes con cáncer. Rev Cubana Med 50(4):359–375Google Scholar
  6. 6.
    Claessens P, Menten J, Schotsmans P, Broeckaert B (2008) Palliative sedation: a review of the research literature. J Pain Symptom Manag 36(3):310–333CrossRefGoogle Scholar
  7. 7.
    Cherny NI, ESMO Guidelines Working Group (2014) ESMO Clinical Practice Guidelines for the management of refractory symptoms at the end of life and the use of palliative sedation. Ann Oncol 25(Suppl 3):iii143–iii152CrossRefPubMedGoogle Scholar
  8. 8.
    Cherny NI, Radbruch L (2009) Board of the European Association for Palliative Care. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 23(7):581–593CrossRefPubMedGoogle Scholar
  9. 9.
    Juth N, Lindblad A, Lynöe N, Sjöstrand M, Helgesson G (2010) European Association for Palliative Care (EAPC) framework for palliative sedation: an ethical discussion. BMC Palliat Care 9:20CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Beller EM, van Driel ML, McGregor L, Truong S, Mitchell G (2015) Palliative pharmacological sedation for terminally ill adults. Cochrane Database Syst Rev 1:CD010206PubMedGoogle Scholar
  11. 11.
    Caraceni A, Zecca E, Martini C, Gorni G, Campa T, Brunelli C, de Conno F (2012) Palliative sedation at the end of life at a tertiary cancer center. Support Care Cancer 20(6):1299–1307CrossRefPubMedGoogle Scholar
  12. 12.
    Alonso-Babarro A, Varela-Cerdeira M, Torres-Vigil I, Rodríguez-Barrientos R, Bruera E (2010) At-home palliative sedation for end-of-life cancer patients. Palliat Med 24(5):486–492CrossRefPubMedGoogle Scholar
  13. 13.
    Santos D, Della Valle A, Barlocco B, Pereyra J, Bonilla D (2009) Sedación paliativa: experiencia en una unidad de cuidados paliativos de Montevideo. Rev Méd Urug 25(2):78–83Google Scholar
  14. 14.
    Mercadante S, Porzio G, Valle A, Aielli F, Casuccio A (2014) Home care-Italy group. Palliative sedation in patients with advanced cancer followed at home: a prospective study. J Pain Symptom Manag 47(5):860–866CrossRefGoogle Scholar
  15. 15.
    Kiman R, Wuiloud AC, Requena ML (2011) End of life care sedation for children. Curr Opin Support Palliat Care 5(3):285–290CrossRefPubMedGoogle Scholar
  16. 16.
    Menten J (2003) Cancer pain: interdiciplinary and comprehensive management (dissertation). Catholic University Leuven, Leuven, BélgicaGoogle Scholar
  17. 17.
    Kohara H, Ueoka H, Takeyama H, Murakami T, Morita T (2005) Sedation for terminally ill patients with cancer with uncontrollable physical distress. J Palliat Med 8(1):20–25CrossRefPubMedGoogle Scholar
  18. 18.
    Stone P, Phillips C, Spruyt O, Waight C (1997) A comparison of the use of sedatives in a hospital support team and in a hospice. Palliat Med 11(2):140–144CrossRefPubMedGoogle Scholar
  19. 19.
    Maltoni M, Scarpi E, Rosati M, Derni S, Fabbri L, Martini F, Amadori D, Nanni O (2012) Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol 30(12):1378–1383CrossRefPubMedGoogle Scholar
  20. 20.
    Elsayem A, Curry Iii E, Boohene J, Munsell MF, Calderon B, Hung F et al (2009) Use of palliative sedation for intractable symptoms in the palliative care unit of a comprehensive cancer center. Support Care Cancer 17(1):53–59CrossRefPubMedGoogle Scholar
  21. 21.
    Blanker MH, Koerhuis-Roessink M, Swart SJ, Zuurmond WW, van der Heide A, Perez RS et al (2012) Pressure during decision making of continuous sedation in end-of-life situations in Dutch general practice. BMC Fam Pract 13:68CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Rietjens JA, van der Heide A, Vrakking AM, Onwuteaka-Philipsen BD, van der Maas PJ, van der Wal G (2004) Physician reports of terminal sedation without hydration or nutrition for patients nearing death in the Netherlands. Ann Intern Med 141(3):178–185CrossRefPubMedGoogle Scholar
  23. 23.
    Gonçalves F, Cordero A, Almeida A, Cruz A, Rocha C, Feio M, Silva P, Barbas S, Neves S (2012) A survey of the sedation practice of Portuguese palliative care teams. Support Care Cancer 20(12):3123–3127CrossRefPubMedGoogle Scholar
  24. 24.
    Cowan JD, Palmer T, Clemens L (2009) Palliative sedation. In: Walsh D, Caraceni AT, Fainsinger R, Foley K, Glare P, Goh C et al (eds) Palliative medicine. Elsevier, Philadelphia, pp 983–988CrossRefGoogle Scholar
  25. 25.
    Vitetta L (2005) Sedation and analgesia-prescribing patterns in terminally ill patients at the end of life. Am J Hosp Pall Care 22:465e473Google Scholar
  26. 26.
    ten Have H, Welie JV (2014) Palliative sedation versus euthanasia: an ethical assessment. J Pain Symptom Manag 47(1):123–136CrossRefGoogle Scholar
  27. 27.
    Bruinsma SM, Rietjens JA, Seymour JE, Anquinet L, van der Heide A (2012) The experiences of relatives with the practice of palliative sedation: a systematic review. J Pain Symptom Manag 44(3):431–445CrossRefGoogle Scholar
  28. 28.
    Abarshi E, Rietjens J, Caraceni A, Payne S, Deliens L, Van Den Block L (2014) Towards a standardized approach for evaluating guidelines and guidance documents on palliative sedation: study protocol. BMC Palliat Care. 13:34CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Biondo CA, da SMJP, Secco LMD (2009) Dysthanasia, euthanasia, orthotanasia: the perceptions of nurses working in intensive care units and care implications. Rev Latino-Am Enfermagem 17(5):613–619CrossRefGoogle Scholar
  30. 30.
    Pastrana T, Warchen R, De Lima L (2012) Atlas de cuidados paliativos en Latinoamérica. IAHPC Press, HoustonGoogle Scholar
  31. 31.
    Ramsay MA, Savege TM, Simpson BR, Goodwin R (1974) Controlled sedation with alphaxalone-alphadolone. Br Med J 2(5920):656–659CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Colombia. Ministerio de Salud y Protección Social, Instituto Nacional de Cancerología, ESE (2012) Plan Decenal para el Control del Cáncer en Colombia. Ministerio de Salud y Protección Social, Bogotá, pp 2012–2021Google Scholar
  33. 33.
    Muller-Busch HC, Andres I, Jehser T (2003) Sedation in palliative care—a critical analysis of 7 years experience. BMC Palliat Care. 2(1):2CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Nogueira FL (2012) Palliative sedation of terminally ill patients. Rev Bras Anestesiol 62(4):580–592CrossRefPubMedGoogle Scholar
  35. 35.
    Morita T (2004) Palliative sedation to relieve psycho-existential suffering of terminally ill cancer patients. J Pain Symptom Manag 28(5):445–450CrossRefGoogle Scholar
  36. 36.
    Arevalo JJ, Brinkkemper T, van der Heide A, Rietjens JA, Ribbe M, Deliens L, Loer SA, Zuurmond WW, Perez RS, AMROSE Site Study Group (2012) Palliative sedation: reliability and validity of sedation scales. J Pain Symptom Manag 44(5):704–714CrossRefGoogle Scholar
  37. 37.
    Schildmann EK, Schildmann J, Kiesewetter I (2015) Medication and monitoring in palliative sedation therapy: a systematic review and quality assessment of published guidelines. J Pain Symptom Manag 49(4):734–746CrossRefGoogle Scholar
  38. 38.
    Maltoni M, Setola E (2015) Palliative sedation in patients with cancer. Cancer Control 22(4):433–441CrossRefPubMedGoogle Scholar
  39. 39.
    Morita T, Tsunoda J, Inoue S, Chihara S (1999) The Palliative Prognostic Index: a scoring system for survival prediction of terminally ill cancer patients. Support Care Cancer 7(3):128–133CrossRefPubMedGoogle Scholar
  40. 40.
    Maltoni M, Miccinesi G, Morino P, Scarpi E, Bulli F, Martini F, Canzani F, Dall’Agata M, Paci E, Amadori D (2012) Prospective observational Italian study on palliative sedation in two hospice settings: differences in casemixes and clinical care. Support Care Cancer 20(11):2829–2836.  https://doi.org/10.1007/s00520-012-1407-x CrossRefPubMedGoogle Scholar
  41. 41.
    Maltoni M, Pirovano M, Scarpi E, Marinari M, Indelli M, Arnoldi E, Gallucci M, Frontini L, Piva L, Amadori D (1995) Prediction of survival of patients terminally ill with cancer. Results of an Italian prospective multicentric study. Cancer 75(10):2613–2622CrossRefPubMedGoogle Scholar
  42. 42.
    Lunney JR (2003) Patterns of functional decline at the end of life. JAMA 289(18):2387–2392CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Clinica SomerRionegroColombia
  2. 2.MedicáncerMedellinColombia
  3. 3.Faculty of MedicineUniversidad Pontificia BolivarianaMedellinColombia
  4. 4.Pain and Palliative Care Group, School of Health Sciences, Palliative Care Unit, Instituto de Cancerología, Clínica Las AméricasUniversidad Pontificia BolivarianaMedellinColombia
  5. 5.Pain and Palliative Care Group, School of Health SciencesUniversidad Pontificia BolivarianaMedellinColombia

Personalised recommendations