Palliative sedation
In medicine, specifically in end-of-life care, palliative sedation is the palliative practice of relieving distress in a terminally ill person in the last hours or days of a dying person's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route.
As of 2013, approximately tens of millions of people a year were unable to resolve their needs of physical, psychological, or spiritual suffering at their time of death. Due to the amount of pain a dying person may face, palliative care is considered important. Proponents claim palliative sedation can provide a more peaceful and ethical solution for such people.
Palliative sedation is an option of last resort for the people whose symptoms cannot be controlled by any other means. It is not considered a form of euthanasia or physician-assisted suicide, as the goal of palliative sedation is to control symptoms, rather than to shorten or end the person's life.
Palliative sedation is legal everywhere and has been administered since the hospice care movement began in the 1960s. The practice of palliative sedation has been a topic of debate and controversy as many view it as a form of slow euthanasia or mercy killing, associated with many ethical questions. Discussion of this practice occurs in medical literature, but there is no consensus because of unclear definitions and guidelines, with many differences in practice across the world.
Definition
Palliative sedation is the use of sedative medications to relieve refractory symptoms when all other interventions have failed. The phrase "terminal sedation" was initially used to describe the practice of sedation at end of life, but was changed due to ambiguity as to what the word 'terminal' meant. The term "palliative sedation" was then used to emphasize palliative care. The level of sedation via palliative sedation may be mild, intermediate or deep and the medications may be administered intermittently or continuously.The term "refractory symptoms" is defined as symptoms that cannot be controlled despite the use of extensive therapeutic resources, with such symptoms having an intolerable effect on the patient's well-being in the final stages of life. The symptoms may be physical, psychological, or both.
General practice
Palliative care
Palliative care is aimed to relieve suffering and improve the quality of life for people with serious and/or life-threatening illness in all stages of disease, as well as for their families. It can be provided either as an add-on therapy to the primary curative treatment or as a monotherapy for people who are on end-of-life care. In general, palliative care focuses on managing symptoms, including but not limited to pain, insomnia, mental alterations, fatigue, difficulty breathing, and eating disorders. In order to initiate the care, self-reported information is considered the primary data to assess the symptoms along with other physical examinations and laboratory tests. However, in people at the advanced stage of the disease with potential experience of physical fatigue, mental confusion or delirium which prevent them from fully cooperating with the care team, a comprehensive symptom assessment can be utilized to fully capture all symptoms as well as their severity.There are multiple interventions that can be used to manage the conditions depending on the frequency and severity of the symptoms, including using medications, physical therapy/modification, or reversal of precipitating causes.
Palliative sedation
Palliative sedation is the last resort if a person's symptoms cannot be managed with other therapies. Symptoms may include pain, delirium, dyspnea, and severe psychological distress.In terms of the initiation of palliative sedation, it should be a shared clinical decision initiated preferably between the person receiving treatment and the care team. If severe mental alterations or delirium is the concern for the person to make an informed decision, consent can be obtained in the early stage of the disease or upon the admission to the hospice facility. Family members can only participate in the decision-making process if explicitly requested by the person in care.
Palliative sedation can be used for short periods with the plan to awaken the person after a given time period, making terminal sedation a less correct term. The person is sedated while symptom control is attempted, then the person is awakened to see if symptom control is achieved. In some cases, palliative sedation is begun with the plan to not attempt to reawaken the person.
Assessment and obtaining consent
Despite best practice palliative care, refractory symptoms can occur. Intentionally sedating a person may be the best option to alleviate intolerable symptoms and suffering. Prior to receiving palliative sedation, persons should undergo careful consideration along with their health care team to make sure all other resources and treatment strategies have been exhausted. In the case the person is unable to participate in decision making, the individual's family member should be consulted. Addressing the distress of family members is also a key component and goal of palliative care and palliative sedation.The first step in consideration of palliative sedation is assessment of the person seeking the treatment.
There are several states that one may be in that can make palliative sedation the preferred treatment, including but not limited to physical and psychological pain and severe emotional distress. More often than not, refractory or intolerable symptoms give a more sound reason to pursue palliative sedation. Though the interdisciplinary health care team is there to help each person make the most sound medical decision, the individual's judgement is considered to be the most accurate in deciding whether or not their suffering is manageable.
According to a systematic review encompassing over thirty peer-reviewed research studies, 68% of the studies used stated physical symptoms as the primary reason for palliative sedation. The individuals involved in the included studies were terminally ill or suffering from refractory and intolerable symptoms. Medical conditions that had the most compelling reasons for palliative sedation were not only limited to intolerable pain, but include psychological symptoms such as delirium accompanied by uncontrollable psychomotor agitation. Severe trouble breathing or respiratory distress were also considered a more urgent reason for pursuing palliative sedation. Other symptoms such as fatigue, nausea, and vomiting were also reasons for palliative sedation.
Once the assessment is completed and palliative sedation has been decided for the person, a written consent for administration to proceed may be given by the individual. This may be mandatory in some jurisdictions. The consent must state their agreement for sedation and lowering their consciousness, regardless of each individual's stage in illness or the treatment period of palliative sedation. In order to make a decision, one must be sufficiently informed of their disease state, the specificities and implications of treatment, and potential risks they may face during the treatment. At the time of consent, the person should fully be aware of and understand all necessary legal and medical consequences of palliative sedation. It is also critical that the individual is making the decision upon their own free will, and not under coercion of any sort. The only exception where the individual's consent is not obtained would be in emergency medical situations where one is incapable of making a decision, in which the individual's family or caregiver must give the consent after adequate education, as one would have been given.
In many situations, palliative sedation is the only route to good symptom control at the end of life, and does not need written consent. Shared decision making with the patient and family members should occur during this process.
Continuous vs. intermittent sedation
Palliative sedation can be administered continuously, until the person's death, or intermittently, with the intention to discontinue the sedation at an agreed upon time. Although not as common, intermittent sedation allows family members of the person to gradually come to terms with their grief and while still relieving the individual of their distress. During intermittent palliative sedation, the person is still able to communicate with their family members. Intermittent sedation is recommended by some authorities for use prior to continuous infusion to provide the person with some relief from distress while still maintaining interactive function.Sedative medications
Sedating agents
Benzodiazepines: This is a drug class that works on the central nervous system to tackle a variety of medical conditions, such as seizures, anxiety, and depression. As benzodiazepines suppress the activities of nerves in the brain, they also create a sedating effect which is utilized for multiple medical procedures and purposes. Among all benzodiazepine agents, midazolam is the most frequently used medication for palliative sedation for its rapid onset and short duration of action. The main indications for midazolam in palliative sedation are to control delirium and alleviate breathing difficulties so as to minimize distress and prevent exacerbation of these symptoms.Opioids: Opioids can be used as an analgesics but should not be used to induce sedation. The optimal balance of effect versus side effect of opioids depends on a person's individual situation. In some settings. drowsiness as a side effect of good pain control may be acceptable, but opioids are not generally used with the primary goal of sedation.
Other agents: Levomepromazine is a sedating antipsychotic that can be used for palliative sedation. As third-line therapy, phenobarbital can be used.