1
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Ponnampalam S, Gregory H. Propofol for palliative sedation in catastrophic bleeding. BMJ Support Palliat Care 2024; 14:305-307. [PMID: 38839247 DOI: 10.1136/spcare-2024-004991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Accepted: 05/20/2024] [Indexed: 06/07/2024]
Abstract
Catastrophic bleeds are life-threatening events. This case report describes the successful use of intravenous propofol infusion in order to facilitate palliative sedation in the context of a catastrophic bleed where traditional medications did not yield the necessary level of effect as the patient survived another 72 hours after the onset of the bleeding event. Given the prolonged period post onset of this patient's catastrophic bleed, this case demonstrates the effective use of an intravenous propofol infusion to facilitate comfort and sedation when drug classes such as benzodiazepines and barbiturates failed to do so. Given the successful outcome detailed in this case, we strongly advocate for the development of guidelines that incorporate propofol alongside other pharmacological measures when addressing palliative sedation.
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Affiliation(s)
| | - Heidi Gregory
- Palliative Care, Austin Health, Heidelberg, Victoria, Australia
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2
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Garcia Romo E, Pfang B, Valle Borrego B, Lobo Antuña M, Noguera Tejedor A, Rubio Gomez S, Galindo Vazquez V, Prieto Rios B. Successful Use of Propofol After Failed Palliative Sedation in Patients With Refractory Symptoms. J Palliat Med 2024. [PMID: 38973718 DOI: 10.1089/jpm.2023.0672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.
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Affiliation(s)
- Eduardo Garcia Romo
- Palliative Care Unit, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Bernadette Pfang
- Health Research Institute of the Jimenez Diaz Foundation, Madrid, Spain
| | | | | | | | - Silvia Rubio Gomez
- Palliative Care Unit, Beata María Ana de Hermanas Hospitalarias Hospital, Madrid, Spain
| | | | - Blanca Prieto Rios
- Palliative Care Unit, Fundación Jiménez Díaz University Hospital, Madrid, Spain
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3
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Camartin C, Björkhem-Bergman L. Palliative Sedation—The Last Resort in Case of Difficult Symptom Control: A Narrative Review and Experiences from Palliative Care in Switzerland. Life (Basel) 2022; 12:life12020298. [PMID: 35207585 PMCID: PMC8876692 DOI: 10.3390/life12020298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022] Open
Abstract
Palliative sedation can be considered as “the last resort” in order to treat unbearable, refractory symptoms or suffering in end-of-life patients. The aim is symptom relief and not to induce death as in the case of euthanasia. The treatment might be one of the most challenging therapeutic options in the field of palliative care, involving both ethical and practical issues. Still, studies have shown that it is a safe and valuable treatment and in general does not shorten the life of the patient. Since patients in Switzerland have the legal option of assisted suicide, palliative sedation is an alternative that has become increasingly important. The use of palliative sedation was reported in 17.5% of all patients admitted to palliative care in Switzerland, making the country of those with the highest use of this treatment. The aim of this narrative review is to discuss ethical and practical issues in palliative sedation, with specific focus on experiences from Switzerland. Indications, ethical considerations, drugs of choice and duration are discussed. Decision making should be based on solid guidelines. When used correctly, palliative sedation is an important and useful tool in palliative care in order to provide good symptom relief.
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Affiliation(s)
- Cristian Camartin
- Palliative Care, Kantonsspital Graubünden, Loestrasse 170, CH-7000 Chur, Switzerland
- Correspondence: ; Tel.: +41-81-254-85-23
| | - Linda Björkhem-Bergman
- Division of Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Blickagången 16, SE-141 83 Huddinge, Sweden;
- Palliative Care, Stockholms Sjukhem, Mariebergsgatan 22, SE-112 19 Stockholm, Sweden
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4
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Ammar MA, Ammar AA, Cheung CC, Akhtar S. Pharmacological Adjuncts to Palliation in the Trauma Patient: Optimal Symptom Management. CURRENT TRAUMA REPORTS 2021. [DOI: 10.1007/s40719-021-00215-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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5
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Takla A, Savulescu J, Wilkinson DJC, Pandit JJ. General anaesthesia in end-of-life care: extending the indications for anaesthesia beyond surgery. Anaesthesia 2021; 76:1308-1315. [PMID: 33878803 PMCID: PMC8581983 DOI: 10.1111/anae.15459] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 01/08/2023]
Abstract
In this article, we describe an extension of general anaesthesia – beyond facilitating surgery – to the relief of suffering during dying. Some refractory symptoms at the end of life (pain, delirium, distress, dyspnoea) might be managed by analgesia, but in high doses, adverse effects (e.g. respiratory depression) can hasten death. Sedation may be needed for agitation or distress and can be administered as continuous deep sedation (also referred to as terminal or palliative sedation) generally using benzodiazepines. However, for some patients these interventions are not enough, and others may express a clear desire to be completely unconscious as they die. We summarise the historical background of an established practice that we refer to as ‘general anaesthesia in end‐of‐life care’. We discuss its contexts and some ethical and legal issues that it raises, arguing that these are largely similar issues to those already raised by continuous deep sedation. To be a valid option, general anaesthesia in end‐of‐life care will require a clear multidisciplinary framework and consensus practice guidelines. We see these as an impending development for which the specialty should prepare. General anaesthesia in end‐of‐life care raises an important debate about the possible role of anaesthesia in the relief of suffering beyond the context of surgical/diagnostic interventions.
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Affiliation(s)
- A Takla
- Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
| | - J Savulescu
- Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - D J C Wilkinson
- Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia.,Department of Neonatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
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6
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Takla A, Savulescu J, Kappes A, Wilkinson DJC. British laypeople's attitudes towards gradual sedation, sedation to unconsciousness and euthanasia at the end of life. PLoS One 2021; 16:e0247193. [PMID: 33770083 PMCID: PMC7997648 DOI: 10.1371/journal.pone.0247193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/02/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Many patients at the end of life require analgesia to relieve pain. Additionally, up to 1/5 of patients in the UK receive sedation for refractory symptoms at the end of life. The use of sedation in end-of-life care (EOLC) remains controversial. While gradual sedation to alleviate intractable suffering is generally accepted, there is more opposition towards deliberate and rapid sedation to unconsciousness (so-called "terminal anaesthesia", TA). However, the general public's views about sedation in EOLC are not known. We sought to investigate the general public's views to inform policy and practice in the UK. METHODS We performed two anonymous online surveys of members of the UK public, sampled to be representative for key demographic characteristics (n = 509). Participants were given a scenario of a hypothetical terminally ill patient with one week of life left. We sought views on the acceptability of providing titrated analgesia, gradual sedation, terminal anaesthesia, and euthanasia. We asked participants about the intentions of doctors, what risks of sedation would be acceptable, and the equivalence of terminal anaesthesia and euthanasia. FINDINGS Of the 509 total participants, 84% and 72% indicated that it is permissible to offer titrated analgesia and gradual sedation (respectively); 75% believed it is ethical to offer TA. Eighty-eight percent of participants indicated that they would like to have the option of TA available in their EOLC (compared with 79% for euthanasia); 64% indicated that they would potentially wish for TA at the end of life (52% for euthanasia). Two-thirds indicated that doctors should be allowed to make a dying patient completely unconscious. More than 50% of participants believed that TA and euthanasia were non-equivalent; a third believed they were. INTERPRETATION These novel findings demonstrate substantial support from the UK general public for the use of sedation and TA in EOLC. More discussion is needed about the range of options that should be offered for dying patients.
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Affiliation(s)
- Antony Takla
- Faculty of Medicine, Nursing and Health Science, Monash University, Clayton, Victoria, Australia
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, United Kingdom
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, United Kingdom
- Murdoch Children’s Research Institute, Melbourne, Australia
| | - Andreas Kappes
- School of Arts and Social Sciences, Department of Psychology, City University of London, London, United Kingdom
| | - Dominic J. C. Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, United Kingdom
- Murdoch Children’s Research Institute, Melbourne, Australia
- John Radcliffe Hospital, Oxford, United Kingdom
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7
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Fredheim OM, Skulberg IM, Magelssen M, Steine S. Clinical and ethical aspects of palliative sedation with propofol-A retrospective quantitative and qualitative study. Acta Anaesthesiol Scand 2020; 64:1319-1326. [PMID: 32632937 DOI: 10.1111/aas.13665] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/29/2020] [Accepted: 06/18/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The anesthetic propofol is often mentioned as a drug that can be used in palliative sedation. The existing literature of how to use propofol in palliative sedation is scarce, with lack of information about how propofol could be initiated for palliative sedation, doses and treatment outcomes. AIM To describe the patient population, previous and concomitant medication, and clinical outcome when propofol was used for palliative sedation. METHODS A retrospective study with quantitative and qualitative data. All patients who during a 4.5-year period received propofol for palliative sedation at the Department of palliative medicine, Akershus University Hospital, Norway were included. RESULTS Fourteen patients were included. In six patients the main indication for palliative sedation was pain, in seven dyspnoea and in one delirium. In eight of these cases propofol was chosen because of the pharmacokinetic properties (rapid effect), and in the remaining cases propofol was chosen because midazolam in spite of dose titration failed to provide sufficient symptom relief. In all patients sedation and adequate symptom control was achieved during manual dose titration. During the maintenance phase three of 14 patients had spontaneous awakenings. At death, propofol doses ranged from 60 to 340 mg/hour. CONCLUSIONS Severe suffering at the end of life can be successfully treated with propofol for palliative sedation. This can be performed in palliative medicine wards, but skilled observation and dose titration throughout the period of palliative sedation is necessary. Successful initial sedation does not guarantee uninterrupted sedation until death. EDITORIAL COMMENT In palliative care, some patients at the end of life can reach a stage where there have been maximal analgesic and or anxiolytic treatments though without achieving comfort in the awake state. This report describes and discusses use of propofol in these infrequent cases to relieve suffering as part of palliative care.
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Affiliation(s)
- Olav M. Fredheim
- Department of Palliative Medicine Akershus University Hospital Lørenskog Norway
- Department of Circulation and Medical Imaging Faculty of Medicine Norwegian University of Science and Technology Trondheim Norway
- National Competence Centre for Complex Symptom Disorders Department of Pain and Complex Disorders St. Olavs Hospital Trondheim Norway
| | | | - Morten Magelssen
- Centre for Medical Ethics Institute of Health and Society University of Oslo Oslo Norway
| | - Siri Steine
- Department of Palliative Medicine Akershus University Hospital Lørenskog Norway
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8
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Sulistio M, Wojnar R, Michael NG. Propofol for palliative sedation. BMJ Support Palliat Care 2020; 10:4-6. [DOI: 10.1136/bmjspcare-2019-001899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/15/2019] [Indexed: 11/03/2022]
Abstract
Palliative sedation is the intentional use of sedatives to manage refractory symptom(s), such as pain and/or terminal restlessness. This case report describes the successful use of propofol, an ultra-fast-acting anaesthetic agent commonly used for anaesthesia induction and maintenance to manage refractory agitated delirium in an acute inpatient palliative medicine setting.
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9
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Bodnar J. The Use of Propofol for Continuous Deep Sedation at the End of Life: A Definitive Guide. J Pain Palliat Care Pharmacother 2019; 33:63-81. [DOI: 10.1080/15360288.2019.1667941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- John Bodnar
- John Bodnar, Penn Hospice at Chester County, West Chester, Pennsylvania, USA
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10
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Miele E, Mastronuzzi A, Cefalo MG, Del Bufalo F, De Pasquale MD, Serra A, Spinelli GP, De Sio L. Propofol-based palliative sedation in terminally ill children with solid tumors: A case series. Medicine (Baltimore) 2019; 98:e15615. [PMID: 31124940 PMCID: PMC6571440 DOI: 10.1097/md.0000000000015615] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE The palliative sedation therapy is defined as the intentional reduction of the alert state, using pharmacological tools. Propofol is a short-acting general anesthetic agent, widely used for induction and maintenance of general anesthesia and rarely employed in palliative care. PATIENT CONCERNS AND DIAGNOSES This case series describes 5 pediatric oncology inpatients affected by relapsed/refractory solid tumors received palliative sedation using propofol alone or in combination with opioids and benzodiazepines. INTERVENTIONS AND OUTCOMES Five terminally ill children affected by solid tumors received propofol-based palliative sedation. All patients were previously treated with opioids and some of them reduced the consumption of these drugs after propofol starting. In all cases the progressive increase of the level of sedation until the death has been the only effective measure of control of refractory symptoms related todisease progression and psychological suffering. LESSONS We evaluated the quality of propofol-based palliative sedation in a series of pediatric oncology patients with solid tumors at the end of their life. We concluded that propofol represents an effective and tolerable adjuvant drug for the management of intractable suffering and a practicable strategy for palliative sedation in pediatric oncology patients at the end of their life.
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Affiliation(s)
- Evelina Miele
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - Angela Mastronuzzi
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - M. Giuseppina Cefalo
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - Francesca Del Bufalo
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - M. Debora De Pasquale
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - Annalisa Serra
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - Gian Paolo Spinelli
- Unità Operativa Complessa Oncology, University of Rome “Sapienza”, Azienda Sanitaria Locale Latina District 1, Aprilia (LT), Rome, Italy
| | - Luigi De Sio
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
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11
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Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2019; 77:1623-1643. [PMID: 28864877 PMCID: PMC5613058 DOI: 10.1007/s40265-017-0804-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
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Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
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12
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van Deijck RH, Hasselaar JG, Krijnsen PJ, Gloudemans AJ, Verhagen SC, Vissers KC, Koopmans RT. The Practice of Continuous Palliative Sedation in Long-Term Care for Frail Patients with Existential Suffering. J Palliat Care 2017; 31:141-9. [DOI: 10.1177/082585971503100303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Some guidelines and recommendations identify existential suffering as a potential refractory symptom for which continuous palliative sedation (CPS) can be administered under certain conditions. However, there has been little research on the characteristics of patients with existential suffering treated with CPS and the degree to which the preconditions are fulfilled. The aim of this study was to provide insight into this specific indication for CPS. Questionnaires were sent to nursing home physicians in the Netherlands, who described 314 patients. Existential suffering was a refractory symptom in 83 of the patients. For most of the patients with refractory existential suffering, other refractory symptoms were also reported, and life expectancy was seven days or less; informed consent for initiating CPS had been obtained in all cases. Consultation and intermittent sedation before the start of CPS were far less frequently reported than one would expect based on the guidelines. Multivariate analysis showed that being male, having previously requested euthanasia, having a nervous system disease, or having an other diagnosis were positively correlated with the administration of CPS for existential suffering. We conclude that more attention should be paid to the suggested preconditions and to the presence of existential suffering in male patients or patients with a nervous system disease.
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Affiliation(s)
| | - Jeroen G.J. Hasselaar
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Petrus J.C. Krijnsen
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden, Netherlands
| | | | - Stans C.A.H.H.V.M. Verhagen
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Kris C.P. Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Raymond T.C.M. Koopmans
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, Netherlands; and De Waalboog, Specialized Geriatric Care Centre Joachim en Anna, Nijmegen, Netherlands
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13
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Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2017. [PMID: 28864877 DOI: 10.1007/s40265‐017‐0804‐3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
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Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
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14
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Covarrubias-Gómez A, López Collada-Estrada M. Propofol-Based Palliative Sedation to Treat Antipsychotic-Resistant Agitated Delirium. J Pain Palliat Care Pharmacother 2017; 31:190-194. [PMID: 28506099 DOI: 10.1080/15360288.2017.1315476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Delirium is a common problem in terminally ill patients that is associated with significant distress and, hence, considered a palliative care emergency. The three subtypes of delirium are hyperactive, hypoactive, and mixed, depending on the level of psychomotor activity and arousal disturbance. When agitated delirium becomes refractory in the setting of imminent dying, the agitation may be so severe that palliative sedation (PS) is required. Palliative sedation involves the administration of sedative medications with the purpose of reducing level of consciousness for patients with refractory suffering in the setting of a terminal illness. Propofol is a sedative that has a short duration of action and a very rapid onset. These characteristics make it relatively easy to titrate. Reported doses range from 50 to 70 mg per hour. The authors present a case of antipsychotic-resistant agitated delirium treated with a propofol intravenous infusion.
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15
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Bispectral Index monitoring in cancer patients undergoing palliative sedation: a preliminary report. Support Care Cancer 2017; 25:3143-3149. [DOI: 10.1007/s00520-017-3722-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/17/2017] [Indexed: 10/19/2022]
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16
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Bodnar J. A Review of Agents for Palliative Sedation/Continuous Deep Sedation: Pharmacology and Practical Applications. J Pain Palliat Care Pharmacother 2017; 31:16-37. [PMID: 28287357 DOI: 10.1080/15360288.2017.1279502] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Continuous deep sedation at the end of life is a specific form of palliative sedation requiring a care plan that essentially places and maintains the patient in an unresponsive state because their symptoms are refractory to any other interventions. Because this application is uncommon, many providers may lack practical experience in this specialized area and resources they can access are outdated, nonspecific, and/or not comprehensive. The purpose of this review is to provide an evidence- and experience-based reference that specifically addresses those medications and regimens and their practical applications for this very narrow, but vital, aspect of hospice care. Patient goals in a hospital and hospice environments are different, so the manner in which widely used sedatives are dosed and applied can differ greatly as well. Parameters applied in end-of-life care that are based on experience and a thorough understanding of the pharmacology of those medications will differ from those applied in an intensive care unit or other medical environments. By recognizing these different goals and applying well-founded regimens geared specifically for end-of-life sedation, we can address our patients' symptoms in a more timely and efficacious manner.
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Ciais JF, Tremellat F, Castelli-Prieto M, Jestin C. Sedation by Propofol for Painful Care Procedures at the End of Life: A Pilot Study. PROPOPAL 1. J Palliat Med 2016; 20:282-284. [PMID: 27673357 DOI: 10.1089/jpm.2016.0184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND At the end of life, patients may feel refractory pain during care procedures although they receive appropriate analgesia. They can benefit from a short-term sedation. Propofol is used for procedural sedation in emergency or reanimation departments. It may be adapted in a palliative care unit. OBJECTIVE The main objective was to verify whether propofol could allow us to administer care without causing major pain to patients with refractory pain at the end of life. DESIGN We conducted an open, prospective, and uncontrolled pilot study. SETTING/SUBJECTS The study was conducted in one palliative care center in France. The subjects were patients with an estimated prognosis less than three months who experienced pain during care procedures, although they receive appropriate analgesia. RESULTS Ten patients were included. Care was delivered with no major pain for 9 patients out of 10. The average duration of induction to reach deep sedation was 4 minutes (2-8) and of care procedures was 13 minutes (7-32). On average, the patient woke up 11.5 minutes after we stopped injecting propofol (7-18). Only one patient experienced a significant adverse effect caused by propofol, but it did not have any harmful consequence except the interruption of care procedures. CONCLUSION Transitory sedation using propofol for terminally ill patients hospitalized in a palliative care unit can offer optimal comfort during painful care procedures without significant complications. Patients woke up quickly. Further studies will have to be conducted to verify these initial results and make sure there are no major drawbacks.
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Affiliation(s)
| | - Flora Tremellat
- Department of Palliative Care, Centre Hospitalier de Nice , Nice, France
| | | | - Caroline Jestin
- Department of Palliative Care, Centre Hospitalier de Nice , Nice, France
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Schur S, Weixler D, Gabl C, Kreye G, Likar R, Masel EK, Mayrhofer M, Reiner F, Schmidmayr B, Kirchheiner K, Watzke HH. Sedation at the end of life - a nation-wide study in palliative care units in Austria. BMC Palliat Care 2016; 15:50. [PMID: 27180238 PMCID: PMC4868021 DOI: 10.1186/s12904-016-0121-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 05/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sedation is used to an increasing extent in end-of-life care. Definitions and indications in this field are based on expert opinions and case series. Little is known about this practice at palliative care units in Austria. METHODS Patients who died in Austrian palliative care units between June 2012 and June 2013 were identified. A predefined set of baseline characteristics and information on sedation during the last two weeks before death were obtained by reviewing the patients' charts. RESULTS The data of 2414 patients from 23 palliative care units were available for analysis. Five hundred two (21 %) patients received sedation in the last two weeks preceding their death, 356 (71 %) received continuous sedation until death, and 119 (24 %) received intermittent sedation. The median duration of sedation was 48 h (IQR 10-72 h); 168 patients (34 %) were sedated for less than 24 h. Indications for sedation were delirium (51 %), existential distress (32 %), dyspnea (30 %), and pain (20 %). Midazolam was the most frequently used drug (79 %), followed by lorazepam (13 %), and haloperidol (10 %). Sedated patients were significantly younger (median age 67 years vs. 74 years, p ≤ 0.001, r = 0.22), suffered more often from an oncological disease (92 % vs. 82 %, p ≤ 0.001, φ = 0.107), and were hospitalized more frequently (94 % vs. 76 %, p ≤ 0.001, φ = 0.175). The median number of days between admission to a palliative care ward/mobile palliative care team and death did not differ significantly in sedated versus non-sedated patients (10 vs. 9 days; p = 0.491). CONCLUSION This study provides insights into the practice of end-of-life sedation in Austria. Critical appraisal of these data will serve as a starting point for the development of nation-wide guidelines for palliative sedation in Austria.
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Affiliation(s)
- Sophie Schur
- Clinical Division of Palliative Care, Department for Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | | | - Christoph Gabl
- Mobile Hospice and Palliative Care Team, Tiroler Hospizgemeinschaft, Innsbruck, Austria
| | - Gudrun Kreye
- Department of Internal Medicine, University Hospital Krems, Krems, Austria
| | - Rudolf Likar
- Department of Anaesthesiology and Intensive Medicine, Interdisciplinary Center of Pain Therapy and Palliative Medicine, General Hospital Klagenfurt, Klagenfurt, Austria
| | - Eva Katharina Masel
- Clinical Division of Palliative Care, Department for Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Michael Mayrhofer
- Clinical Division of Palliative Care, Department for Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Franz Reiner
- Department for Palliative Care, Salzkammergut-Klinikum, Vöcklabruck, Austria
| | - Barbara Schmidmayr
- Department of Internal Medicine, Krankenhaus der Elisabethinen, Graz, Austria
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Herbert Hans Watzke
- Clinical Division of Palliative Care, Department for Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Hunter-Johnson L, Wheeler WL. Use of Propofol To Manage Nonmalignant Intractable Nausea and Vomiting: A Case Study. J Palliat Med 2016; 19:252-3. [DOI: 10.1089/jpm.2015.0453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Leslie Hunter-Johnson
- Division of Palliative Medicine, Sunrise Hospital and Medical Center, Las Vegas, Nevada
| | - Warren L. Wheeler
- Division of Palliative Medicine, Elaine Wynn Palliative Care Program, Nathan Adelson Hospice, Las Vegas, Nevada
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Schildmann EK, Schildmann J, Kiesewetter I. Medication and monitoring in palliative sedation therapy: a systematic review and quality assessment of published guidelines. J Pain Symptom Manage 2015; 49:734-46. [PMID: 25242022 DOI: 10.1016/j.jpainsymman.2014.08.013] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/14/2014] [Accepted: 08/25/2014] [Indexed: 11/29/2022]
Abstract
CONTEXT Palliative sedation therapy (PST) is increasingly used in patients at the end of life. However, consensus about medications and monitoring is lacking. OBJECTIVES To assess published PST guidelines with regard to quality and recommendations on drugs and monitoring. METHODS We searched CINAHL, the Cochrane Library, Embase, PsycINFO, PubMed, and references of included articles until July 2014. Search terms included "palliative sedation" or "sedation" and "guideline" or "policy" or "framework." Guideline selection was based on English or German publications that included a PST guideline. Two investigators independently assessed the quality of the guidelines according to the Appraisal of Guidelines for Research and Evaluation II instrument (AGREE II) and extracted information on drug selection and monitoring. RESULTS Nine guidelines were eligible. Eight guidelines received high quality scores for the domain "scope and purpose" (median 69%, range 28-83%), whereas in the other domains the guidelines' quality differed considerably. The majority of guidelines suggest midazolam as drug of first choice. Recommendations on dosage and alternatives vary. The guidelines' recommendations regarding monitoring of PST show wide variation in the number and details of outcome parameters and methods of assessment. CONCLUSION The published guidelines on PST vary considerably regarding their quality and content on drugs and monitoring. Given the need for clear guidance regarding PST in patients at the end of life, this comparative analysis may serve as a starting point for further improvement.
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Affiliation(s)
| | - Jan Schildmann
- Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum, Bochum, Germany.
| | - Isabel Kiesewetter
- Department of Palliative Medicine, Munich University Hospital, Munich, Germany; Department of Anesthesiology, Munich University Hospital, Munich, Germany
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21
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Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol 2014; 12:77-92. [DOI: 10.1038/nrclinonc.2014.147] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Irwin SA, Pirrello RD, Hirst JM, Buckholz GT, Ferris FD. Clarifying delirium management: practical, evidenced-based, expert recommendations for clinical practice. J Palliat Med 2013; 16:423-35. [PMID: 23480299 PMCID: PMC3612281 DOI: 10.1089/jpm.2012.0319] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2013] [Indexed: 12/30/2022] Open
Abstract
Delirium is highly prevalent in those with serious or advanced medical illnesses. It is associated with many adverse consequences, including significant patient, family, and health care provider distress. This article suggests a novel approach to delirium assessment and management and provides useful, practical guidance for clinicians based on a complete review of the existing literature and the expert clinical opinion of the authors and their colleagues, derived from over a decade of collective bedside experience. Comprehensive assessment includes careful description of observed symptoms, signs, and behaviors; and an understanding of the patient's situation, including primary diagnosis, associated comorbidities, functional status, and prognosis. The importance of incorporating goals of care for the patient and family is discussed. The concepts of potential reversibility versus irreversible delirium and delirium subtype are proffered, with a description of how diagnostic and management strategies follow from these concepts. Pharmacological interventions that provide rapid, effective, and safe relief are presented. Employing both pharmacological and nonpharmacological interventions, including patient and family education, improves symptoms and relieves patient and family distress, whether the delirium is reversible or irreversible, hyperactive or hypoactive. All interventions can be provided in any setting of care, including patients' homes.
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Affiliation(s)
- Scott A Irwin
- San Diego Hospice and The Institute for Palliative Medicine, San Diego, CA 92103, USA.
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Brinkkemper T, van Norel AM, Szadek KM, Loer SA, Zuurmond WWA, Perez RSGM. The use of observational scales to monitor symptom control and depth of sedation in patients requiring palliative sedation: a systematic review. Palliat Med 2013; 27:54-67. [PMID: 22045725 DOI: 10.1177/0269216311425421] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Palliative sedation is the intentional lowering of consciousness of a patient in the last phase of life to relieve suffering from refractory symptoms such as pain, delirium and dyspnoea. AIM In this systematic review, we evaluated the use of monitoring scales to assess the degree of control of refractory symptoms and/or the depth of the sedation. DESIGN A database search of PubMed and Embase was performed up to January 2010 using the search terms 'palliative sedation' OR 'terminal sedation'. DATA SOURCES Retro- and prospective studies as well as reviews and guidelines containing information about monitoring of palliative sedation, written in the English, German or Dutch language were included. RESULTS The search yielded 264 articles of which 30 were considered relevant. Most studies focused on monitoring refractory symptoms (pain, fatigue or delirium) or the level of awareness to control the level of sedation. Four prospective and one retrospective study used scales validated in other settings: the Numeric Pain Rating Scale, the Visual Analogue Scale, the Memorial Delirium Assessment Scale, the Communication Capacity Scale and Agitation Distress Scale. Only the Community Capacity Scale was partially validated for use in a palliative sedation setting. One guideline described the use of a scale validated in another setting. CONCLUSIONS A minority of studies reported the use of observational scales to monitor the effect of palliative sedation. Future studies should be focused on establishing proper instruments, most adequate frequency and timing of assessment, and interdisciplinary evaluation of sedation depth and symptom control for palliative sedation.
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Affiliation(s)
- Tijn Brinkkemper
- Department of Anaesthesiology, VU University Medical Centre, Amsterdam, The Netherlands.
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Benze G, Geyer A, Alt-Epping B, Nauck F. [Treatment of nausea and vomiting with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatinantagonists, benzodiazepines and cannabinoids in palliative care patients : a systematic review]. Schmerz 2012; 26:481-99. [PMID: 22983450 DOI: 10.1007/s00482-012-1235-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Various recommendations exist for the treatment of nausea and vomiting in palliative care but only few studies and even less systematic reviews look into antiemetic therapy for patients receiving palliative care. OBJECTIVES This systematic review aims to analyze the current evidence for antiemetic treatment with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines and cannabinoids in palliative care patients with far advanced cancer not receiving chemotherapy or radiotherapy, acquired immune deficiency syndrome (AIDS), chronic obstructive pulmonary disease (COPD), progressive heart failure, amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS). Results regarding evidence of treatment with prokinetic and neuroleptic agents will be published separately. METHODS The electronic databases PubMed and EmBase were systematically searched for studies (published 1966-2011) dealing with antiemetic therapy in palliative care and electronic retrieval was completed by manual searching. Studies with patients undergoing chemotherapy or radiotherapy, pediatric studies and studies published in languages other than English or German were excluded. Studies addressing therapy with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines or cannabinoids were identified and selected for this systematic review. RESULTS In the general search 75 relevant studies were found. Of those 36 addressed 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines and cannabinoids, 13 considered 5HT3 receptor antagonists, 10 somatostatin antagonists, 9 steroids, 5 cannabinoids, 4 anticholinergics, 1 antihistamines and none benzodiazepines. Furthermore six systematic reviews exist. Evidence for any drug used as an antiemetic is low. Concerning 5HT3 receptor antagonists data are insufficient for recommendations on the treatment of patients with AIDS and MS due to the small size of included patient groups. For patients with cancer contradictory results were published: the larger studies showed a positive effect of 5HT3 receptor antagonists and better efficacy, as compared to metoclopramide, dexamethasone and neuroleptics. Heterogeneous results were found for steroids, with a positive trend for patients with cancer. Data are insufficient for antihistamines. Studies prove effectiveness of butylscopolammonium in the treatment of nausea and vomiting caused by malignant gastrointestinal obstruction, whereas octreotide is superior to butylscopolammonium. Regarding benzodiazepines for symptom control of nausea and vomiting in palliative care patients no studies were detected. Cannabinoids were found to relieve nausea and vomiting in patients with cancer and AIDS but with notable side effects. Furthermore, the studies compared cannabinoids to less recent antiemetic drugs but not, for example to 5HT3 receptor antagonists. Regarding symptom control of nausea and vomiting in patients with COPD, progressive heart failure and ALS no studies were undertaken in patients receiving palliative care. CONCLUSIONS In palliative care patients with nausea and vomiting 5HT3 receptor antagonists can be used if treatment with other antiemetics, such as metoclopramide and neuroleptics is not sufficient. There is a trend that steroids in combination with other antiemetics improve symptom relief. Cannabinoids rather have a status as a second line antiemetic. In cases of nausea and vomiting caused by malignant gastrointestinal obstruction octreotide showed the best and butylscopolammonium bromide the second best results. Concerning antihistamines and benzodiazepines insufficient data was found. Recommendations in the literature are mainly based on studies in patients with cancer. The overall strength of evidence is low. More well designed studies in palliative care patients are needed in order to provide evidence-based therapy. The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").
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Affiliation(s)
- G Benze
- Abteilung Palliativmedizin, Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Georg-August-Universität Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
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Papadimos TJ, Maldonado Y, Tripathi RS, Kothari DS, Rosenberg AL. An overview of end-of-life issues in the intensive care unit. Int J Crit Illn Inj Sci 2012; 1:138-46. [PMID: 22229139 PMCID: PMC3249847 DOI: 10.4103/2229-5151.84801] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.
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Affiliation(s)
- Thomas J Papadimos
- Department of Anesthesiology, Division of Critical Care Medicine, The Ohio State University Medical Center, Columbus OH 43210, USA
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Anghelescu DL, Hamilton H, Faughnan LG, Johnson LM, Baker JN. Pediatric palliative sedation therapy with propofol: recommendations based on experience in children with terminal cancer. J Palliat Med 2012; 15:1082-90. [PMID: 22731512 DOI: 10.1089/jpm.2011.0500] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The use of propofol for palliative sedation of children is not well documented. OBJECTIVE Here we describe our experience with the use of propofol palliative sedation therapy (PST) to alleviate intractable end-of-life suffering in three pediatric oncology patients, and propose an algorithm for the selection of such candidates for PST. PATIENTS AND METHODS We identified inpatients who had received propofol PST within 20 days of death at our institution between 2003 and 2010. Their medical records were reviewed for indicators of pain, suffering, and sedation from 48 hours before PST to the time of death. We also tabulated consumption of opioids and other symptom management medications, pain scores, and adverse events of propofol, and reviewed clinical notes for descriptors of suffering and/or palliation. RESULTS Three of 192 (1.6%) inpatients (aged 6-15 years) received propofol PST at the end of life. Consumption of opioids and other supportive medications decreased during PST in two cases. In the third case, pain scores remained high and sedation was the only effective comfort measure. Clinical notes suggested improved comfort and rest in all patients. Propofol infusions were continued until the time of death. CONCLUSIONS Our experience demonstrates that propofol PST is a useful palliative option for pediatric patients experiencing intractable suffering at the end of life. We describe an algorithm that can be used to identify such children who are candidates for PST.
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Affiliation(s)
- Doralina L Anghelescu
- Division of Anesthesiology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA.
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Lindblad A, Juth N, Fürst CJ, Lynöe N. Continuous deep sedation, physician-assisted suicide, and euthanasia in Huntington's disorder. Int J Palliat Nurs 2011; 16:527-33. [PMID: 21135785 DOI: 10.12968/ijpn.2010.16.11.80019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To investigate the attitudes among Swedish physicians and the general public towards continuous deep sedation (CDS) as an alternative treatment for a competent, not imminently dying patient with Huntington's disorder requesting physician-assisted suicide (PAS) and euthanasia. DESIGN A questionnaire was distributed to 1200 physicians in Sweden and 1201 individuals in Stockholm. It consisted of three parts: 1) A vignette about a competent patient with Huntington's disease requesting PAS. When no longer competent, relatives request euthanasia on behalf of the patient. Responders were asked about their attitudes towards these requests and whether CDS would be an acceptable alternative. 2) General questions about PAS and euthanasia. 3) Background variables. RESULTS The response rate was 56% (physicians) and 52% (general public). The majority of the general public and a fairly large proportion of physicians reported more liberal views on CDS than are expressed in current Swedish and international recommendations. CONCLUSION In light of the results, we suggest that there is a need for a broader discussion about the recommendations for CDS, with a special focus on the needs of patients with progressive neurodegenerative disorders.
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Affiliation(s)
- Anna Lindblad
- Stockholm Centre for Healthcare Ethics, Karolinska Institutet, Stockholm, Sweden
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Abstract
Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. The content is also available on www.palliativedrugs.com and will feature in future editions of the Hospice and Palliative Care Formulary USA and its British and Canadian counterparts. The series editors welcome feedback on the articles (hq@palliativedrugs.com).
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Affiliation(s)
- Staffan Lundström
- Stockholms Sjukhem Foundation and Karolinska Institute, Stockholm, Sweden
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29
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Sedierung in der Palliativmedizin*: Leitlinie für den Einsatz sedierender Maßnahmen in der Palliativversorgung. Schmerz 2010; 24:342-54. [DOI: 10.1007/s00482-010-0948-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kirk TW, Mahon MM. National Hospice and Palliative Care Organization (NHPCO) position statement and commentary on the use of palliative sedation in imminently dying terminally ill patients. J Pain Symptom Manage 2010; 39:914-23. [PMID: 20471551 DOI: 10.1016/j.jpainsymman.2010.01.009] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2009] [Accepted: 01/04/2010] [Indexed: 11/25/2022]
Affiliation(s)
- Timothy W Kirk
- Department of History & Philosophy, City University of New York-York College, Jamaica, New York 11451, USA.
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McWilliams K, Keeley PW, Waterhouse ET. Propofol for terminal sedation in palliative care: a systematic review. J Palliat Med 2010; 13:73-6. [PMID: 19827968 DOI: 10.1089/jpm.2009.0126] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION We undertook a systematic review of published evidence of the effectiveness of propofol for terminal sedation. INCLUSIONS: Prospective or retrospective trials (controlled or uncontrolled) or case series of propofol for sedation in advanced incurable disease in either generalist setting or specialist palliative care units. EXCLUSIONS Use in anesthetic or intensivist settings (e.g., intensive care units); pediatric use. Identification of relevant studies: Using the search terms: [Hospice Care/OR Terminal Care/OR Palliative Care/OR palliative.mp] AND [Propofol/]. Studies were identified using a detailed search strategy from a number of electronic databases: Embase (1988-2005); MEDLINE (1966-2005) Cinahl (1982-2005), Cancerlit (1962-2005) The Cochrane Database of Systematic Reviews 2005 Issue 4. Hand searches of a number of palliative care journals were also undertaken (Palliative Medicine, Journal of Pain and Symptom Management, Progress in Palliative Care, Journal of Palliative Care, Journal of Palliative Medicine). No restriction was placed on the language of the original article. RESULTS Four articles--all case series or case reports--reporting generally favorable reports of the use of propofol as sedation for intractable symptoms in the last days of life especially when one or more other drugs have failed. Since these four articles are essentially hypothesis-generating, the article also discusses the possibility of the design of a clinical trial to compare propofol with other drugs used in this situation.
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Davis MP, Hallerberg G. A systematic review of the treatment of nausea and/or vomiting in cancer unrelated to chemotherapy or radiation. J Pain Symptom Manage 2010; 39:756-67. [PMID: 20413062 DOI: 10.1016/j.jpainsymman.2009.08.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 07/31/2009] [Accepted: 08/04/2009] [Indexed: 11/21/2022]
Abstract
CONTEXT A systematic review of antiemetics for emesis in cancer unrelated to chemotherapy and radiation is an important step in establishing treatment recommendations and guiding future research. Therefore, a systematic review based on the question "What is the evidence that supports antiemetic choices in advanced cancer?" guided this review. OBJECTIVES To determine the level of evidence for antiemtrics in the management of nausea and vomiting in advanced cancer unrelated to chemotherapy and radiation, and to discover gaps in the evidence, which would provide important areas for future research. METHODS Three databases and independent searches using different MeSH terms were performed. Related links were searched and hand searches of related articles were made. Eligible studies included randomized controlled trials (RCTs), prospective single-drug studies, studies that used guidelines based on the etiology of emesis, cohort studies, retrospective studies, and case series or single-patient reports. Studies that involved treatment of chemotherapy, radiation, or postoperation-related emesis were excluded. Studies that involved the treatment of emesis related to bowel obstruction were included. The strength of evidence was graded as follows: 1) RCTs, A; 2) single-drug prospective studies, B1; 3) studies based on multiple drug choices for etiology of emesis, B2; and 4) cohort, case series, retrospective, and single-patient reports, E. Level of evidence was determined by the Oxford Centre for Evidence-Based Medicine Levels of Evidence (May 2001) (A, B, C, D). RESULTS Ninety-three articles were found. Fourteen were RCTs, most of them of low quality, based either on lack of blinding, lack of description of the method of randomization, concealment, and/or attrition. Metoclopramide had modest evidence (B) based on RCTs and prospective cohort studies. Octreotide, dexamethasone, and hyoscine butylbromide are effective in reducing symptoms of bowel obstruction, based on prospective studies and/or one RCT. There was no evidence that either multiple antiemetics or antiemetic choices based on the etiology of emesis were any better than a single antiemetic. There is poor evidence for dose response, intraclass or interclass drug switch, or antiemetic combinations in those individuals failing to respond to the initial antiemetic. CONCLUSION There are discrepancies between antiemetic studies and published antiemetic guidelines, which are largely based on expert opinion. Antiemetic recommendations have moderate to weak evidence at best. Prospective randomized trials of single antiemetics are needed to properly establish evidence-based guidelines.
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Affiliation(s)
- Mellar P Davis
- The Harry R Horvitz Center for Palliative Medicine, Division of Solid Tumor, The Taussig Cancer Center, The Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Abstract
Delirium remains the most common and distressing neuropsychiatric complication in patients with advanced cancer. Delirium causes significant distress to patients and their families, and continues to be underdiagnosed and undertreated. The most frequent, consistent, and, at the same time, reversible etiology is drug-induced delirium resulting from opioids and other psychoactive medications. The objective of this narrative review is to outline the causes of delirium in advanced cancer, especially drug-induced delirium, and the diagnosis and management of opioid-induced neurotoxicity. The early symptoms and signs of delirium and the use of delirium-specific assessment tools for routine delirium screening and monitoring in clinical practice are summarized. Finally, management options are reviewed, including pharmacological symptomatic management and also the provision of counseling support to both patients and their families to minimize distress.
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Affiliation(s)
- Shirley H Bush
- Department of Palliative Care & Rehabilitation Medicine, University of Texas M.D. Anderson CancerCenter, Houston, Texas, USA.
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Cherny NI, Radbruch L. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009; 23:581-93. [PMID: 19858355 DOI: 10.1177/0269216309107024] [Citation(s) in RCA: 405] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review.
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Affiliation(s)
- Nathan I Cherny
- Shaare Zedek Medical Center, Department of Oncology, Jerusalem, Israel.
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When cancer symptoms cannot be controlled: the role of palliative sedation. Curr Opin Support Palliat Care 2009; 3:14-23. [PMID: 19365157 DOI: 10.1097/spc.0b013e3283260628] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Palliative sedation, the intentional lowering of consciousness for refractory and unbearable distress, has been much discussed during the last decade. In recent years, much research has been published about this subject that will be discussed in this review. The review concentrates on: a brief overview of the main developments during the last decade, an exploration of current debate regarding ethical dilemmas, the development of clinical guidelines, and the application of palliative sedation. RECENT FINDINGS Main findings are that palliative sedation is mostly described in retrospective studies and that the terminology palliative sedation in now common in the majority of the studies. In addition, life-shortening effects for palliative sedation are scarcely reported, although not absent. A number of guidelines have been developed and published, although systematic implementation needs more attention. Consequently, palliative sedation has become more clearly positioned as a medical treatment, to be distinguished from active life shortening. SUMMARY Caregivers should apply palliative sedation proportionally, guided by the symptoms of the patient without striving for deep coma and without motives for life shortening. Clinical and multidisciplinary assessment of refractory symptoms is recommended as is patient monitoring during sedation. Future research should concentrate on proportional sedation rather than continuous deep sedation exclusively, preferably in a prospective design.
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Palliative Sedierungstherapie in der Pädiatrie. Wien Med Wochenschr 2008; 158:659-63. [DOI: 10.1007/s10354-008-0617-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Accepted: 10/28/2008] [Indexed: 11/26/2022]
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Herndon CM, Zimmerman E. High-Dose Propofol Drip for Palliative Sedation: A Case Report. Am J Hosp Palliat Care 2008; 25:492-5. [DOI: 10.1177/1049909108319268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Oftentimes, patients at the end of life may present with challenging symptoms refractory to conventional therapies. Agitation and terminal restlessness, 2 common symptoms encountered in the hospice population, are frequently managed using benzodiazepines or typical antipsychotics. In clinical scenarios that either preclude their use or in which they prove ineffective, alternative pharmacotherapy must be considered. Propofol, a sedative-hypnotic unrelated to any other class of drug, may provide palliation of agitation and terminal restlessness refractory to benzodiazepines or antipsychotics. Here, the authors present a hospice patient admitted to the general medical floor of a small community hospital for pain and symptom management. A history of polysubstance abuse contributes to rapidly escalating doses of opioids and midazolam. Failure to control her symptoms resulted in the initiation and successful titration of propofol.
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Affiliation(s)
- Christopher M. Herndon
- Department of Pharmacy Practice, Southern Illinois University Edwardsville School of Pharmacy, Edwardsville,
| | - Ethan Zimmerman
- Department of Pharmacy Practice, Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, Department of Community and Family Medicine, St. Louis University School of Medicine, Belleville Family Health Center, Belleville Illinois
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Use of palliative sedation for intractable symptoms in the palliative care unit of a comprehensive cancer center. Support Care Cancer 2008; 17:53-9. [DOI: 10.1007/s00520-008-0459-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Accepted: 04/09/2008] [Indexed: 01/21/2023]
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Abstract
Despite advances in cancer survival rates, end of life care remains a vital aspect of cancer management. The use of integrated care pathways can facilitate effective care of dying patients in a generalist setting. However, it remains important that staff are able to recognise the onset of the dying process, not only in order to make symptom control provision, but also that appropriate communication can occur with patients and those close to them. This allows the exercise of choice over place and style of care. The key symptoms at the end of life are restlessness, agitation, breathlessness, pain and noisy respiration from retained airway secretions. Ethical tensions arise from the assumptions that the use of opioids and sedatives hastens dying, but this is contradicted by available evidence.
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Affiliation(s)
- Nigel Sykes
- Palliative Medicine, St. Christopher's Hospice, Lawrie Park Road, London, United Kingdom.
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de Graeff A, Dean M. Palliative Sedation Therapy in the Last Weeks of Life: A Literature Review and Recommendations for Standards. J Palliat Med 2007; 10:67-85. [PMID: 17298256 DOI: 10.1089/jpm.2006.0139] [Citation(s) in RCA: 237] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
PURPOSE Palliative sedation therapy (PST) is a controversial issue. There is a need for internationally accepted definitions and standards. METHODS A systematic review of the literature was performed by an international panel of 29 palliative care experts. Draft papers were written on various topics concerning PST. This paper is a summary of the individual papers, written after two meetings and extensive e-mail discussions. RESULTS PST is defined as the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness, using appropriate drugs carefully titrated to the cessation of symptoms. The initial dose of sedatives should usually be small enough to maintain the patients' ability to communicate periodically. The team looking after the patient should have enough expertise and experience to judge the symptom as refractory. Advice from palliative care specialists is strongly recommended before initiating PST. In the case of continuous and deep PST, the disease should be irreversible and advanced, with death expected within hours to days. Midazolam should be considered first-line choice. The decision whether or not to withhold or withdraw hydration should be discussed separately. Hydration should be offered only if it is considered likely that the benefit will outweigh the harm. PST is distinct from euthanasia because (1) it has the intent to provide symptom relief, (2) it is a proportionate intervention, and (3) the death of the patient is not a criterion for success. PST and its outcome should be carefully monitored and documented. CONCLUSION When other treatments fail to relieve suffering in the imminently dying patient, PST is a valid palliative care option.
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Affiliation(s)
- Alexander de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, F.02.126 Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Laser Literature Watch. Photomed Laser Surg 2006; 24:222-48. [PMID: 16706704 DOI: 10.1089/pho.2006.24.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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