Palliative Sedation for the Terminally Ill Patient

Palliative sedation (PS) is performed in the terminally ill patient to manage one or more refractory symptoms. Proportional PS, which means that drugs can be titrated to the minimum effective dose, is the form most widely used. From a quarter to a third of all terminally ill patients undergo PS, with a quarter of these requiring continuous deep sedation. The prevalence of PS varies according to the care setting and case mix. The most frequent refractory physical symptoms are delirium and dyspnea, but PS is also considered for existential suffering or psychological distress, which is an extremely difficult and delicate issue to deal with. Active consensus from the patient and advanced care planning is recommended for PS. The decision-making process concerning the continuation or withdrawal of other treatments is not the same as that used for PS. The practice differs totally from euthanasia in its intentions, procedures, and results. The most widely used drugs are midazolam and haloperidol for refractory delirium, but chlorpromazine and other neuroleptics are also effective. In conclusion, some patients experience refractory symptoms during the last hours or days of life and PS is a medical intervention aimed at managing this unbearable suffering. It does not have a detrimental effect on survival.

A Protocol for the Control of Agitation in Palliative Care

Background:

Agitation is a distressing and dangerous behavior for all involved.

Objective:

To study a protocol effectiveness and safety.

Methods:

The time when the protocol was initiated and when the agitation was controlled, the number of doses needed and the complications observed were recorded.

Results:

One hundred and thirty-five inpatients of a palliative care service were included. The most frequent diagnosis was head and neck cancer, 37 (27%). The protocol was used 584 times, from 1 to 31 times on each patient, median of 3 times. Five hundred and thirty-four (91%) agitation episodes were controlled with only the first dose of the protocol, without significant complications.

Conclusion:

From those results, it can be said that this protocol is effective and safe.

Palliative sedation for intolerable suffering

PURPOSE OF REVIEW

The purpose of this review is to provide an update on palliative sedation in palliative and end-of-life care. Palliative sedation is the medical procedure used to deal with refractory symptoms in advanced cancer patients when all other specific approaches have failed.

RECENT FINDINGS

Palliative sedation, in the strictest sense of the term, is a proportionate (proportionate palliative sedation, PPS) and intrinsically variable procedure used on an individual basis to relieve refractory symptoms in terminally ill patients, without the intention of hastening death. Completely separate from any other end-of-life decision and not intended to hasten death, palliative sedation has been shown not to have a detrimental impact on survival.

SUMMARY

To maintain palliative sedation as a legitimate clinical procedure from any ethical or clinical point of view, it must be limited to the restricted area for which it was conceived, that is, relief from refractory suffering as deemed necessary by a patient and by an experienced palliative care team. In this way, there is no risk of associating palliative sedation with other end-of-life decisions. Close collaboration is needed between oncologists and palliative care physicians for this clinical procedure.

End-of-life delirium: issues regarding recognition, optimal management, and the role of sedation in the dying phase

CONTEXT

In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase.

OBJECTIVES

To review delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium.

METHODS

We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO, and CINAHL) to inform this narrative review.

RESULTS

The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high-level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health-care staff, clear communication, education, and emotional support are vital components to assist with decision making and direct the treatment care plan.

CONCLUSION

Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement is needed in this patient population.

Variation in the incidence of agitated delirium during the day in a palliative care unit: a preliminary report

In the literature regarding delirium and agitation in palliative care, there are references of their worsening as the hours of the day flows from afternoon on, with an inversion of the awake-sleep cycle. We studied the frequency of the use of our protocol for the control of agitation. From June 18, 2007, to January 4, 2010, 27 (5.3%) patients from the 509 admitted were sedated intermittently 86 times, in strict compliance with the protocol, because of episodes of agitation. We verified that from 8 pm until 6 am, the number of observed cases clearly exceeds the expected cases, if the distribution was uniform. The reverse situation occurs in all other hours of the day. The chi-square goodness of fit test proves that the differences are statistically significant (P < .001).