What are the EAPC guidelines for palliative sedation in patients with cancer?

Updated: Jun 01, 2019
  • Author: Winston W Tan, MD, FACP; more...
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In 2009, the European Association of Palliative Care (EAPC) published guidelines to address the key clinical issues surrounding palliative sedation. The recommendations in the guidelines are intended to be modified to reflect local culture; legal considerations; and specific needs of the home, hospital, or hospice-based setting. The recommendations include the following [16] :

  • Sedation can be considered for patients with intolerable distress due to physical symptoms and a lack of other methods of palliation
  • Continuous deep sedation should be considered only in the very terminal stages of illness with expected death within hours to days at most
  • Evaluation should be performed by a clinician with expertise in palliative care; whenever possible, evaluation should be multidisciplinary
  • Assessment should include estimates at to whether death is anticipated within minutes to hours, hours to days, days to weeks, or longer, and evaluation of the patient’s capacity to make decisions about ongoing care; if decisional capacity is in doubt, evaluation by a psychiatrist may be required
  • For patients with decisional capacity, the aims, benefits, and risks of the proposed sedation should be discussed with the patient and preferably with participation of family members
  • For patients lacking capacity to decide, and without advance directives, permission should be obtained from a legally recognized proxy
  • In actively dying patients who have no advanced directive or health care proxy and are in severe distress, comfort measures, including the use of sedation if necessary, is the standard of care
  • If the family members are not participants in the decision process, permission should be sought to inform them of the decision
  • The level of sedation should be the lowest level necessary to provide relief of suffering
  • Intermittent or mild sedation should be attempted first

The presence of refractory psychological symptoms does not necessarily indicate a far advanced state of physiological deterioration; sedation should be reserved for patients in advanced stages of terminal disease under the following circumstances:

  • Symptoms should be designated as refractory only after repeated assessment by clinicians with psychological treatment expertise who have established a relationship with the patient and family and have attempted routine approaches for anxiety, depression, and existential distress
  • Evaluation should be conducted by a multidisciplinary team that includes psychiatrists, chaplains, ethicists, and persons providing direct care for the patient
  • In the rare cases where sedation is appropriate, sedation should be delivered on a respite basis for 6-24 hours with planned downward titration
  • Continuous sedation should be considered only after repeated trials of respite sedation with intensive intermittent therapy

The 2014 European Society of Medical Oncology (ESMO) guidelines for use of palliative sedation in advanced-stage cancer are derived from the EAPC guidelines and contain no major variances in the recommendations. [1]

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