Palliative Sedation in End-of-Life Care

Susan D. Bruce, RN, BSN, OCN; Cristina C. Hendrix, DNS, APRN-BC, GNP, FNP; Jennifer H. Gentry, RN, MSN, ANP, APRN-BC, PCM

Disclosures

Journal of Hospice and Palliative Nursing. 2006;8(6):320-327. 

In This Article

Palliative Sedation: Defined

Although palliative sedation has been described amply in the medical literature, there is a paucity of information in the nursing literature. Palliative sedation is defined as the monitored use of medications to relieve refractory and unendurable symptoms by inducing varying degrees of unconsciousness-but not death-in patients who, given their disease state, progression, and symptom constellation, are expected to die within hours or days.[3] Kohara and colleagues[4] defined palliative sedation as a medical procedure to decrease the level of consciousness in order to relieve severe physical distress refractory to standard interventions. Morita and colleagues[5] stressed two factors as the core nature of sedation: (1) the presence of intractable or severe distress refractory to standard palliative treatment and (2) the use of sedative medications with the primary aim of relieving severe symptoms by reduction in consciousness.

Palliative sedation is also known as terminal sedation, total sedation, sedation therapy, controlled sedation, deep sedation, and sedation in imminently dying patients. These many synonyms may explain why only 40% of physician respondents could agree on a definition for palliative sedation without reservation.[6] With palliative sedation, a patient is sedated to unconsciousness to be freed from refractory symptoms. Refractory symptoms are defined by Cherney and Portenoy[3] as symptoms that cannot be controlled adequately in a tolerable time frame despite aggressive use of usual therapies and seem unlikely to be controlled adequately by further invasive or noninvasive therapies without excessive or intolerable acute or chronic side effects/complications. The incidence of refractory symptoms as reported by the authors range anywhere from 16% to 52%. Further, Cherney and Portenoy[3] distinguish refractory symptom as having the following three attributes: (1) Aggressive efforts short of sedation fail to provide relief. (2) Additional invasive/noninvasive treatments are incapable of providing relief. (3) Additional therapies are associated with excessive/unacceptable morbidity, unlikely to provide relief within a reasonable time frame.

It is important to differentiate between palliative sedation and physician-assisted suicide (PAS). Under PAS, a physician prescribes medication for a patient to be used at the time of his or her choice with the express intent of ending the patient's life. In palliative sedation, however, the physician monitors the delivery of the medication and makes adjustments as appropriate to ensure that pain and distress are minimized to the extent possible. The intent in palliative sedation is the relief of suffering.

A review of the literature has found great variability in the prevalence of palliative sedation, ranging from 2% to 52% among terminally ill patients.[7] The study conducted by Ventafridda et al[8] found that more than 50% of cancer patients dying at home die with physical suffering that is only controllable by means of sedation. Between 10% and 50% of patients in programs devoted to palliative care still report significant pain 1 week prior to death.[9] The most common symptoms experienced by these patients were dyspnea, pain, delirium, and vomiting. Most symptoms are reported to be physical in nature. In a retrospective analysis by Kohara et al,[10] 54% of patients were found to have more than one uncontrollable symptom.

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