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

Indications and Categories of Palliative Sedation

Shaiova[11] defined two therapeutic indications for palliative sedation and outlined the categories of the time course and depth of sedation. The indications for palliative sedation are relief of intractable pain when specific pain-relieving protocols or interventions are ineffective and relief of intractable emotional or spiritual anguish. Palliative sedation is an intervention that can be titrated to achieve desired clinical outcomes. The depth and intensity both can be titrated based on the needs of the patient. Shaiova categorizes palliative sedation as partial, total, temporary, and permanent. Partial sedation is titrated sedation against patient responsiveness with a patient-directed end point. Total sedation is titrated sedation against (apparent) complete unresponsiveness of patients (unconsciousness). The intent of temporary sedation is to provide a reversible deep sedation, as opposed to permanent sedation, in which the intent is to provide deep sedation until death occurs and without concern for reversibility.

The work of Morita et al[12] proposes a combination of five subcategories of palliative sedation therapy as a way of handling the inconsistencies in definitions and describing the degree and duration of sedation. Duration of sedation is either continuous or intermittent. Continuous sedation is sedation in which a reduced level of consciousness is maintained without specifying plans to discontinue. This form of sedation continues to alter the patient's level of consciousness until he or she dies. On the other hand, intermittent sedation reduces the patient's consciousness for prolonged periods but also provides periods when the patient is alert by discontinuing or reducing sedative medications. Respite sedation, in which the patient is rendered unconscious for a period of time to bring about management of refractory symptoms, is an example of intermittent sedation. Degree of sedation is classified as mild or deep. Mild sedation is sedation to the degree that consciousness is maintained so that a patient can verbally or nonverbally communicate with caregivers. Deep sedation causes near or complete unconsciousness so that a patient is rendered unable to communicate with caregivers. Morita et al[12] added a category that addresses the pharmacological properties of the medications used to induce palliative sedation. Sedation can be primary or secondary. Primary sedation is achieved by sedative medications that have not been proved to be pharmacologically effective to relieve underlying distress. Secondary sedation allows reduced unconsciousness accompanied with pharmacologically effective sedations for the relief of underlying symptoms. Based on these definitions, sedation can be described as primary-continuous-deep sedation for physical or psychological distress in patients with vital organ failure.[6] Opioid dose escalation for severe pain that induces somnolence can be expressed as secondary-mild sedation for patients in pain without vital organ failure, including intermittent-continuous subtypes of sedation.[13]

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