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

The Process of Palliative Sedation

Four factors should be present for a patient to be considered for palliative sedation. First, the patient should have a terminal diagnosis. Second, the patient should have symptoms that are unbearable and refractory. Third, a do not resuscitate (DNR) order must be in effect. Fourth, death must be imminent (within hours to days), although this can be challenging to determine.[17,23] If a patient meets these four factors, the patient-if able-along with the appropriate family members should have a meeting with members of the hospice or palliative care team to discuss the option of palliative sedation. It may require several meetings with the patient and family to facilitate discussion and decision making. If the patient does not have decision-making capacity, the designated healthcare proxy should be present for the meeting and approached for consent. It is important to assess the patient's and family's cultural and religious beliefs or concerns that may affect their decision regarding palliative sedation. During the meeting, it is important to discuss the options, goals, risks, and benefits of palliative sedation. An explicit treatment plan should be well documented and include the drug used, dosage, and criteria for titrating the dose. A separate consent for palliative sedation should be signed. Before proceeding with palliative sedation of patients with uncontrolled symptoms, it is imperative that careful consideration be given to establishing whether the patient's symptoms are merely difficult to control or truly refractory to reasonable palliative interventions.[24] An ethics committee consultation may be beneficial if there is a question as to whether symptoms are refractory and palliative sedation should be initiated. The ethics committee can be useful in helping resolve conflicts within the family and can provide support for staff who may be in conflict with the decision.

A variety of medications can be used for palliative sedation ( Table 2 ). Important considerations when selecting a drug for palliative sedation include efficacy of the drug, potential untoward side effects, route of administration, cost, the symptom that is being targeted, and the preference of the provider. Medications can be used as a single agent or in combination with others to achieve the desired effect. Some of these medications can be administered by various routes. The medication selected for use is usually a benzodiazepine or barbiturate. Some of these medications are used for anesthesia or procedures that require conscious sedation. The medication selected is started at the lowest appropriate dose and titrated upward gradually to the lowest dose that provides relief or control of the refractory symptoms. Additional doses can be administered when necessary. It may become necessary to render the patient unconscious in order to alleviate suffering. All previous comfort medications the patient has been on should be continued with the initiation of palliative sedation.

Although many drugs have been used to provide effective sedation, there are currently no controlled trials comparing efficacy. Midazolam is the most commonly used drug and has efficacy as a sedative. If symptoms are not controlled with one drug, a trial of another drug is warranted. It is important to remember doses may vary since they are determined by patient weight, renal and hepatic function, hydration status, and concurrent medications.

The infusion is initiated and generally titrated to a point at which the patient seems to be comfortable and symptoms are controlled. Once the patient is sedated, medications are generally not increased unless there is evidence of renewed distress. Gradual deterioration of respiration is expected in terminal patients and should not be used solely as a reason to decrease sedation. Assessment of the patient should include the severity of suffering, level of consciousness, and untoward side effects. The frequency of assessment varies depending on the location where the patient is receiving palliative sedation (home versus inpatient facility) and the policies in place. A registered nurse assesses the patient continuously during the initiation phase of palliative sedation therapy, then less frequently once adequate sedation has been achieved.

Palliative sedation can be delivered in several different settings. Patients receiving palliative sedation can be cared for in the inpatient care setting or at home with hospice support. Administration of palliative sedation does not necessarily require admission to the hospital. Patients with refractory symptoms are often hospitalized, and 81% of the reported cases of palliative sedation occur in inpatient settings, such as a hospital or hospice.[25] In the inpatient setting, the medications used are generally given subcutaneously or intravenously and on a continuous-rather than intermittent-schedule.

Very little literature is available on the number of palliative sedation cases being handled in the home or the process used in the home.

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