Palliative Sedation in Hospice Care
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The word "sedation" is of Latin derivation, with sedare meaning "to settle, to calm" in Latin. Use of the word transferred to the English language (from the French sedation) in the mid-16th century but did not become a commonly used term until about 1950. Since then, various forms of sedation have found clinical use, from temporary sedation for clinical procedures to palliative sedation to manage distressing symptoms at end-of-life, to name just two examples.
Palliative sedation (PS) is defined as the lowering of a dying patient’s consciousness using sedative medications with the intent of limiting patient awareness of intractable and intolerable suffering. Suffering encompasses the broad range of injuries or threats to one’s being (i.e. physical, psychosocial, spiritual, temporal, and existential). Intractable suffering is suffering that has not adequately responded to all trialed interventions and for which additional interventions are either unavailable or impractical; this may also be described as refractory suffering that cannot be adequately controlled despite aggressive efforts to identify therapy that does not compromise consciousness. Intolerable suffering is suffering that is “unbearable,” as described by the patient and verified by the patient’s interdisciplinary team. When a patient is unable to communicate, the family should consider whether, based on the known values and wishes of the patient, suffering has reached a level that the patient would declare as intolerable.
The use of PS in appropriate cases has been repeatedly upheld by the courts, but, as with any treatment, careful ethical consideration by qualified clinicians is necessary. The goal of PS is to decrease suffering but not to kill or hasten death. Euthanasia shares the same goal of decreasing suffering but differs in its intent (to end life), its process (administration of a lethal drug dose), and its immediate outcome (death). Assessment of core ethical principles assists clinicians in determining if PS is appropriate for a given patient. The National Hospice and Palliative Care Organization (NHPCO), American Academy of Hospice and Palliative Medicine (AAHPM), and Hospice & Palliative Nurses Association (HPNA), among other organizations, have issued position statements that may assist clinicians in determining if PS is appropriate.
The two most common indications for PS are delirium and dyspnea, but PS has been used to successfully manage myriad other symptoms, as well (e.g. pain, vomiting, itching, bleeding, psychological distress, seizures, malaise, panic, clots, fecal retention, etc.). “Proportional sedation,” where sedation is titrated to the minimal level of sedation that permits the patient to tolerate the unbearable symptom(s), is the most commonly used approach today, versus deeper sedation practices that had been used more in the past. Another potential option is “respite sedation” (also known as “intermittent sedation”), where consciousness is reduced for predetermined periods followed by periods of wakefulness. This “respite sedation” is accomplished by reducing or discontinuing the sedative and may reveal if the distress (especially psychological or existential) can be resolved by “breaking the cycle” of fear, fatigue, or insomnia near end-of-life.
Figure: Checklist in Preparation for Palliative (Adapted from National Hospice and Palliative Care Organization (NHPCO) Position Statement 2010.)
- Terminal illness with refractory and intolerable symptoms verified
- Exhaustion of all other feasible palliative care treatments (and documented as such)
- Consideration of psychiatric, ethical, and spiritual consultations
- Do-not-resuscitate (DNR) order in place
- Determination regarding discontinuation of nutritional and hydration support in patients receiving such treatments
- Informed consent
- Selection of most appropriate and cost-effective sedative(s)
- Consideration of a trial of respite sedation, if appropriate
An important aspect of a PS plan is the selection of the appropriate sedative(s) to achieve the appropriate level of sedation. The three most commonly used classes of “primary sedatives” are benzodiazepines (such as lorazepam, diazepam, or midazolam), barbiturates (such as phenobarbital), and anesthetics (such as propofol). Midazolam, in its injectable form, is the most commonly used agent in the hospital setting, and lorazepam is the most commonly used agent in the home and nursing home settings. Nasal midazolam has also been used, but the cost may be prohibitive. Phenobarbital may be particularly beneficial when benzodiazepines are ineffective or not well tolerated. Propofol has been the subject of increased scrutiny and is generally reserved for refractory cases in the inpatient setting. Agents such as opioids, antipsychotics, and the anesthetic ketamine are considered “adjunctive sedatives” and are generally added in addition to one of the aforementioned sedatives to manage certain symptoms (but not generally utilized as the sole agent to achieve PS).
In the rare circumstance that palliative sedation is being considered, remember you have a team of hospice and palliative expert pharmacists available 24/7/365. They can help review for any possible remaining therapies or regimens to manage distressing and intolerable symptoms or pain and review for any obstacles potentially reducing the efficacy of current treatments. If every option has been exhausted, a ProCare HospiceCare hospice and palliative pharmacist can help guide medication selection and appropriate dosing for palliative sedation.
Written by: Brett Gillis, Pharm.D., R.Ph.
References:
1. American Academy of Hospice and Palliative Medicine (AAHMP). Position Statement 2014.
2. Bodnar J. A review of agents for palliative sedation/continuous deep sedation. J of Pain & Pall Care 2017;31(1):16-37.
3. Hahn M. Review of palliative sedation and its distinction from euthanasia and lethal injection. J of Pain & Pall Care 2012;26(1):30-39.
4. Hospice & Palliative Nurses Association (HPNA). Position Statement 2016.
5. Maltoni M, et al. Palliative sedation in patients with cancer. Ca Contr 2015;22(4):433-441.
6. Narula P. Palliative sedation. ProCare 2016.
7. National Hospice and Palliative Care Organization (NHPCO). Position Statement 2010.
8. Patel C, et al. Palliative sedation: a safety net for the relief of refractory and intolerable symptoms at the end of life. AJGP 2019;48(12):838-845.
9. Twycross R. Reflections on palliative sedation. Pall Care: Res and Treat 2019;1-16.
