Exploring Palliative Sedation
The What, Why, When, and How?
Debra Nobbe, RN, CNS, ACHPN [email protected] Brian Bagley-Bonner, MDivbbonner#@hospicewr.org
Objectives
Define and discuss Palliative Sedation by reviewing current evidenced based research
Explore legal and ethical precedents
Objectives
Discuss Hospice of the Western Reserve’s Practice and Procedure
Discuss refractory pain and suffering by building on a holistic model
One Definition
Palliative Sedation is the monitored use of medications to relieve refractory and unendurable physical, spiritual and psycho-social distress for patients with a terminal diagnosis, by inducing varied degrees of unconsciousness. The purpose of the medication is to provide comfort and relieve suffering and not to hasten death.
- Hospice and Palliative Care Federation of Massachusetts.
Levels of Sedation
3 levels of sedation – Mild (Somnolence) pt awake - level of
consciousness lowered – Intermediate/Respite (stupor) pt asleep but can
be woken to communicate briefly – Deep (coma) the patient is unconscious and
unresponsive DeGraeff & Dean
Legal Precedent
1997 US Supreme Court ruled:
“a patient who is suffering from a terminal illness and who is experiencing great pain has no legal barriers to obtaining medication, from qualified physicians, to alleviate suffering, even to the point of causing unconsciousness and hastening death…”
Sedation as a Side Effect
Sedation as Primary Means of Reducing Suffering
How Can We Stop the Cycle?How Can We Stop the Cycle?
PhysicianAssisted Suicide (PAS) as Primary Means of Ending Suffering
Meds Meds cause cause drowsinesdrowsinesss
Meds Meds allow allow sleepsleep
Respite
Sedation
Meds Meds ensurensureesleepsleep
Palliative
Sedation
P A SP A S
Double Double EffectEffect
Sedation as a Side Effect
Sedation as Primary Means of Reducing Suffering
PhysicianAssisted Suicide (PAS) as Primary Means of Ending Suffering
Who? Assessing Appropriateness:
Terminal Illness Symptoms
Dyspnea Delirium/Agitation Physical Pain N/V and Uncontrolled Bleeding Anxiety/psychological distress *
* Not The American Medical Association (AMA)
When?
How to determine when a symptom is truly refractory?– Are further interventions capable of providing relief?– Is the anticipated acute or chronic morbidity of the
intervention tolerable to the patient?– Are the interventions likely to provide relief within a
tolerable time frame?
*J. Hallenbeck, MD National Ethics Tele-Conference 7/26/06
30 years old Stage 4 lymphoma Drug/Alcohol Abuse Juvenile Behavior Limited Coping Skills Multiple Wounds Refractory
Pain/Anxiety w/dressing changes
Breaking Cycle
Hospice of the Western Reserve’s Practice and
Procedure Purpose
– To safely and effectively induce and monitor palliative sedation (lowered conscious awareness) as a means to manage refractory symptoms. The determination of when palliative sedation is being utilized is based solely on the intent for which it is prescribed, rather than the medication used, the
dose, or the route by which it is given.
Hospice of the Western Reserve’s Practice and
Procedure
Procedure Requirements– Define refractory symptom (s)– DNRCC in effect– Patient/Family Education– Review/complete psychosocial and spiritual
assessment
How?Medications
“The choice of an agent is dependent , for the most part, upon clinical institutional policy and formulary restrictions. Also in difficult cases a second medication may be needed to sedate a patient adequately. Medications may be administered sublingually, rectally, intravenously or subcutaneously.”
Rousseau End of Life Online Curriculum
Medications and Suggested Doses for Palliative Sedation
Drug Suggested Dose (a)
Midazolam 0.5-5 mg bolus IV/SC, then CII/CSI at 0.5-1 mg/h; usual maintenance dose, 20-120 mg/d
Lorazepam 0.5-2 mg PO, SL, or SC every 1-2 hours OR1-5 mg bolus IV/SC, then CII/CSI at 0.5-1 mg/h; usual maintenance dose, 4-40 mg/d
Chlorpromazine
10-25 mg PO, IV, or PR every 2-4 hours
Haloperidol 0.5-5 mg PO or SC every 2-4 hours OR1-5 mg bolus IV/SC, then CII/CSI at 5 mg/d; usual maintenance dose, 5-15 mg/d
Pentobarbital 60-200 mg PR every 2-4 hours OR2-3 mg/kg bolus IV, then CII at 1 mg/h; titrate upward to maintain sedation
Thiopental 5-7 mg/kg bolus IV, then CII at 20 mg/h; usual maintenance dose, 70-180 mg/h
Propofol 10 mg/h as CII; may titrate by 10 mg/h every 15-20 minutes; bolus of 20-50 mg may be used for emergency sedation
a Clinicians should consult pharmacy textbooks, pharmacists, and other knowledgeable professionals for further dosing suggestions. PO=oral; PR = per rectum; SL=sublingual; SC=subcutaneous; CII=continuous intravenous infusion; CSI=continuous subcutaneous infusion. Rousseau P. 2004 used with permission
Hastening Death?
Recent studies have found no difference in survival between hospice patients who required sedation for intractable symptom control during their last days and those who did not.
M. Maltone, C Pittureri, L Piccinini et all.
Implementation into Practice
Intent
Individualized
Education - early conversations
Emotional
Spiritual
Physical
Social
In Summary Patients need and deserve
assurance that suffering will be effectively addressed, as both the fear of suffering and the suffering itself add to the burden of the terminal illness
- AAHPM position Statement 9/15/2006b
References Slide 2 – Palliative Sedation Protocol -Resources
and conferences -Best Practices – Reports – Hospice and Palliative Care Federation of Massachusetts Web Page http://www.hospicefed.org
Slide 3 – DeGraef A and Dean M, Palliative Sedation Therapy in the Last Weeks of Life; A Literature Review and Recommendations for Standards, Journal of Palliative Medicine, vol 10 Number 1, 2007
Slide 7 - Compassion in Dying v Washington, 79 F3d 790 (9th Cir 1996) (en banc) and Quill v Vacco, 830 F3d 716 (2nd Cir 1996).
Slide 14 – AMA meeting: AMA OKs palliative sedation for terminally ill. O’Reilly, K, amednews.com July 7,2008
Slide 15 –Hallenbeck J, MD http://www.ethics.va.gov/pubs/netsum.asp National Ethics Tele-Conference 7/26/06
Slide 19 -Rousseau P. Existential suffering and palliative sedation: a brief commentary with a proposal for clinical guidelines. American Journal of Hospice and Palliative Care 2001;18:226-228
References Slide 24 - Maltoni M, Pittureri C, Piccinini L et al.
Palliative sedation therapy does no hasten death: results from a prospective multicenter study Annals of Oncology 2009 20:1163-1169
Slide 25 – Rousseau P. Palliative Sedation in the management of refractory symptoms. J Support Oncol. 2004 Mar-Apr; 2(2):181-6
Kirk T, Mahon M, NHPCO Positions Statement and Commentary on the Use of Palliative Sedation in Imminently Dying Terminally Ill Patients. Journal of Pain and Symptom Management Special Article 2010 doi 10.1016/j.jpainsymman.201.01.009
Seale, C Continuous Deep Sedation in Medical Practice . Journal of Pain and Symptom Management Vol. 39 No. 1 January 2010 doi 10.1016/j.jpainsymman.2009.06.007
PEDIATRIC – Anghelescu D, Hamilton H, Faughnan et al. Pediatric Palliative Sedation Therapy with Propofol: Recommendations Based on Experience in Children with Terminal Cancer. Journal of Palliative Medicine 2012 15(10): 1082-1090