Exploring Palliative Sedation

The What, Why, When, and How?

Debra Nobbe, RN, CNS, ACHPN dnobbe@hospicewr.org 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

Precedents to Consider

Legal

Ethical

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…”

Ethical Principles

Double Effect

Beneficence

Why?

To alleviate a patient’s pain and suffering.

Cycle of Pain and Suffering

Emotional

Spiritual

Physical

Social

PainPain

SufferingSuffering

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

Patient goal drives titration phase

State and Federal Laws

Benzodiazepines

Lorazepam (Ativan)

Midazolam (Versed)

Antipsychotic

Chlorpromazine (Thorazine)

Butyrophenone

Haloperidol (Haldol)

Barbiturates

Phenobarbital

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

Questions

Thoughts

Comments