1

Managing Symptoms at End-of-Life

Kathleen Broglio, DNP, ANP-BC, ACHPN, CPE, FPCN

Nurse Practitioner, Section of Palliative Care

Assistant Professor of Medicine

Dartmouth Hitchcock Medical Center

Lebanon, NH

Kathleen.broglio@hitchcock.org

Disclosures

• Royalty: UpToDate

• Legal Consulting- TASA

Objectives

• Describe prevalence of distressing symptoms

at the end of life

• Provide pharmacologic suggestions for

management of common distressing

symptoms at end of life

• Discuss treatment of refractory symptoms at

the end of life

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Prevalence of Symptoms End of Life

• Systematic Review 12 studies – 2416 patients

in last days to 2 weeks of life

• 43 unique symptoms – highest prevalence

– Dyspnea 56.7%

– Pain 52.4%

– Respiratory secretions - ‘death rattle’ 51.4%

– Confusion 50.1%

Kehl & Kowalkowski. Am J Hospice Palliat Med. 2012;30(6): 601-616

Symptoms – End-of-Life Nursing Homes

• Symptoms worsened toward end of life

• Patients with dementia had more challenging

behavior (40.6%) compared to those without

(20.65%)

• Delirium occurred in about 30% in both

groups

Eastbrooks et al. JAMDA. 2015;16:515e520

Comfort Care Order Sets

OR

Anticipatory Prescribing

• Consider likely symptoms to occur

• Ensure pharmacologic agents available

especially if patient is in the home setting

• Consider risk benefit of prescribing or not

prescribing

National Clinical Guideline Center. Care of dying adults in the last days of life. 2015

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PAIN

Prevalence of Pain at End of Life

• Longitudinal study (proxy reported pain) – 60% in last year of life1

• Systematic review– 52% pain in last two weeks of life2

• Cross-sectional data 2004 National Nursing Home Survey– 36.6% older patients receiving hospice/palliative

services had pain, but only 11.4% had cancer as primary diagnosis3

Take home – pain is prevalent in serious illness and at the end of life

1Singer et al. Ann Intern Med. 2015;162(3):175-183. 2 Kehl & Kowalkowski. Am J Hosp Palliat Care.

2013;30(6):601-16. 3Hanlon et al. J Am Med Dire Assoc. 2010;11(8):579-83.

Pain

• One of most ‘feared’ symptoms for patients

• May be secondary to disease process or toward end of life may be secondary to metabolicderangement, positioning

• May not be easy to assess in the patient at end oflife who may cognitive changes

– Always assume pain present if patient has reason to have pain

Broglio. In: Practical Guide to Chronic Pain Syndromes. 2010;285-300.

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Pharmacologic Approaches

• Mainstay of treatment at end of life

• WHO ladder approach to pain management

o Oral

o Around the clock

o Individualized

• Use of multimodal analgesia

o Non-opioids, adjuvant therapies may provide analgesiaand be opioid sparing but may be of limited use at the end of life

Auret &Schug. Best Practice & Research Clinical Anaesthesiology. 2013:545-561.

Opioids – General Guides

• Recent RCT – no significant differences in pain control/side effects/response in comparison morphine,oxycodone, fentanyl, buprenorphine for chronic cancer pain1

• Substantial individual variation in the response to the agent, so rotation may be necessary2

• Selection of opioid typically based on clinical judgement, formulary access, cost, or availability of a parenteral formulation2

1 Corli et al. Ann Oncol. 2016;27(6):1107-15. 2Auret & Schug Best Practice & Research Clinical Anaesthesiology.2013: 545-561,

Broglio & Portenoy. UpToDate, 2015.

Mu Opioid Subc or IV PO

Morphine 10 30

Hydrocodone 30

Hydromorphone 1.5 7.5

Meperidine 75 300

Oxycodone - 20

Oxymorphone 1 10

Fentanyl 100 mcg 1 mcg/hr TD =2

mg/24h morphine

Adapted with Permission Chris Pasero, 2016

Equianalgesic Dosing Chart

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A FEW POINTS ABOUT SOME

ANALGESICS USED AT END OF LIFE

Morphine – The Caveats

• Longest history use for pain

• Active metabolites morphine 3-gluconoride and morphine 6-gluconoride are renally excreted • Accumulation causes increased side effects including

excess sedation, agitation, confusion

• Use CAUTION with the use of morphine with renalinsufficiency and renal failure• Changes in renal function in advanced disease even

with normal creatinine

Prommer. Cancer Control. 2015;22(4):412-25.

Hydromorphone• Significantly more potent than morphine

• 1.5 mg IV hydromorphone = 10 mg IV morphine

• 7.5 mg oral hydromorphone=30 mg oral morphine

• Can be concentrated to allow for higher dose infusions subcutaneously

• No clinically relevant metabolites confirmed

• Can be used in renal failure

Broglio & Portenoy. UpToDate. 2015

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Fentanyl

• Synthetic opioid, no active metabolites • Tends to be well- tolerated in the older, frail population; renal

insufficiency

• Fentanyl transdermal• May need to be changed q48h versus q72h

• Fever/application of heat increase absorption and cause overdose

• Fentanyl oral transmucosal/nasal• Not dose equivalent- indicated only for break-through pain

related to cancer

• Quicker onset than immediate release oral opioids

. Broglio & Portenoy. UpToDate. 2015.

Opioid Dosing

• Must be individualized

• In hospitalized patient with severe pain

frequent dosing with morphine 2-5 mg IV or

hydromorphone 0.4-0.8 mg IV every 15-30

minutes may be needed until pain controlled

then a ‘basal’ dose should be prescribed with

breakthrough medications available

Blinderman & Billings. NEJM. 2015;373(26):2549-62.

Breakthrough Pain

• Transitory increase in intensity when baseline painis controlled on a regimen of analgesics¹

• Causes – multifactorial²• End-of-dose failure• Incident pain• Unknown causes

• Incidence• Systematic review 59% with cancer experience

breakthrough pain3

1Portenoy & Hagen. Pain. 1990;41:273-281. 2Mercadante et al. Cancer. 2001:94:832-839. 3Deandrea et al. J Pain Symptom

Manage. 2014;47(1):57-76.

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Breakthrough Medications

• General principle use 5-15% of total daily dose opioids and utilize same opioid¹ – In general use single entity agents (i.e; w/o APAP)

• Confirmatory study demonstrated IV morphine tolerated at 20% total daily dose³

• Transmucosal rapid acting fentanyl products may be superior to immediate release oral opioids3

– Access may be limited due to cost; requires TransmucosalImmediate Release Fentanyl (TIRF) Risk Evaluation and Mitigation Strategy (REMS) program registration

1Pasero et al. In Pain Assessment and Pharmacologic Management. 2011;448-50. 2 Mercadante et al. J Pain Symptom

Manage. 2008;35:307-313. 3 Zeppetella & Davies. Cochrane Database Syst Review. 2013.

http://www.cochranelibrary.com/

Opioid Rotation

• Consider opioid rotation

• Pain controlled but adverse side effects

• Pain not adequately controlled but dose escalation not possible due to side effects

• Pain is not controlled despite opioid titration

• Clinical improvement seen in more than 50%1 to 65%2 patients

Take home: opioid rotation should always be a consideration

¹Mercadante & Bruera, Cancer Treat Rev. 2006;32:304-315. 2Reddy et al. Oncologist. 2013;18(2):212-220

Opioid Rotation

• Use equianalgesic table to calculate dose of new opioid

• Dose new agent to 50-75% of equianalgesic dose (except methadone – may need to decrease by 90%)

• If rotating to fentanyl transdermal, do not reduce equianalgesic dose

• Consider further dose reductions if person is older, has organ failure

• Consider less of dose reduction if pain is severe

Pasero et al. In: Pain Assessment and Pharmacologic Management. 2011;18:473-483.

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Opioid Titration

• Consider when using more than 3-4 doses immediate releasebreakthrough medication daily

• Calculate total amount supplemental medication in last 24 hours and convert into fixed-schedule administration.

• Titration of a dose increment of 25-50% of existing doseusually considered safe

• Titration may be 100% in those with severe pain who are inmonitored setting

• Titrate extended release every 2-3 days except methadone

Pasero et al. In: Pain Assessment and Pharmacologic Management. 2011:450-4.

Adjuvant Analgesics

• Component of multimodal pain management

• Include agents such as corticosteroids,anticonvulsants, tricyclic antidepressants,serotonin-norepinephrine reuptake inhibitors, and anesthetics – but evidence of efficacy limited fortreatment in cancer pain1

• Include use of agents to treat side effects such aspsychostimulants, antiemetics, sedative hypnotics,benzodiazepines

1van den Beuken-van Everdingen et al. Pain Pract. 2016; (epub ahead of print)

Adjuvant Analgesics

• May be of limited utility toward end of life

when oral administration may be difficult1

• Corticosteroids may provide pain relief in

acute neuropathic symptoms toward end of

life and can be given intravenously2

1

1Blinderman & Billings. NEJM. 2015;373(26):2459-61. 2 Haywood et al. Cochrane Database Syst Rev. 2015;4:CD010756

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Intravenous Lidocaine

• Utilized for pain refractory to opioid therapywith reported favorable responses

• Different approaches to therapy including a one time bolus therapy and continuous infusion

• Therapeutic responses without cardiotoxicity at0.5-1 mg/kg/hr continuously or by short-terminfusion

Ferrini & Paice. J Support Oncol. 2004;2(1):90-94

Ketamine

• N-methyl-d-aspartate (NMDA) receptor agent most commonly used as an anesthetic agent; positive effect in the setting of severe, opioid refractory pain

• Difficult side effect profile, including nightmares and delirium

• Start at 0.1 mg/kg/hr by continuous infusion, titrate slowly to 0.5mg/kg/hr

• Pretreat with a low dose antipsychotic or benzodiazepine agent prior to initiation and as needed

Paice. Advance Practice Palliative Care Nursing, 2016:221-232.

Routes of Administration

• Oral preferred route but rotation to other routes may be necessary in up to 70% of cases1

• Preferred non-oral routes - subcutaneous,intravenous and enteral

• Mixed evidence for preference buccal, rectal and transdermal gel routes

• Systematic review alternative routes 2

• Subcutaneous as effective as intravenous

• Rectal route comparable to parenteral route

Take home – multiple routes available to provide analgesia1Kestenbaum et al. Pain Med. 2014;15:1129-53. 2Radbruch et al. Palliat Med. 2011;25(5):578-96.

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Sublingual Opioids

• Sublingual opioids often chosen at end of life when no intravenous access

• Sublingual morphine – only 18% absorbed through sublingual mucosa

• Sublingual absorption of other agents:

– Fentanyl 51%

– Buprenorphine 55%

– Methadone 34%

– Oxycodone 16%Weinberg et al. Clin Pharmacol Ther. 1988;44(3):335-42

DYSPNEA

Definition

• Dyspnea (or breathlessness)

– ‘a subjective experience of breathing discomfort

that consists of qualitatively distinct sensation

that varies in intensity’

– ‘experience of dyspnea derives from interactions

of physiological, psychological, social and

environmental factors that may induce secondary

physiological and behavioral responses’

Parshall,et al. Am J Respir Critic Care Med. 2012;185(4):435-52

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Pathophysiology

• Mechanism/pathways not well understood

• Changes in activity central chemoreceptors

• Hypercapnia/hypoxia induce ‘air hunger’

• Changes in mechanoreceptor activity in lung,chest wall, upper airway, facial receptors

• Neuromechanical dissociation

• Similar neural networks may mediate pain and dyspnea

Chan et al.. In Hanks et al. Oxford Textbook of Palliative Medicine, 4th Ed. 2010:

http://online.statref.com/Document.aspx?fxId=109&docId=595

Opioids

• Opioids – first line treatment– Decrease respiratory drive

– Alter responses to hypoxia and hypercapnia

– Changes in bronchoconstriction

• In Systematic review/meta-analysis opioids efficacious– Morphine most widely studied

– Other studies confirm efficacy: hydromorphone,subcutaneous oxycodone, fentanyl

Ben-Aharon I, et al. Acta Oncol. 2012; 51(8): 996-1008.

Opioids

• CHF- RCT comparing morphine, oxycodone, and placebo did not demonstrate efficacy but noadverse effects1

• Multi-site RCT chronic dyspnea (54% with COPD)treated with morphine ER 10-30 mg daily-effective over time2

• Results studies COPD, cancer, heart failure norelationship opioids - respiratory compromise

1Oxberry et al. Eur J Heart Fail. 2011;13(9):1006-12. 2. Currow et al. J Pain Symptom Manage. 2011;42(3):388-99.

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Opioid Dosing

• Start with low dose morphine 2.5-5 mg PO or

hydromorphone 0.5-1 mg PO q2h PRN and

titrate to effect

• If unable to take PO can administer

subcutaneously or intravenously – utilize 50%

of PO dose

Myers & Dudgeon. In. Oxford American Handbook of Hospice and Palliative Medicine. 2011:177

Benzodiazepines

• Although evidence does not support use formanagement– may treat affective response

• Prospective non-randomized trial (n = 26) cancercombination lorazepam/opioids significantreduction dyspnea1

• Retrospective review hospitalized patients palliative care (n = 115), those receiving benzodiazepine/opioids better relief2

1. 1Clemens et al. Support Care Cancer. 2011;19:2027-33. 2Gomutbutra et al. J Pain Symptom Manage. 2013; 45(4):885-91.

Benzodiazepines

• Lorazepam recommended

– Short half life

– Available IV, tablet, liquid

– Can start as low as 0.25 PO or IV mg q4h

Take home – consider as adjunct to opioids

especially when affective component anxiety

Quill et al. In Primer of Palliative Care, 6th Ed. 2014:52

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Oxygen

• Chronic Obstructive Pulmonary Disease–Systematic Review (18 studies, n = 431)1 and (4studies n = 331 – overlap 2 studies)2

– dyspnea improved with oxygen when mildly or nothypoxemic

• Multisite RCT (n = 211) compared oxygen versus room air delivered by nasal cannula– subjective feeling dyspnea relieved at same rates for

those receiving room air 31Uronis et al. Cochrane Database Syst Rev. 2011;6:78. 2Ameer et al. Cochrane Database of Syst Rev. 2014; 6: CD000238. 3Abernethy AP, et al. Lancet. 2010; 376(9743): 784-93.

Fans

• Hypothesis – cool air on nasoreceptors maydecrease feeling of dyspnea

• Randomized controlled cross-over study (n = 50)evaluated handheld fan on leg and face – positive result on face1

Take home – trial warranted due to low cost andlow risk

1Galbraith et al. J Pain Symptom Manage. 2010;39(5):831-8.

DELIRIUM

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Delirium

• Definition – disturbance in cognition that

evolves over short period of time; most often

associated with a medical condition1

• Subtypes: hyperactive, hypoactive, mixed1

• Prevalence at end of life - 58.8%- 88%2

• Multifactorial causes at end of life – multi-

organ failure, CNS pathology, metabolic

derangement, infectious pathology3

1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 2013:596-602. 2Hosie et al. Palliat Med. 2013:27:486-98. 3Bush et al. J Pain Symptom Manage. 2011; 41: 394-401.

Delirium Management

• If death not imminent and consistent with goals of care –

identify causes and initiate treatment if benefits

outweigh risks

– Electrolyte imbalance, polypharmacy, infections, pain,

constipation, urinary retention1

• No approved medications; antipsychotics utilized but

mixed evidence.1

• No strong evidence for non-pharmacologic techniques in

delirium at end-of-life2

1 Burhen. In: Advanced Practice Palliative Care Nursing, 2016: 311-320, 2Reston et al. Ann Intern Med.

2013;158:375-80.

Terminal Delirium Management

• Haloperidol – first line use (0.5-1 mg q2-12h) may

not be as sedating as atypical antipsychotics

• Atypical antipsychotics – olanzapine (2.5-5 mg

q12/24h), quetiapine (12.5-100 mg q12/24h);

risperidone (0.25-1 mg q12/24h) may be more

sedating than haloperidol

• Aripiprazole 5-30 mg q24h – may be more

effective hypoactive delirium

Burhen. In: Advanced Practice Palliative Care Nursing, 2016: 311-320. Bush et al. J Pain Symptom Manage.

2011;41:394-401.

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Terminal Delirium Management

Agitation

• Chlorpromazine (12.5-50 mg q4h- 6h) – use

for agitated delirium not responsive to less

sedating antipsychotics

• Short acting benzodiazepine in combination

with antispsychotic may be indicated –

generally not used alone as can worsen

delirium

Bush et al. J Pain Symptom Manage. 2011;41:394-401.

RESPIRATORY SECRETIONS

“DEATH RATTLE”

Death Rattle

• Definition – increased respiratory secretions at

the end of life – also known as ‘noisy

secretions’, ‘increasing retained secretions’

• Prevalence in studies ranged from 12%-92%

• Impact – may not be distressing to patients,

but distressing to family members and

professionals

Lokker et al. J Pain Symptom Manage. 2014;47:105-122.

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Death Rattle Treatment

• High quality studies lacking

• Antimuscarinic medications often utilized (scopolamine, hyoscine butylbromide,glycopyrrolate, atropine), but evidence forefficacy equivocal

• No agent proved superior

• Management including repositioning, suctioning and decreasing hydration also lack of evidence forefficacy

• Reassurance to family members importantLokker et al. J Pain Symptom Manage. 2014;47:105-122

Medication Dosing

• Atropine 1% ophthalmic 1-2 drops sublingual

every 2 hours PRN (may be the least

expensive)

• Glycopyrrolate 1-2 mg PO BID-TID PRN or 0.2-

0.4 mg Subcut/IV q4-8h PRN (costly)

• Scopolamine 1.5 mg TD q72h (takes time for

onset)

• Hyoscyamine – 0.125-0.25 mg PO/SL q4h PRN

(may have less CNS side effects)Quill et al. In: Primer of Palliative Care, 6th Ed. 2014:57

ANXIETY AND INSOMNIA

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Anxiety

• Fears and worries common in those near

death

– Treating distressing symptoms may decrease

anxiety1

• Minimal evidence for pharmacologic

treatment – however expert consensus

opinion support use of benzodiazepines2

1Blinderman & Billings. NEJM. 2015;373(26): 2549-61. 2Lindqvist et al. J Palliat Med. 2013;15(1): 38-43.

Insomnia

• Common toward end of life and may be

related to physical discomfort and anxiety

• Research into appropriate treatment lacking

• Benzodiazepines may be useful if anxiety is

contributing to insomnia

1Blinderman & Billings. NEJM. 2015;373(26): 2549-61.

Medication Management

• Lorazepam – 0.5- 1 mg up to 4 times daily

(available PO/SL/IV)

• Clonazepam 0.25- 2 mg two to three times

daily (may help for sleep at night due to longer

duration of action)

Quill et al. In: Primer of Palliative Care. 6th Ed. 2014:110

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NAUSEA AND VOMITING

Nausea and Vomiting

• Multiple causes ranging from inflammation,

obstruction, medications, constipation,

bleeding, metabolic changes, intracranial

pressure, anxiety, vestibular disease

• Evaluation includes trying to reverse potential

causes if possible while still treating symptoms

Quill et al. In: Primer of Palliative Care. 6th Ed. 2014:74-76.

Management

• Treat underlying pathology when indicated if benefitoutweighs burden of treatment– Opioid induced nausea –rotation

– Obstruction – surgical intervention when indicated

– Constipation - bowel regimen

– Hypercalcemia – hydration, bisphosphonates

– Ascites - paracentesis

– Brain metastases - corticosteroids, radiation

– Peptic ulcer disease- PPIs treatment

– Infection – antibiotics

– Anxiety – anxiolytics, supportive counseling

Dalal. In: Oxford American Handbook of Hospice and Palliative Medicine. 2011:128-137.

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Pharmacologic Treatment

• Mechanistic approach – treat based on

etiology limited as may be multifactorial

– If using multiple anti-emetics, select anti-emetics

with different mechanisms of action

• Most treatment has been based on clinical

preference

• No specific guidelines for drug selection and

dosing – limited high quality evidenceLevine & Shega. In: Evidence Based Practice of Palliative Medicine. 2013: 141-146., Glare et al. Clin Interv Aging.2011;6:243-259.

Examples Medication Management

• Gastroparesis or medication induced

– Metoclopramide 10 mg IV/PO q6h

• Medication induced/toxins/unspecified

– Haloperidol 1.5-5 mg PO or 0.5-2 mg IVTID PRN

– Ondansetron 8 mg PO/ODT q8h PRN

– Dexamethasone 4-8 mg IV/PO daily

• Increased intracranial pressure/bowelobstruction

– Dexamethasone 4 -8 mg IV/PO daily

Blinderman & Billings. NEJM. 2015;373(26): 2549-61

Pharmacologic Pearls

• Eliminate any medications that may be contributing to nausea

• Consider cardiac effects of anti-emetics (if death not imminent)

– QTc prolongation – ex; ondansetron

• Consider anti-emetic effects on bowels

– Constipation -ondansetron

• Consider use of medication to treat more than one symptom

– Example – haloperidol if also has delirium, dexamethasoneif has pain secondary to bony metastases

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CONSTIPATION

Definition

• Defined as infrequent bowel movements or

difficult moving bowels or incomplete

evacuation

• Defined by patient experience

• Prevalence in advanced cancer estimated 70-

100%

Fadul & Nooruddin. In: Oxford American Handbook of Hospice and Palliative Medicine. 2011:145-152

Causes

• Drugs: opioids/anticholinergics/chemotherapy

• Neurogenic disorders/autonomic dysfunction

• Decreased oral intake

• Dehydration

• Immobility

• Electrolyte imbalance: hyperkalemia/hypercalcemia

• Endocrine abnormalities

• Bowel obstruction

Clemens et al. Curr Opin Support Palliat Care. 2013;7:183-91. Fadul & Nooruddin . Oxford American Handbook of Hospice and

Palliative Medicine. 2011:145-5352.

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Pharmacologic treatmentClass Agent

Osmotics Polyethylene glycol (may be superior to Lactulose)

Lactulose

Sorbitol

Magnesium Sulfate

Stimulants Senna (can take up to 8 daily)

Biscadoyl

Surfactants Docusate sodium (no evidency of increased efficacy when added to senna)

Suppositories Glycerin, Bisacodyl

Enemas Tap water, mineral oil

Saline, sodium phosphate (not recommended older – cause dehydration- renal)

Opioid receptor agonists Methylnaltrexone (caution if obstruction – can cause perforations)

Chloride channel activator Lubiprostone

Fadul & Nooruddin. In: Oxford American Handbook of Hospice and Palliative Medicine 2011: 145- 52. Quill et al. In: Primer

of Palliative Care. 6th Ed. 2014: 82-3.

Clinical Pearls

• Consider treatment in the last days of life if

benefit outweighs burden

• Rectal suppositories or methylnaltrexone (if

opioid induced) may be necessary if oral

intake is decreased

CACHEXIA - ANOREXIA

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Prevalence

• Prevalence not well studied

• Heart failure or COPD 5-15%

• Cancer– 50-85% patients GI, pancreatic, lung colorectal

cancers at diagnosis

• Advanced cancer – 60-80%– Weight loss – part of disease trajectory incurable

malignancies

Barcos. In: Evidence Based Practice of Palliative Medicine. 2013: 158-61.

Cachexia-Anorexia Syndrome

• Complex incompletely understood

multidimensional syndrome – progressive

over time

– Muscle wasting

– Negative protein-energy balance (decreased

intake, abnormal metabolism)

– Decreased food intake

– Hypercatabolism

Barcos. In: Evidence Based Practice of Palliative Medicine. 2013:153-7.

Pharmacologic Management

• NO one medication consistently effective –

• At end of life consider corticosteroids

– May increase food intake

– Suitable short duration advanced disease

Del Fabbro. In: Oxford American Handbook of Hospice and Palliative Medicine; 2011: 87-95.

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Clinical Pearls

• Educate family and caregivers

• Encourage patient to eat for pleasure, but do

not force toward the end of life

IN THE LAST HOURS OF LIFE

Most important medications for

home at the end of life…

• Pain

– Opioids such concentrated liquid (morphine 20 mg/ml)

• Anxiety

– Lorazepam liquid 2 mg/ml

• Nausea- restlessness

– Halperidol or lorazepam liquid

• Secretions

– Atropine opthlalmic (give sublingual) or glycopyrrolate

Quill et al. In: Primer of Palliative Care. 6th Ed. 2014:192

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WHEN SYMPTOMS ARE

REFRACTORY TO TREATMENT

Palliative Sedation

• Utilized at the end-of-life when symptoms are

refractory to treatment

• Goal is to reduce suffering in dying patient

• Level of sedation proportional to need to

decrease symptom distress

• Sedation to level of unconsciousness only in cases

of severe intractable suffering at end of life

American Academy Hospice Palliative Medicine. 2014. Retrieved from http://aahpm.org/positions/palliative-sedation

Palliative Sedation

• Should only be initiated if severe symptoms

refractory to treatment

• Life expectancy is hours to days

• Requires interdisciplinary approach; informed

consent

• Palliative care specialists should be involved

• Institutions should have palliative sedation

policyNelson. In: Advanced Practice Palliative Nursing. 2016: 487-495.

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Palliative Sedation

• Medications utilized include barbiturates,

benzodizepines and anesthetics

• Intravenous or subcutaneous route preferred

• Opioids should be continued if utilized for

management of pain or dyspnea

• Goal of medication is to induce sedation

without untoward side effects

Nelson. In: Advanced Practice Palliative Nursing. 2016: 487-495.

The Double Effect

• Recognize the goal is to relieve suffering

• Treatment may include sedation, but not with

purpose of hastening death

• Use of sedation to relieve intractable suffering

outweighs risk of hastening death

Billings. In: Palliative Care and Ethics. 2014:209-30.

Conclusion

• Palliation of symptoms is important

component of end of life care

• “Comfort” care at the end of life often

requires intensive symptom management

• Develop a comfort order set to address

distressing symptoms at the end of life