Forum.

Aim of Sedation in Palliative Care

D. Cameron, K. Groves

1. Introduction

Although it might seem unnecessary to define words we use so often, it does help to ensure we are all talking about the same thing. Morita and colleagues have carefully outlined the difficulties that arise from the inconsistencies in the definition of sedation and make a plea for its clarification.1

“Aim” refers to an intent or a plan to do something or achieve something.
“Sedation” is the use of a sedative or tranquillizing drug to induce a state of calm, restfulness or drowsiness.

“Palliate” (i) to alleviate a symptom without curing the underlying medical condition (ii) to reduce the intensity or severity of something (iii) to make an offence seem less serious by providing excuses or mitigating evidence [15C. Latin palliat- past participle of palliare ‘cover or hide’]

“Care” to look after or supervise somebody or something, to provide whatever is needed for somebody’s well-being, caution to avoid damage or loss2

The aim of sedation is, like everything else in palliative care, the relief of symptoms and not the shortening of life3.  ‘Let us take, therefore, this opportunity to clearly and firmly state that the goal of palliative sedation is the relief of suffering via the titration of medications to the cessation of symptoms – not the cessation of life.’4 

2. Literature review

 We performed a MEDLINE search using the terms “Aims of sedation” or “use of sedatives or hypnotics” and  “palliative care”, “terminal care” or “hospice care” (1995-2003).
Thirty-two articles were identified and of these, twelve mentioned the aim or purpose of sedation. Taken together, these twelve articles affirm that the overall aim of sedation in palliative care is to reduce the level of consciousness of patients near death in order to relieve a diverse range of intolerable, refractory symptoms 1,5-14. Sedation for existential distress alone is used very infrequently9 but may be increasing.15.

Lack of clarity and consensus regarding the meaning of terms and the intent of sedation is a cause for concern and highlights the need for further research1,6,7. 

3. Discussion

We will discuss three issues related to the use and purpose of sedation in patients receiving palliative care.

1. Many of the drugs used in palliative care for the relief of symptoms, such as pain or vomiting, may result in sedation as a secondary or side effect. In most cases this effect is not intended and is a temporary phenomenon, although the side effect of drowsiness may be beneficial in a restless patient.  Sometimes, especially when dealing with a restless agitated patient, a certain degree of drowsiness caused by appropriate sedation, is desirable to avert a crisis (such as a patient injuring himself or his carers) or to relieve the extreme distress of the severely confused patient. The degree of drowsiness that may be needed to control such symptoms varies a great deal, so the amount of medication used will also vary a great deal. However, the intention can be assessed by the proportionality or adequacy of the action.3 In palliative care, in contrast to euthanasia, the combination and amount of drugs used will be sufficient, but not more than is needed, to achieve a state of calmness or restfulness, with or without drowsiness. The use of increasing amounts of drugs beyond what is needed to control the distressing symptom disregards this fundamental principle of palliative care. We acknowledge, however, that it is not always easy to judge proportionality. The practice of reflecting on and discussing such difficult situations with knowledgeable and experienced colleagues is further evidence good palliative practice.
2. At times the adequate control of symptoms may be very difficult, and the knowledge, skill and resources required to palliate such intractable symptoms may not be available. Thus the labelling of a symptom as refractory may depend as much upon the experience of the physician as it does upon the severity of the symptom. We are concerned that if a physician is unable to relieve a distressing symptom he/she may feel pressured to use sedation and even disproportionate sedation.

Ideally a physician should label a symptom as refractory only if all available and acceptable palliative care options have proved unsuccessful and if the symptom is unbearable to the patient.  Several authors have proposed that the deliberate reduction of the patient’s level of consciousness is an acceptable option for managing such refractory symptoms.1,3,8,10-16 Others would propose that managing such symptoms adequately with drugs specific for those symptoms rather than sedatives, may result in a reduction in the patient’s level of consciousness that may be acceptable but not intended.17  Rather than work in isolation, the physician should discuss such difficulties with the rest of the team and if necessary seek advice from more experienced colleagues. These days it is relatively easy to obtain such advice from colleagues around the world by means of e-mail or the internet. We should make further efforts to ensure that these resources are known and accessible to all. . We also need to continue the search for better answers to symptoms currently labelled as refractory.

Other concerns include the wide variation in the reported use of sedation6, the proportion of symptoms that are labelled as refractory18and the use of sedation in a patient who is incapable of making his or her wishes known. 19

3. In evaluating the severity of a symptom, the health professional relies on what the patientsays. The degree to which a symptom causes suffering is heavily dependent upon the meaning that a patient attaches to that symptom.  Existential distress may complicate matters further if the patient is reluctant or unable to deal with the cause of such distress. What is intolerable to one person may not be so for another, and the use of heavy sedation in such patients is controversial.7,9,20   Proxy reports from relatives must be carefully evaluated as relatives may be describing their own distress rather than that of the patient21. It is, however, very important to understand and respect the cultural background of the patient and the family. Careful discussion and documentation will help to lessen conflicts between families and staff.22

Viewing sedation as the desired outcome may discourage regular review and further consideration of non-sedating alternatives. Good palliative care requires regular review of each patient, and this is especially true when a patient is sedated. A short trial of sedation followed by a reduction in the level of sedation to see if things have improved is a useful strategy. Some apparently refractory symptoms have responded to this approach23-25.

Coyle has highlighted the danger of fatigue clouding the thinking and actions of the doctor when dealing with dying patients with difficult symptoms.
'There is a risk that the practitioner, faced with profound suffering and
severe symptoms, may fatigue much as we observe the exhaustion of the
patient and family in this situation. This fatigue may result in less
careful monitoring and diminished efforts to control symptoms.26
The perceived imminence of a patient’s death may influence the doctor to prescribe sedation rather than look for alternatives.

Recommendation

1. The aim of sedation in palliative care should be to adequately relieve refractory and unbearable symptoms by means of appropriate sedative drugs carefully titrated “to the cessation of symptoms – not the cessation of life”4. (Level of evidence: IV)
   
2. The physician should regularly review the patient’s condition and continue to search for non-sedating alternatives. (Level of evidence: IV)
3. The aims of sedation should be clearly documented. (Level of evidence V)

References

1. Morita T, Tsuneto S & Shima Y. Definition of sedation for symptom relief: a systemic literature review and a proposal of operational criteria. Journal of Pain and Symptom Management 2002; 24(4): 447-453.
2. Rooney K, editor. Encarta Concise English Dictionary. London: Bloomsbury; 2001.
3. Broeckaert B, Nunez Olarte JM. Sedation in palliative care: facts and concepts. In: ten Have H, Clark D, editors. The ethics of palliative care: European perspectives. Facing Death series. Buckingham: Open University Press, 2002: 166-180.
4. Jackson WC, Palliative sedation vs. terminal sedation: What’s in a name? American Journal of Hospice and Palliative Care. 2002; 19(2): 81-82.
5.  Sykes N.  Thorns A. The use of opioids and sedatives at the end of life. Lancet Oncology 2003; 4(5):312-8.
6. Beel A.  McClement SE.  Harlos M.  Palliative sedation therapy: a review of definitions and usage. International Journal of Palliative Nursing 2002;  8(4):190-9.
7. Jansen LA. &  Sulmasy DP.  Sedation, alimentation, hydration, and equivocation: careful conversation about care at the end of life.  Annals of Internal Medicine 2002; 136(11):845-9.
8. Cowan JD.  Walsh D. Terminal sedation in palliative medicine--definition and review of the literature.  Supportive Care in Cancer 2001;  9(6):403-7
9. Morita T.  Tsunoda J.  Inoue S.  Chihara S.  Terminal sedation for existential distress.  American Journal of Hospice & Palliative Care 2000; 17(3):189-95.
10. Rousseau P.  The ethical validity and clinical experience of palliative sedation.                     Mayo Clinic Proceedings 2000; 75(10):1064-9.
11. . Fainsinger RL.  Waller A.  Bercovici M.  Bengtson K.  Landman W.
    Hosking M.  Nunez-Olarte JM.  deMoissac D.  A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients. Palliative Medicine 2000; 14(4):257-65.
12. Wein S.  Sedation in the imminently dying patient. Oncology (Huntington)  2000; 14(4):585-92.
13. Quill TE.& Byock IR.  Responding to intractable terminal suffering: the role of terminal sedation and voluntary refusal of food and fluids. Annals of Internal Medicine 2000; 132(5):408-14.
14. Chater S.  Viola R.  Paterson J. & Jarvis V. Sedation for intractable distress in the dying--a survey of experts.  Palliative Medicine 1998; 12(4):255-69.
15. Muller-Busch CH, Andres I & Jehser T. Sedation in palliative care – a critical      analysis of 7 years experience. BMC Palliative Care 2003; 2:2
16. Cherny NI & Portenoy RK. Sedation in the Management of Refractory Symptoms: Guidelines for evaluation and treatment. Journal of Palliative Care 1994; 10: 31-38.
17. Regnard C. Palliative Sedation Consensus (e-mail communication to Palliative Sedation Consensus Group 13/03/2003)
18. Sales JP. Sedation and terminal care. European Journal of Palliative Care 2001; 8(3):97-100.
19. Roy DJ, MacDonald N. Ethical issues in palliative care. In: Doyle D, Hanks GWC & MacDonald N, editors. Oxford Textbook of Palliative Medicine. 2nd ed. Oxford: Oxford University Press; 1999. p.97-138.
20. Rousseau P, Existential suffering and palliative sedation in terminal illness. Progress in Palliative Care 2002; 10(5):222-224.
21. Addington-Hall J, Kalra L, Who should measure quality of life. BMJ
    2001:322; 1417-1420
22. Morita T, Inoue S & Chihara S. Sedation for symptom control in Japan: The Importance of intermittent use and communication with family members. J Pain and Symptom Management 1996; 12: 32-38.
23. Cherny NI. Sedation in response to refractory existential distress: walking the fine line. J Pain & Symptom Management 1998; 16: 404-06.
24. Rousseau P. Existential suffering and palliative sedation: a brief commentary with a proposal for clinical guidelines. Am J Hospice & Palliative Care 2001 (18): 3; 151-153.
25. Fainsinger, RL, Landman W, Hoskings M & Bruera E. Sedation for uncontrolled symptoms in a South African Hospice. J Pain & Symptm Management. 1998; 16(3): 145-152.
26. Coyle N, Adelhardt J, Foley K, Portenoy R. Character of terminal illness in
    the advanced cancer patient: pain and other symptoms during the last four
    weeks of life. J of pain and Symptom management 1990; 5(2): 83-93.

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