Forum.
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.
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