Forum.
RESULTS
Fourteen studies that provided the broadest information regarding the use of sedatives in the care of cancer patients in the final stages of life are summarised in Tables 1 and 2.(7-20) Other studies reporting on the selective use of a particular sedative have been used to gather information on doses used (Table 3). (2, 21-31)
Patterns of sedative use
The proportion of patients receiving sedation varies between 1-88%. For ‘proportional’ and ‘sudden’ sedation mean frequency was 45% and 16% respectively. Sedatives are mainly used for patients with agitated delirium and breathlessness, around 2/3 and 1/4 respectively. Drugs used vary between settings and countries, but a benzodiazepine, generally midazolam, was the most frequently used sedative, reported in 2/3 of all studies (4). The most popular psychotropic drugs appear to be haloperidol and levomepromazine, often given in conjunction with benzodiazepines. Phenobarbital and propofol are used relatively infrequently, often as sedative drugs of last resort. Opioids do not feature as sedatives except in Japan and Taiwan.(13-15) Many consider opioids inefficient sedatives, with sedation occurring at doses that may be associated with undesirable effects, e.g. nausea, delirium.
Duration of sedation
In one study, of those patients receiving doses of drugs the authors defined as likely to sedate, 56% commenced them within the last 48h of life. Only 13% had been receiving them for at least 7 days prior to death.(10)
Dose and dose titration
Table 3 summarises doses administered in the last 48h of life of the more frequently used sedatives. There is little data regarding dose titration. In one study, the median daily dose of midazolam increased from 10mg on the penultimate day to 23mg on the day of death. (23) The median daily dose of levomepromazine was 50mg and remained unchanged over the last 48h. The daily dose of phenobarbital was generally 200-500mg, except in one patient who increased from 700mg on the penultimate day to 1200mg on the day of death.(10)
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