Forum.
RECOMMENDATIONS (INCLUDING STRENGTH OF EVIDENCE)
- As long as other drug and non-drug alternatives have been considered and found ineffective or inapplicable to the situation, sedation of the imminently dying is an acceptable means of providing good palliation. In this setting they do not appear to shorten life (Level III-IV). (I’ll leave this for now, but may suggest deleting it as, although perfectly true, it is not specifically concerned with drug selection and monitoring. Other papers tackle this)
- The dose of sedative should be individually titrated to the relief of the symptom and the distress it causes. Only rarely is ‘sudden’ sedation necessary, e.g. massive haemorrhage (Level III-IV).
- The dose of the sedative should be titrated by close monitoring of the expected outcome.
- Benzodiazepines (in particular midazolam) should be considered first-line choice in the absence of delirium. Midazolam may be administered, subcutaneously or intravenously, in single dose or continuous infusion and has anxiolytic, anti-epileptic and muscle relaxant properties (Level III).(32)
- Benzodiazepines should not be used alone for the management of delirium (Level II).(33)
- Haloperidol and levomepromazine should be used alone or in combination with a benzodiazepine for the management of delirium (Level II).(33) Antipsychotics can lower the epileptic threshold and may precipitate myoclonus in severely ill patients.(32) (This is a statement rather than a recommendation. Can you rephrase it to something like, “Because they lower the eplileptic threshold and may precipitate myoclonus,, use antipsychotics with care in severely ill patients”?) I’m happy to leave the last sentence out for consistency as we do not go into undesirable effects of the other drugs (AW).
- For severe agitation unresponsive to other sedatives phenobarbitone and propofol may be used (Level III).(30-32)
- Prior failure of one sedative does not prevent response to another one. (Level III) (6)
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