Forum.
Propositions
In order to take these points into consideration, a practical situation may be seen as follows.A partial sedation titrated according to the patient’s comfort and respecting some level of communication ability may be seen as a matter of sedation of anxiety (which results in a relation quality improvement (34)) and therefore no longer as a matter of a loss of consciousness. Moreover, if interaction abilities are preserved by the way of a partial sedation, the patient still keeps his ability to ask for its termination when he wishes. So, the only real problem concerns a voluntary sedation making the patient completely unconscious. So, we will focus on that single aspect thereafter.
1. No difficulty exists about giving a patient some sedative drug to find sleep (8, 37) at night when he can’t find sleep by his own ways. No more difficulty in accepting to administrate such a treatment whatever the cause of the patient’s inability to find sleep (anguish, pain, dyspnoea, …). The hours at which the patient chooses to get some sleep are his own choice. The sleeping time is finite and ends with recovering previous level of consciousness. An intermittent sedation solicited by the patient doesn’t seem to be an intrinsically different situation. In a formal way, such an occurrence supposes :
- definition with the patient of the duration of the « sleep » he wants, then of the time at which he wants sedation to be alleviated,
- a sufficient degree of certainty by the prescriber of the reality of the choice of the patient, then a discussion with team and/or family about possible misunderstanding of that choice,
- a sufficient confidence inside team and with family about the genuine intention to meet the patient’s wish, then a report of the discussion above in the medical and nursing files.
2. If the patient (or his surrogate if the patient is unable) doesn’t ask himself for such a treatment under the same circumstances, but accepts the suggestion of a doctor, the situation could be seen only as a variant of 1).
3. If the patient is unable and no surrogate exists, then the team has to act as a surrogate. It is therefore a variant of 2), except that being a group decision, no item of the sedation decision should stay unsaid, particularly concerning the aims and the following criterions.
4. Continuous sedation inducing unconsciousness can’t meet the same parallelism. So far, we can’t find any argument for a continuous form of sedation (i.e. with no planned suspension of the sedation), meaning that any sedation to unconsciousness should be intermittent at first, even if reinduced if needed again upon awakening.
It is assumed here that it is technically possible to manage sedation / « awakening » precisely. That is not an easy matter anyway, and the lack of precision of the timetable should be integrated in any decision. For this aim, either a short acting benzodiazepine or propofol are recommended drugs to be used.
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