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Guidelines and consensus statements
We found eight guidelines for the use of palliative sedation (Cherny 1994; Wein 2000; Quill 2000; Rousseau 2000/2001; Verhagen 2002; Hawryluck 2002; Cowan 2002, Cherny 2003). They used the following indications and conditions:
- The presence of intractable/refractory physical or mental symptoms (Wein 2000; Rousseau 2000; Quill 2000; Verhagen 2002; Hawryluck 2002; Cowan 2002).
Cherny defined a symptom as being refractory (as opposed to difficult to treat) when the clinician perceives that further invasive or non-invasive interventions are a) incapable of providing adequate relief, b) associated with excessive and intolerable acute or chronic morbidity, and/or c) unlikely to provide relief within a tolerable time frame (Cherny 1994, Cherny 2003).
Rousseau specified the following symptoms (without excluding other symptoms) (Rousseau 2000):
- terminal agitation and restlessness refractory to neuroleptics
- pain refractory to opioids and adjuvant analgesics
- vomiting refractory to aggressive anti-emetic therapy
- dyspnoea refractory to oxygen, bronchodilators, corticosteroids and opioids
- psychological and/or existential distress refractory to appropriate interventions, including but not limited to psychological agents (e.g. antidepressants) and religious or spiritual support
In his specification a multidimensional approach (i.e. an approach addressing the physical, psychological, social and existential dimensions) to physical symptoms is plainly missing. The author defines the refractoriness of delirium, pain, vomiting, and dyspnoea only by the ineffectiveness of increased pharmacological treatments. However, a palliative, multidimensional approach to management of these syndromes might have resulted in strategies other than sedation.
- If necessary, a palliative care or other relevant expert (e.g. a pain specialist or a psychiatrist) should be consulted (Rousseau 2000, Wein 2000; Hawryluck 2002; Cherny 2003)
- The palliative care team should reach consensus about the refractoriness of the symptom (Verhagen 2002) and, in difficult cases, reach consensus through a case conference (Cherny 2003).
- In the case of permanent sedation without administering fluids, the disease should be irreversible and advanced, with death expected imminently within hours to a week or two (Wein 2000; Verhagen 2002, Cowan 2002). If life expectancy is longer, withholding fluids may hasten death.
- Sedation should be in line with the patients’ wishes and be discussed with the patient (if possible) and/or his family (Wein 2000; Rousseau 2000; Quill 2000; Verhagen 2002; Cowan 2002). It should be stated clearly that the aim of sedation is to alleviate symptoms and not to hasten death (Wein 2000; Verhagen 2002; Hawryluck 2002; Cowan 2002; Cherny 2003)
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