Forum.
Summary
In palliative care practice, sedation is considered for symptoms refractory to optimal palliative treatment. A symptom is considered refractory if it cannot be alleviated, if the side-effects of treatment are unacceptable and/or if the patient will continue to suffer during the prolonged time required to control the symptom. However, optimal palliative treatment is very often not defined and may not include skilled multidimensional assessments acknowledging ‘total suffering’ phenomena (Clark 1999). Often syndrome assessments that allow diagnosis of predictors of reversibility are missing and appropriate methods of symptom management besides up-titration of pharmacological treatments are lacking. There are large variations between centres in the percentage of patients treated with sedation (presumably due to differences in patient selection and management and to regional, international and cultural differences) and also in symptom frequencies necessitating sedation, (presumably due to differences in terminology, patient selection and symptom management). Delirium, refractory to neuroleptics and benzodiazepines, is the most frequent indication for sedation, followed by intractable dyspnoea, pain and nausea and vomiting. Psychological and existential distress is only rarely a reason to consider sedation. Sedation is regarded as adequate if distress is relieved (proportional approach) independent of the level of (un)consciousness needed. The effects of sedation on patients and their families have not been adequately studied.
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