Forum.
Recommendations
The following recommendations are based on level IV evidence.
Sedation may be considered for refractory symptoms. A symptom is considered to be refractory if it cannot be alleviated, if the side-effects of treatment are unacceptable to the patient and/or if it will take too long to alleviate it. This implies that the team looking after the patient has enough expertise and experience to judge the symptom as refractory and that there is consensus on this subject. The team should perform a complete multidimensional symptom assessment including psychosocial and existential dimensions, and be alert for reversible causes of severe distress. If the team does not have adequate experience and expertise, expert opinion should be sought.
Indications include but are not limited to:
- terminal agitation and restlessness refractory to benzodiazepines and neuroleptics, after causes for reversible delirium have been considered for diagnosis and treatment.
- pain refractory to opioids and adjuvant analgesics after risk factors for poor pain control have been controlled for and opioid rotation and invasive measures have at least been considered.
- dyspnoea refractory to oxygen, bronchodilators, corticosteroids and opioids, after a multidimensional assessment has judged the impact of anxiety or existential distress on the refractoriness of dyspnoea.
- severe vomiting refractory to aggressive anti-emetic therapy, after all risk factors for emesis have been considered and treated.
Sedation for psychological or existential distress should only be considered in exceptional circumstances and after consultation with experts in this area.
Sedation for refractory symptoms is often permanent (until death) in which case life expectancy should be no more than 1-2 weeks. In some circumstances temporary sedation may be considered and in those cases life expectancy may be longer.
Informed consent from the patient or the designated or legally recognised decision-maker should be obtained. All should understand that the aim of sedation is to alleviate symptoms and not to hasten death.
There is a need for prospective studies in this area with emphasis on the achievement of high-quality multidimensional assessments and management of refractory symptoms and on the evaluation and measurement of the effects of sedation on patients and their families.
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