Forum.
Introduction
The clinical evolution of sedation as an adjuvant treatment in palliative care has been hampered by several factors. Although palliative sedation research is increasing, it remains difficult to generalize because of differences in definitions, methodology, and culture (Rousseau; Fainsinger). Rost lists three important questions upon which consensus must be reached before progress can be made toward evidence-based care for a condition, such as symptom intractability: (a) what are the criteria for identifying the condition? (b) how do we systematically determine which patients meet the criteria? (c) how do we control for concurrent factors (that is, in addition to potential interventions) that can affect outcomes?(60) Implied in (b) is the selection of appropriate interventions for qualifying patients.
We conducted online searches of the PubMed, CINAHL, and PsychInfo databases and the Google search engine, using the search terms “palliative sedation;” “terminal sedation;” and “sedation” linked with “end of life,” “dying,” “suffering,” “intractable,” and “symptom.”
We reviewed papers from the palliative care and general medical literature for definitions of palliative sedation (or an equivalent term) and intractability; processes or criteria for establishing that a symptom is intractable; and participants in the process. The majority of papers were in English, and the remainder in Swedish (2), Spanish (1) and German (1), which were translated by one of the authors (CP – Swedish) or colleagues. We also reviewed guidelines, protocols and position statements of professional organizations that came to our attention.
We looked for answers to the following questions: (see Appendix):
- Do the authors define, describe, or otherwise identify “refractory” or “intractable” symptoms or distress?
- Do the authors describe a process or set of criteria for determining refractoriness?
- Is there a reported difference in approach when psychological, spiritual, or existential distress (rather than physical distress) is the primary reason for considering sedation?
- Is expert consultation identified as necessary or desirable in the determination of refractoriness?
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