Forum.
Introduction
Sedation for symptom management at the end of life should, like any other symptom-control measure, be regularly reviewed to assess symptom control. Family members require support when the patient is sedated, and the sedation procedure should also be regularly reviewed. But two large, international studies of sedation at end of life did not address monitoring of the patient, nor the care and support of the family ,. In fact, the literature contains very little information on the monitoring and continuing care of patients sedated for palliative care indications. There is also little information on how to support the family of the sedated patient. Therefore, we broadened our literature search to include studies addressing the monitoring of patients who are sedated for procedures, or in an intensive care unit.
Consciousness is a dynamic state defined as a general awareness of oneself and the surrounding environment in which attention is focused on immediate matters. There are three properties of consciousness that can be independently affected by disease or medication ( Teasdale & Jennett, 1974 ) .
- Arousal (a state of responsiveness to sensory stimulation)
- Alertness (a condition of being mentally quick, active, and keenly aware of the environment) i.e. orientation and communication.
- Appropriate voluntary motor activity.
Levels of consciousness have been defined as follows:
- Full consciousness: patient is aware of self and environment, as evidenced by the ability of the patient to be aroused, perceive internal or external stimuli and respond appropriately on a cognitive and motor level.
- Lethargy/drowsiness: patient is inactive and indifferent, the response to stimuli is without purpose and verbal response may be absent.
- Coma: The patient has a total absence of awareness of self and environment. Response to painful stimuli may be absent.
The comatose patient has none of the three properties of consciousness so the responses essential for comfort and self-preservation are absent e.g. shifting position to avoid pressure damage to skin; eating and drinking; bladder and bowel control, etc. Thus, the sedated/comatose patient requires monitoring for fluid and nutrition status, signs of, and relief from, pressure, etc. Although in an intensive care unit attention is paid to, for example, fluid and electrolyte balance, in a palliative care unit the priority is patient comfort, and family support.
The sedated patient may have a level of consciousness anywhere on a spectrum from just below full consciousness through to coma Monitoring and care will depend upon the level of consciousness.
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