Symptom control is a major aspect of palliative care. Although most patients
have symptom control and are able to maintain personally satisfying lives, for
a subset of patients, symptomatic control remains elusive. For these patients,
palliative sedation therapy, a treatment of last resort, may prove beneficial.
Its controversial nature exists secondary to an absent standardized definition,
ill defined indications for use and implementation, and misinterpretation as
euthanasia. The intention behind euthanasia is death of the patient, while the
intention behind palliative sedation therapy is relief of intractable
Christine A. Zawistowski
Palliative sedation therapy (PST) is the use of sedatives to relieve
intolerable suffering from refractory symptoms through reduction of the
patient’s consciousness. Intolerable suffering implies the existence of
specific symptoms, as determined by the patient or patient’s proxy, which
the patient does not wish to endure. A symptom is considered refractory when
further invasive or noninvasive interventions are incapable of providing
adequate relief, when the symptom is associated with excess or intolerable
acute or chronic morbidity, and standard therapies are unlikely to provide
relief within an acceptable time frame for the patient.
The decision-making process surrounding PST should be similar to that for
any other medical intervention addressing terminal illness. This includes
attention to psychological and spiritual evaluations, assessment of the
patient’s wishes and goals for treatment and alleviation of symptoms and
suffering. There are several questions to ask in a shared decision-making
framework prior to implementing PST. Are the patient’s symptoms
refractory? Is palliative sedation therapy appropriate for this patient? How
will it be implemented? How will the patient be monitored? What criteria will
be used to assess the efficacy of the therapy? What other treatments will be
continued or discontinued?
There are various levels of PST that can be adjusted to meet the
patient’s needs. Rather than framing it as the institution and maintenance
of sedation to the level of coma, it should be thought of and used as a therapy
titrated to alleviate suffering. At a mild level of sedation (somnolent), the
patient would be awake but with a lowered level of consciousness. If the
patient was still suffering, the therapy could be increased to an intermediate
level where he/she was asleep but able to be awakened to communicate briefly.
When necessary, sedation can be increased to induce coma.
There are four medication groups used for palliative sedation:
anoxiolytic/sedatives (midazolam, lorazepam), sedating antipsychotics
(haloperidol), barbiturates (phenobarbital, pentobarbital), and general
anesthetics (propofol). Many of these medications can be administered
intravenously or subcutaneously, as continuous infusions or intermittent doses.
It is recommended to work with a pharmacist to determine the appropriate dosage
in an individual patient.
Artificial nutrition and hydration may need to be addressed in patients who
will be placed in a medically induced stupor or coma. This should be discussed
separately from PST. If a patient’s level of sedation is likely to be a
deep but transient trial of therapy and the patient has a life expectancy of
more than one week, it may be indicated to provide hydration and/or nutrition
during the PST.
Palliative sedation therapy is part of the continuum of good palliative
care. When this therapeutic option has been thoroughly discussed with the
patient, family, and health care team, it can be a valuable therapy to use for
patients in whom all conventional methods have failed to alleviate their
Christine Zawistowski, MD, is a Pediatric Palliative Care and Intensive
Care Doctor at the Cancer Institute of New Jersey and Bristol Myer Squibb
Children’s Hospital at Robert Wood Johnson University Hospital, New