Palliative Care

Considerations of palliative sedation therapy

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 suffering.

Christine A. Zawistowski, MD
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 suffering.

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 Brunswick, N.J.

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 suffering.

Christine A. Zawistowski, MD
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 suffering.

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 Brunswick, N.J.