18.2 Sedation at the end of life

Question 1

What is palliative sedation therapy? How deep is the sedation that is induced?

Answer 1

controlled sedation sometimes to the point of unconsciousness to relieve refractory suffering in the terminally ill patient

as deep as needed to relieve refractory symptom

Question 2

List three of the most common reasons for palliaitve sedation

Answer 2

pain
dyspnea
agitated delirium
vomiting

Question 3

List three potential side effects of palliative sedation therapy

Answer 3

respiratory depression
hypotension
hastened death

Question 4

A patient has a distressing refractory agitated delirium and cannot provide consent for palliative sedation therapy. There is no known SDM. Whose input should be obtained before initiating sedation?

Answer 4

another senior palliative care physician

FS: ? Adult guardianship

hospital ethics committee

Question 5

What are the four provisos that must be met to take an action that may have negative and positive effect (ie. law of double effect)?

Answer 5

The action:

1) must be undertaken for a proportionally grave reason (ie. rule of probability)

2) must be undertaken with the intention of achieving only the good effect(s) - Possible bad effects may be foreseen but must not be intended

3) must not achieve the good effect by means of the bad effect

4) must not be immoral in itself

Question 6

Palliative sedation therapy is initiated in a patient. List 4 things you would document in the chart.

Answer 6

patient’s overiding goal of care is comfort

patient has an advanced terminal illness

patient is suffering from severe refractory physical or neuropsychiatric symptoms or psychosocial problems

there is an order to withhold life sustaining tx

informed consent for palliative sedation unconsciousness has been obtained

Question 7

List four risks of artificial nutrition and hydration at eol

Answer 7

pulmonary edema
pleural effusions
respiratory secretions
ascites
anasarca
dyspnea
pain

Question 8

A patient who is still eating makes a reasonable request for palliative sedation therapy for refractory symptoms. Do artificial food/fluids need to be provided to the patient while sedated?

Answer 8

It is the patient’s terminal illness that makes sedation necessary and they are dying of this illness not from lack of hydration/nutrition

Question 9

List 6 pre-requisites for palliative sedation therapy

Answer 9

1. The patient must have a severe, chronic, life threatening illness
2. The patient must be suffering from one or more severe physical or neuropsychiatric symptoms
3. The distressing symptom(s) must be refractory to standard palliative care interventions
4. Comfort must be the overriding goal of the patient’s care
5. Where possible an active order must exist to withhold life sustaining treatments
6. Informed consent for palliative sedation that may unintentionally hasten death must be obtained from the patient or SDM
7. Team must be informed (all staff involved in care of patient)

Question 10

A patient is suffering from refractory social distress due to loneliness. What type of sedation should be offered?

Answer 10

respite or temporary sedation (trialled at least once before permanent sedation offered)

Question 11

For a patient with a planned terminal extubation, how is palliative sedation therapy different?

Answer 11

sedation intended to not for refractory symptoms but to ensure patient does not experience severe dyspnea in the time between ventilator removal and death

If patient already receiving sedation to treat or prevent discomfort with mechanical ventilation, this should be maintained and adjusted if needed.

Because most agents used for pal sed do not contain opioid, an opioid should be added if not already present to treat dyspnea

Question 12

There is a plan to terminally extubate a patient. Morphine and midazolam are given. Ventilation is reduced to pressure support. The patient develops evidence of discomfort.
- List three signs of discomfort in this situation.
- What should you do?

Answer 12

tachypnea
agitation
grimacing

the previous level of ventilatory support should be reinstituted and the doses of midaz and morphine adjusted. The assessment should then be repeated

Question 13

A patient on hydromorphone requests palliative sedation therapy. Why should this not be achieved by increased HM?

Answer 13

puts the patient at risk for counterproductive and uncomfortable SE such as myoclonus, hyperalgesia, agitated delirium

opioids alone not reliable at achieving sedation

Question 14

What is the role of neuroleptics in palliative sedation?

Answer 14

good treatments for agitated delirium but none reliably induce unconsciousness

Question 15

List 3 effects of propofol other than consistent induction of sedation

Answer 15

anxiolytic
antiemetic
antipruritic
anticonvulsant
muscle relaxant

Seizure, anxiety, vomiting

Question 16

What is the loading dose and infusion rate doing for midazolam for palliative sedation in a benzo naive patient?

Answer 16

loading dose: 0.03-0.05mg/kg

infusion rate: 0.020 - 0.1mg/kg