Palliative Sedation Flashcards
1
Q
Definition of Palliative Sedation
A
- Monitored use of medications intended to induce a state of decreased or absent awareness to relieve the burden of otherwise intractable suffering
- Done in a manner ethically acceptable to patient, family, and healthcare providers
- Generally a last resort approach
- Goal is to control symptoms at lightest and lowest dose of sedatives possible with judicious and proportionate titration to clinical effect
- Start low and go slow (except in the case of catastrophic hemorrhage, etc.)
2
Q
Prerequisites for initiating palliative sedation
A
- Intolerable suffering due to refractory symptoms
* Occurs when further invasive/non-invasive interventions are:
- Incapable of providing adequate relief
- Too burdensome or associated with unacceptable toxicity
- Unlikely to provide relief within an acceptable time frame
- Not accessible in preferred care setting - Presence of an incurable disease
- Imminence of death
- Some guidelines recommend death expected within hours to days, others within 1-2 weeks (Canadian guidelines)
- Otherwise, sedation may hasten death if patient unable to eat or drink - Consent of patient or SDM if patient lacks capacity and discussion of how PS differs from euthanasia
- DNR in place
- Discussion with interprofessional care team and guidance/consultation by specialist palliative care
- Documentation of all of the above
3
Q
Consent process for palliative sedation
A
- With SDM (if patient lacks capacity) or patient
Discussion of:
- GoC and Palliative Sedation
- Intent to reduce suffering, not hasten death
- What PS involves and why it is being considered (other options have been attempted and are ineffective or unacceptable)
- DNR should be in place - Titration of the medication to find the lowest dose possible and lightest level of sedation to achieve the desired goal
- Fact that reduced awareness will reduce ability to communicate
- Fact that sedation will impair ability to eat/drink
4
Q
Indications for palliative sedation
A
- Refractory dyspnea
- Agitated delirium
- Pain
- Vomiting
- Psychological/spiritual distress (More controversial). If indicated, consider either intermittent (‘respite’) sedation or very mild sedation
5
Q
Ethical difficulties of providing palliative sedation for treatment of psychological/spiritual distress
A
- More difficult to establish that psychological/spiritual distress is truly refractory
- Severity of symptoms may be dynamic and idiosyncratic and many patients will adapt and cope
- Standard treatment approaches have low intrinsic morbidity and risk
- Presence of these symptoms does not necessarily indicate a far advanced state of physiological deterioration
- Treatment requires adequate time
6
Q
Scenarios in which Palliative Sedation may be misused
A
- Primary goal of hastening death (euthanasia)
- Inadequate patient assessment where reversible causes are overlooked
- Situations where physicians resort to sedation because they are frustrated/fatigued by symptom burden
- Provided with inadequate monitoring of symptom distress/relief (disproportionate dosing)
- Use of inappropriate medications (e.g. opioids)
- Failure to engage family and other caregivers
7
Q
Why are clinical practice guidelines essential to the practice of Palliative Sedation
A
- In light of poor practices and ethical concerns, need for guidelines to ensure best practices are adhered to
- Ensure the credibility of the field of palliativ medicine
- Avoidance of patient harm
8
Q
How does Palliative Sedation differ from euthanasia
A
- Intent is to provide symptom relief, not hasten death
- Intervention is proportionate to symptom, severity, and goals of care
- Death is not a criterion for treatment success (rather, comfort is)
9
Q
Ethical considerations around Palliative sedation (generally)
A
- Acceptable therapeutic option as long as appropriate indications are met
- Narrow therapeutic index given potential adverse outcomes
- Acceptable given doctrine of double effect
- Note that some care providers or family members may perceive palliative sedation as a slow form of euthanasia, though research does not suggest that when done correctly it hastens death
10
Q
Doctrine of double effect
A
Provides ethical justification for an act provided that:
- Action is morally good or neutral
- Foreseen yet undesired result is not directly intended
- Good effect is not direct result of foreseen untoward effect
- Good effect is proportionate to untoward effect
- No other way to achieve desired ends without untoward effct
11
Q
Importance of self-awareness in context of palliative sedation
A
- Studies show that healthcare professionals experiencing burnout or those with little training/experience in Palliative Care have a lower threshold for initiating palliative sedation, even when it may not be necessarily required
12
Q
Medications to use for palliative sedation
A
- Midazolam
- Sedating and amnestic properties
- Lack of active metabolites and short half life, rapid onset of action = easily titratable
- Most guidelines suggest initial loading dose, then continuous infusion of midaz titrated to effect
- May use a bolus ‘rescue’ dose - Methotrimeprazine
- Consider for patients exhibiting paradoxical agitation or requiring high doses of midazolam - Phenobarbital
- Consider in patients with tolerance to midazo or methotrimeprazine
Opioids are not sedatives and should not be used
13
Q
What to do with other medications during palliative sedation
A
- Continue medications used for symptom palliation
- Continue opioids to ensure no withdrawal, but if symptoms are well palliated or there is evidence of toxicity, may reduce
14
Q
Other care issues when initiating palliative sedation
A
- Mouth care
- Bowel care (supps or enema 1-2x per week)
- Regular repositioning to avoid pressure ulcers
- Urinary catheter PRN for patients with deeper sedation. Also, monitor for urinary retention
15
Q
Monitoring in Palliative Sedation
A
Frequency
- Titration phase
- q15-30 minutes checks - Maintenance phase
- q4H (if at home, then q1-2x daily)
Parameters
- Level of sedation
- Level of comfort
- Airway patency (may consider RR or SpO2) and consider repositioning PRN if concern for airway occlusion
Consider use of a scale or instrument, though note most are only validated in critical care.
- RASS (Richmond Agitation-Sedation Scale)
16
Q
Respite sedation indications
A
- Incident pain
- Severe pain related to therapeutic/diagnostic procedures - Severe refractory social or existential suffering
- May break a cycle of anxiety and distress - Patient requests temporary trial
- Severe and refractory physical/neuropsych symptoms
- Temporary relief from discomfort
- May relieve fatigue associated with distress
17
Q
Caveats for respite sedation
A
- Consent must include possibility that patient may not reawaken and death could be unintentionally hastended
- Consider artificial hydration if continued for more than a few hours
18
Q
Palliative sedation for discontinuation of mechanical ventilation
A
- Sedation intended to ensure patient does not experience severe dyspnea prior to death
Principles:
- Continue existing sedation while on vent, with adjustments to ensure comfort during and after extubation
- Opioid therapy should be continued and augmented in light of likely dyspnea. Titrate to resp rate and absence of laboured breathing
Titration:
- If sedation/opioids not in place prior to extubation, should be started with a trial of room air and vent mode to pressure support with opioids/sedation then titrated to patient comfort prior to actual extubation (watch for apnea vs. grimacing/agitation)
Neuromuscular blockade
- Stop neuromuscular blockade and allow effects to wear off prior to initiating palliative sedation (otherwise, paralysis will mean patient cannot express discomfort and titration cannot occur)
- If there is not time for neuromuscular blockade to have warn off prior to extubation, ensure that patient is sedated to unconsciousness to avoid discomfort
