Palliative Sedation - CBM Flashcards
What is palliative sedation?
- Monitored use of medications
- Intended to induce state of decreased or absent awareness to relieve intractable suffering
- Ethically acceptable to patient, family and health care providers
- Goal is lightest level and lowest dose of sedative medication possible -titration to clinical effect
What are the PRE-REQUISITES for initiating Palliative Sedation?
- Intolerable suffering from refractory symptoms
- Imminent death (days to 1-2 weeks)
- Presence of incurable disease
- Informed consent from patient or SDM
- Comfort goals of care/do not resuscitate goals
What constitutes a refractory symptom?
If further interventions:
- are incapable of providing relief
- will have excessive/intolerable toxicity
- are unlikely to help in an acceptable time frame
- are not available in preferred setting of care.
How often is Palliative Sedation required?
- difficult because of different definitions and use
- 5-15% using more recent definitions of PS
- higher rates in PCU, lower rates in community.
What are the common INDICATIONS (symptoms) for Palliative Sedation?
- dyspnea
- agitated delirium most common
- pain
- vomiting
What are the concerns with using PS to treat refractory existential or psychological suffering?
controversial, lack of consensus
- difficult to establish if truly refractory
- Severity of distress can be dynamic, and common part of dying process
- Standard treatment options have low morbidity
- Presence of psychological distress does not always equal advanced disease.
European Association of Palliative Care = consider light or intermittent (respite) sedation first.
How can Palliative Sedation be misused?
- It is unethical to sedate a patient with primary goal of hastening death.
- Inappropriate clinical situation/ insufficient symptom evaluation.
- Inappropriate attention to good and safe practices.
Why are clinical practice guidelines essential for palliative sedation?
- patient safety
- maintain credibility of palliative medicine and professionals
- meticulous adherence to guidelines and monitoring of good practice is essential.
Checklist for Palliative Sedation
- Terminal illness
- Refractory symptom(s)
- Failure of all other palliative interventions
- Prognosis hours to days (<1-2 weeks)
- DNR / Comfort goals of care
- Discussion with interprofessional team
- conscientious objectors given a chance to excuse themselves
- Guidance from palliative care specialist team
- Assessment and documentation of patient capacity
- Discussion with pt and family : effects/adverse effects/difference between PS and MAID.
- Informed consent documented
- All care providers informed
- DOCUMENT EVERYTHING.
What are the differences between Palliative Sedation and MAID?
- Intent of PS is to provide symptom relief, NOT hasten death
- Sedation is proportionate to symptom, severity and goals of care (lowest possible dose)
- Death of patient is not a criteria of success of the treatment.
List some ethical considerations in palliative sedation
- broad consensus that pall sedation is acceptable therapeutic option (moral imperative)
- adequate symptom control is overriding goal at end of life
- narrow therapeutic index of palliative sedation (decreased consciousness, and possibility of shortening life)
What is the principle of Double Effect?
- ethical justification for using pall sedation even if life may be shortened.
- Pall sedation has both a good effect and a bad effect.
- It is permissible if:
- Action is morally good or neutral.
- Undesired result is not directly intended
- Good effect is not direct result of foreseen bad effect.
- Good effect is proportionate to bad effect.
- No other way to achieve goal without the bad effect. The actio is undertaken for a proportionately grave reason
Does Palliative Sedation shorten life?
- no difference in survival between sedation and non-sedated patients (*ref)
- however risk of shortening life cannot be ignored:
- respiratory depression
- aspiration
- hemodynamic instability
- airway compromise
How does artificial nutrition and hydration affect palliative sedation?
- controversial
- when death is imminent, withholding/ withdrawing does not affect natural dying process.
- no evidence nutrition/hydration in final hours/days improves quality or quantity of life.
- some may decide to continue hydration as a non burdensome intervention (cultural, familial, individual beliefs).
What medication is considered first line for Palliative Sedation?
- Midazolam ( GABAa agonist, sedative, amnestic, no active metabolites, short half life, short onset)
- bolus dose, then sc/iv infusion at the same time
- 1 to 10-20 mg/hour, titrate q 10 minutes to RASS score
- bolus rescue doses 2-5 mg q 15 minutes.
- If bolus dose required, can increase infusion by 1 mg / hour.
ADVANTAGES:
- rapid onset
- water soluble
- compatible with most sc meds
- useful for seizure control, muscle spasms, nausea, vx, cetral pruritis
- reversal agent available (flumazenil)
DISADVANTAGES:
- risk of paradoxical agitation
- risk of impaired metablolism with liver disease
- risk of psychotic reactions
What other medications can be used for palliative sedation (Methotrimeprazine):
METHOTRIMEPRAZINE:
- D2, 5HT2, H1, alpha1, alpha 2 and muscarinic antagonist
- analgesic and amnestic
- onset 20-40 min
- 12.5-25 mg sc/iv/im q 8-12h with 6.25-25 mg q1h prn
- continuous infusion 2-3mg/hour sc
- typically used when high doses benzos not effective
ADVANTAGES:
- sedative, analgesic, anxiolytic
- quick onset
- useful for n/vx, delirium, agitation
- can use with other meds -sc, iv, im
DISADVANTGES:
- anticholinergic effects
- orthostatic hypotension
- akasthisia
- acute dystonic reactions
- seizures
- cardiotoxicity with Qt prolongation
What other medications can be used for palliative sedation (Phenobarbital)?
PHENOBARBITAL:
- enhances GABA, inhibits glutamate
- long active sedative, hypnotic, anticonvulsant
- Loading dose 100-200 mg IV/IM
- 0.5 mg/kg/hour IV/Sc continuous infusion (800-2400 mg/day)
- 60-90 mg sc tid for intemittent dosing
- second line option (first line in OXFORD)
ADVANTAGES:
- effective in tolerance to benzos and antipsychotics
- controls seizures
- continuous infusion available.
DISADVANTAGES:
- paradoxical agitation
- hypotension, bradycardia, nausea, vomiting, cutaneous allergic reactions
- can decrease serum concentration of other medications
What other medications can be used for palliative sedation (propofol)?
PROPOFOL: -ultra rapid acting general anesthetic -GABAa agonist, glutamate inhibitor -continuous infusion 5 ug/kg/min IV -titrate every 5-10 min by 5-10 ug/kg/min -effective dose = 5-50 ug/kg/min -second (third?) line option for refractory agitation in palliative sedation ADVANTAGES: -reliable and rapid unconsciousness. -useful in extreme tolerance to benzos/antipsychotics -controls nausea/vx/seizures DISADVANTAGES: -infusion site pain, phlebitis -no SUBQ option -higher risk of line infection -requires pump -apnea, hypotension, allergic reactions (soy and egg) -bradycardia -propofol infusion syndrome** (higher doses > 48 hours) - bradycardia –> arrest - metabolic acidosis -rhabdo -hyperlipidemia -enlarged liver
What other medications can be used for palliative sedation (Clorpromazine)?
CHLORPROMAZINE:
- same as methotrimeprazine MOA
- 12.5-25 mg IV/IM q4-12 hours
- Infusion 3-5 mg/hour IV
- Rectal 100 mg q6-12 hours
- ]use if methtrimeprazine not available
ADVANTAGES:
- quick onset
- same as methotrimeprazine
DISADVANTAGES:
- no SC option (tissue damage and pain)
- same as methotrimeprazine
Can OPIOIDS be used for palliative sedation?
NO
No sedative effect
What should you do with patient’s other medications if palliative sedation is started?
- continue meds for symptom control
- opioids continued, may require reduction
- do not abruptly discontinue
- irrelevant medications to goals of care should be discontinued or weaned.
What other care issues are considered in palliative sedation?
- mouth care
- eye care
- bed positioning for pressure sores
- urinary catheterization
- regular monitoring
- ongoing support to family and care team
How is monitoring provided in palliative sedation?
- Titration phase
- q15-30 min
- Maintenance phase q4 hours (less possibly in the home)
- LEVEL OF SEDATION (all scales validated for crit care only but used in pall care)
- RASS (Richmond Agitation and Sedation Scale)
- Ramsay Sedation Scale
- Riker Sedation - Agitation Scale (SAS)
- LEVEL OF COMFORT
- use pt facial expressions, etc.
- AIRWAY PATENCY
- obstruction, apnea - repositioning, jaw thrust
- difficult to differentiate from dying
- RR, 02 sats not generally recommended.
- Normal part of dying. Case by case.
- LEVEL OF SEDATION (all scales validated for crit care only but used in pall care)
What are medications can be used for palliative sedation (PROPOFOL)?
PROPOFOL
- GABA recetor agonist
- fast onset (15-30 seconds)
- Duration of action 5-10 minutes
- Half life 1-30 hours
- Infusion 2.5-5 ug/kg/min (10-20 mg / hour)
- Titrate q10 min by 10-20 mg/hour
- Boluses of 10-20 mg q10 min prn
ADVANTAGES
- rapidly titrateable
- anxiolytic, antiemetic, anticonvulsant, antimyoclonic properties
DISADVANTAGES:
- hypotension
- respiratory depression
- burning at injection site
- seizure threshold?
- propofol infusion syndrome with long term use
- No anesthetic properties
- Use outside of OR, ER, ICU may be difficult
Respite Sedation
- Time limited unconsciousness for terminally ill patients considered if:
- Incident pain (movement for clinical care, procedures, etc)
- Severe existential or social/emotional suffering (break the cycle of anxiety)
- Patient requests trial of temporary sedation (may releive fatigue)
- from a few minutes to a few days
- Hydration if sedation expected to be > few days
- Monitoring based on patient goals and values
Ventilator weaning/ discontinuation at end of life:
- terminal extubation will likely result in dyspnea
- How is palliative sedation different in this situation?
- Sedation may not be intended to relieve existing dyspnea but to prevent it prior to death.
- Same prerequesites for palliative sedation when discontinuing mechanical ventilation
- terminal illness, goals of care comfort, order to withdraw care, informed consent, prepared staff.
Terminal discontinuation of mechanical ventilation : principles
- continue current sedation and titrate
- opioid therapy continue or add
- Initiate opioids and sedation prior to removal of ventilator
- Weaning :
- change to pressure support mode
- Peep 5
- Observe
- if agitated, resume prior settings and increase sedation
- if apneic and now pain, dose reduce medications to lowest effective dose
- if minimum doses and unconscious and apneic, remove ventilator
- Stop paralytics prior to palliative sedation (to assess effect of sedation)
Oxford protocol for Palliative Sedation Table
