Palliative sedation

Question

Recommendations

1. Use palliative sedation in patients in the last days of life who are suffering due to one or more refractory symptoms.

Rationale

GDG has made a weak recommendation in favour of using palliative sedation in such patients (patients in the last days of life who are suffering due to one or more refractory symptoms), given that the quality of the evidence on the effects is overall very low and there is substantial uncertainty about and variability in how patients and their families value the outcomes.

Additionally, a list of key clinical considerations has been drawn up regarding the implementation of the recommendation made. These focus on improving the process of palliative sedation, including the need to reach a consensus among the multidisciplinary team on the indication of sedation, the obtaining of informed consent, types of sedation, monitoring, measures to tailor therapy and achieve a reasonable level of comfort, and the approach of health professionals, as well as the documentation of the process in the medical record.

Complete clinical question

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http://portal.guiasalud.es/guia-en-capas/gpc_612__atencion_paliativa_sud-2/#question-6

References

6. The goals of medicine. Setting new priorities. Hastings Cent Rep. 1996;26(6):S1-27.

20. Grupo de Trabajo de la Guía de Práctica Clínica sobre Cuidados Paliativos. Guía de Práctica Clínica sobre Cuidados Paliativos. Vitoria: Agencia de Evaluación de Tecnologías Sanitarias del País Vasco; Guías de Práctica Clínica en el SNS: OSTEBA Nº 2006/08.

68. Stevens I, Whyte F. Advance care planning: will it work in diseases other than cancer? European Journal of Palliative Care. 2011;18(6):280-4.

143. Kehl KA, Kowalkowski JA. A systematic review of the prevalence of signs of impending death and symptoms in the last 2 weeks of life. Am J Hosp Palliat Care. 2013;30(6):601-16. DOI: 10.1177/1049909112468222.

167. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274(20):1591-8.

168. Doyle D, Woodruff R. The IAHCP Manual of Palliative Care. 2ª ed. International Association for Hospice and Palliative Care Press; 2008.

169. Morita T, Chinone Y, Ikenaga M, Miyoshi M, Nakaho T, Nishitateno K, et al. Efficacy and safety of palliative sedation therapy: a multicenter, prospective, observational study conducted on specialized palliative care units in Japan. J Pain Symptom Manage. 2005;30(4):320-8. DOI: 10.1016/j.jpainsymman.2005.03.017.

170. Cowan JD, Clemens L, Palmer T. Palliative sedation in a southern Appalachian community. Am J Hosp Palliat Care. 2006;23(5):360-8. DOI: 10.1177/1049909106292173.

171. de Graeff A, Dean M. Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. J Palliat Med. 2007;10(1):67-85. DOI: 10.1089/jpm.2006.0139.

172. Cherny NI, Radbruch L, Board of the European Association for Palliative Care. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med. 2009;23(7):581-93. DOI: 10.1177/0269216309107024.

173. Cherny NI, Portenoy RK. Sedation in the management of refractory symptoms: guidelines for evaluation and treatment. J Palliat Care. 1994;10(2):31-8.

174. Beller EM, van Driel ML, McGregor L, Truong S, Mitchell G. Palliative pharmacological sedation for terminally ill adults. Cochrane Database Syst Rev. 2015;1(1):CD010206-CD. DOI: 10.1002/14651858.CD010206.pub2.

175. Alonso-Babarro A, Varela-Cerdeira M, Torres-Vigil I, Rodríguez-Barrientos R, Bruera E. At-home palliative sedation for end-of-life cancer patients. Palliat Med. 2010;24(5):486-92. DOI: 10.1177/0269216309359996.

176. Bulli F, Miccinesi G, Biancalani E, Fallai M, Mannocci M, Paci E, et al. Continuous deep sedation in home palliative care units: case studies in the Florence area in 2000 and in 2003-2004. Minerva Anestesiol. 2007;73(5):291-8.

177. Caraceni A, Zecca E, Martini C, Gorni G, Campa T, Brunelli C, et al. Palliative sedation at the end of life at a tertiary cancer center. Support Care Cancer. 2012;20(6):1299-307. DOI: 10.1007/s00520-011-1217-6.

178. Chiu TY, Hu WY, Lue BH, Cheng SY, Chen CY. Sedation for refractory symptoms of terminal cancer patients in Taiwan. J Pain Symptom Manage. 2001;21(6):467-72. DOI: 10.1016/s0885- 3924(01)00286-x.

179. Fainsinger RL, Landman W, Hoskings M, Bruera E. Sedation for uncontrolled symptoms in a South African hospice. J Pain Symptom Manage. 1998;16(3):145-52. DOI: 10.1016/s0885- 3924(98)00066-9.

180. Kohara H, Ueoka H, Takeyama H, Murakami T, Morita T. Sedation for terminally ill patients with cancer with uncontrollable physical distress. J Palliat Med. 2005;8(1):20-5. DOI: 10.1089/ jpm.2005.8.20.

181. Maltoni M, Pittureri C, Scarpi E, Piccinini L, Martini F, Turci P, et al. Palliative sedation therapy does not hasten death: results from a prospective multicenter study. Ann Oncol. 2009;20(7):1163-9. DOI: 10.1093/annonc/mdp048.

182. Maltoni M, Miccinesi G, Morino P, Scarpi E, Bulli F, Martini F, et al. Prospective observational Italian study on palliative sedation in two hospice settings: differences in case mixes and clinical care. Support Care Cancer. 2012;20(11):2829-36. DOI: 10.1007/s00520-012-1407-x.

183. Muller-Busch HC, Andres I, Jehser T. Sedation in palliative care – a critical analysis of 7 years experience. BMC Palliat Care. 2003;2(1):2-. DOI: 10.1186/1472-684X-2-2.

184. Radha Krishna LK, Poulose VJ, Goh C. The use of midazolam and haloperidol in cancer patients at the end of life. Singapore Med J. 2012;53(1):62-6.

185. Rietjens JAC, van Zuylen L, van Veluw H, van der Wijk L, van der Heide A, van der Rijt CCD. Palliative sedation in a specialized unit for acute palliative care in a cancer hospital: comparing patients dying with and without palliative sedation. J Pain Symptom Manage. 2008;36(3):228- 34. DOI: 10.1016/j.jpainsymman.2007.10.014.

186. Stone P, Phillips C, Spruyt O, Waight C. A comparison of the use of sedatives in a hospital support team and in a hospice. Palliat Med. 1997;11(2):140-4. DOI: 10.1177/026921639701100208.

187. Sykes N, Thorns A. Sedative use in the last week of life and the implications for end-of-life decision making. Arch Intern Med. 2003;163(3):341-4. DOI: 10.1001/archinte.163.3.341.

188. Vitetta L, Kenner D, Sali A. Sedation and analgesia-prescribing patterns in terminally ill patients at the end of life. Am J Hosp Palliat Care. 2005;22(6):465-73. DOI: 10.1177/104990910502200601.

189. Prado BL, Gomes DBD, Usón Júnior PLS, Taranto P, França MS, Eiger D, et al. Continuous palliative sedation for patients with advanced cancer at a tertiary care cancer center. BMC Palliat Care. 2018;17(1):13-. DOI: 10.1186/s12904-017-0264-2.

190. Boulanger A, Chabal T, Fichaux M, Destandau M, La Piana JM, Auquier P, et al. Opinions about the new law on end-of-life issues in a sample of french patients receiving palliative care. BMC Palliat Care. 2017;16(1):7-. DOI: 10.1186/s12904-016-0174-8.

191. Bruinsma SM, Brown J, van der Heide A, Deliens L, Anquinet L, Payne SA, et al. Making sense of continuous sedation in end-of-life care for cancer patients: an interview study with bereaved relatives in three European countries. Support Care Cancer. 2014;22(12):3243-52. DOI: 10.1007/s00520-014-2344-7.

192. Bruinsma SM, van der Heide A, van der Lee ML, Vergouwe Y, Rietjens JAC. No negative impact of palliative sedation on relatives’ experience of the dying phase and their wellbeing after the patient’s death: an observational study. PLOS ONE. 2016;11(2):e0149250-e. DOI: 10.1371/journal.pone.0149250.

193. Eun Y, Hong I-W, Bruera E, Kang JH. Qualitative study on the perceptions of terminally ill cancer patients and their family members  regarding  end-of-life  experiences focusing on palliative sedation. J Pain Symptom Manage. 2017;53(6):1010-6. DOI: 10.1016/j. jpainsymman.2016.12.353.

194. Fainsinger RL, Núñez-Olarte JM, Demoissac DM. The cultural differences in perceived value of disclosure and cognition: Spain and Canada. J Palliat Care. 2003;19(1):43-8.

195. Morita T, Ikenaga M, Adachi I, Narabayashi I, Kizawa Y, Honke Y, et al. Family experience with palliative sedation therapy for terminally ill cancer patients. J Pain Symptom Manage. 2004;28(6):557-65. DOI: 1016/j.jpainsymman.2004.03.004.

196. Shen H-S, Chen S-Y, Cheung DST, Wang S-Y, Lee JJ, Lin C-C. Differential family experience of palliative sedation therapy in specialized palliative or critical care units. J Pain Symptom Manage. 2018;55(6):1531-9. DOI: 10.1016/j.jpainsymman.2018.02.007.

197. Tursunov O, Cherny NI, Ganz FD. Experiences of family members of dying patients receiving palliative sedation. Oncol Nurs Forum. 2016;43(6):E226-E32. DOI: 10.1188/16. ONF.E226-E232.

198. van Dooren S, van Veluw HTM, van Zuylen L, Rietjens  JAC, Passchier  J, van  der  Rijt CCD. Exploration of concerns of relatives during continuous palliative sedation of  their family members with cancer. J Pain Symptom Manage. 2009;38(3):452-9. DOI: 10.1016/j. jpainsymman.2008.11.011.

199. Vayne-Bossert P, Zulian GB. Palliative sedation: from the family perspective. Am J Hosp Palliat Care. 2013;30(8):786-90. DOI: 10.1177/1049909112472930.

200. Rietjens JAC, Deschepper R, Pasman R, Deliens L. Medical end-of-life decisions: does its use differ in vulnerable patient groups? A systematic review and meta-analysis. Social science & medicine (1982). 2012;74(8):1282-7. DOI: 10.1016/j.socscimed.2011.12.046.

201. Benítez-Rosario MA, Morita T. Palliative sedation in clinical scenarios: results of a modified Delphi study. Support Care Cancer. 2019;27(5):1647-54. DOI: 10.1007/s00520-018-4409-5.

202. Raus K, Brown J, Seale C, Rietjens JAC, Janssens R, Bruinsma S, et al. Continuous sedation until death: the everyday moral reasoning of physicians, nurses and family caregivers in the UK, The Netherlands and Belgium. BMC Med Ethics. 2014;15:14-. DOI: 10.1186/1472-6939- 15-14.

203. Papavasiliou EE, Payne S, Brearley S, Euroimpact. Current debates on end-of-life sedation: an international expert elicitation study. Support Care Cancer. 2014;22(8):2141-9. DOI: 10.1007/ s00520-014-2200-9.

204. Abarshi E, Rietjens J, Robijn L, Caraceni A, Payne S, Deliens L, et al. International variations in clinical practice guidelines for palliative sedation: a systematic review. BMJ Support Palliat Care. 2017;7(3):223-9. DOI: 10.1136/bmjspcare-2016-001159.

205. Schildmann EK, Schildmann J, Kiesewetter I. Medication and monitoring in palliative sedation therapy: a systematic review and quality assessment of published guidelines. J Pain Symptom Manage. 2015;49(4):734-46. DOI: 10.1016/j.jpainsymman.2014.08.013.

206. Sedación paliativa del prcpex, uso y recomendaciones. Guía clínica [Internet]. Mérida: Servicio Extremeño de Salud. FundeSalud; 2014. [accessed 4 Feb 2020]. Available from: saludextremadura.ses.es.

207. Sedación paliativa. Guía [Internet] Madrid: Consejo General de Colegios Oficiales de Médicos; 2012. [accessed 4 Feb 2020]. Available from: www.cgcom.es.

208. Voeuk A, Nekolaichuk C, Fainsinger R, Huot A. Continuous palliative sedation for existential distress? a survey of canadian palliative care physicians’ views. J Palliat Care. 2017;32(1):26-33. DOI: 1177/0825859717711301.

209. Rodrigues P, Crokaert J, Gastmans C. Palliative sedation for existential suffering: a systematic review of argument-based ethics literature. J Pain Symptom Manage. 2018;55(6):1577-90. DOI: 10.1016/j.jpainsymman.2018.01.013.

210. Henry B. A systematic literature review on the ethics of palliative sedation: an update (2016). Curr Opin Support Palliat Care. 2016;10(3):201-7. DOI: 10.1097/ SPC.0000000000000224.

211. Twycross R. Reflections on palliative sedation. Palliat Care. 2019;12:1178224218823511. DOI: 1177/1178224218823511.

212. Ely EW, Truman B, Shintani A, Thomason JWW, Wheeler AP, Gordon S, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation- Sedation Scale (RASS). JAMA. 2003;289(22):2983-91. DOI: 10.1001/jama.289.22.2983.

213. Benítez-Rosario MA, Castillo-Padrós M, Garrido-Bernet B, González-Guillermo T, Martínez- Castillo LP, González A, et al. Appropriateness and reliability testing of the modified Richmond Agitation-Sedation Scale in Spanish patients with advanced cancer. J Pain Symptom Manage. 2013;45(6):1112-9. DOI: 10.1016/j.jpainsymman.2012.05.015.

214. Sacristán Rodea A, Peláez Moya S. Bullich Marín I, García Aparicio M, Coords. Manejo en domicilio de pacientes al final de la vida que requieran sedación paliativa en el contexto de la pandemia por COVID-19. Madrid: Ministerio de Sanidad; 2020. Available from: www.mscbs.gob.es.