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EPERC Fast Fact and Concepts #106
Controlled Sedation for Refractory Suffering Part I of II
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Author(s): Mike Salacz; David E. Weissman
Controlled Sedation for Refractory Suffering (a.k.a. total, palliative,
terminal) can be defined as: "sedation for intractable distress in the
dying". The use of sedation has been reported to be anywhere from 2%-50%
of hospice patients. Muller-Busch reported the indications for sedation
included: anxiety/psychological distress (40%), dyspnea (35%) and
delirium/agitation (14%).
While there exists objective criteria for quantifying and treating
physical distress, evaluating psychological distress (a.k.a. existential
suffering) is more difficult; there are no simple and clinically oriented
tools to evaluate spiritual and psychosocial components of mental
suffering. Many clinicians find the idea of sedation for existential
suffering to be ethically more challenging than similar treatment for
physical suffering. In either case, the decision to begin a trial of
sedation is always difficult for clinicians, requiring thorough patient
assessment and discussions with the patient, family and other team
members.
Ethical/Legal Basis
In the United States, Supreme Court rulings (Vacco v Quill (1997),
Washington v Glucksberg (1997)) supported the concept of sedation when
used to relieve intractable suffering. However, controversy still
surrounds the use of sedation due to confusion with euthanasia. From an
ethical and legal standpoint, the key difference is intent. In euthanasia
the intent is to produce a hastened death. In sedation, the intent is to
relieve intractable suffering, not hasten death. Of note, recent studies
have found no difference in survival between hospice patients who required
sedation for intractable symptom control during their last days and those
who did not.
What is a refractory/intractable symptom?
Cherney and Portenoy clarified the distinction between a difficult vs. a
refractory symptom. A refractory symptom, that is, one in which total
sedation may be appropriate, should have the following three attributes:
* Aggressive efforts short of sedation fail to provide relief.
* Additional invasive/non-invasive treatments are incapable of providing
relief.
* Additional therapies are associated with excessive/unacceptable
morbidity, unlikely to provide relief with a reasonable time frame.
Guidelines
Several similar sedation guidelines have been published; listed below are
Rousseau?s guidelines for sedation in patients with existential suffering;
these guidelines would also be appropriate for decisions concerning
physical symptoms.
The patient must have a terminal illness
All palliative treatments must be exhausted, including treatment for
depression, delirium, anxiety, etc
Psychological assessment by a skilled clinician
Spiritual assessment by a skilled clinician or clergy
A DNR order must be in effect and informed consent obtained and documented
Nutrition/hydration issues need to be addressed prior to sedation
One additional consideration proposed by Rousseau and others is the
concept of Respite Sedation -- a time limited trial (usually 24 - 48
hours) in an attempt to break a cycle of psychological suffering. Fast
Fact #107 will review the techniques of sedation.
References
Cherny NI. The use of sedation in the management of refractory pain.
Principles and practice of supportive oncology Updates. 2000 3:1-11
Cherny NI and Portenoy RK. Sedation in the management of refractory
symptoms: guidelines for evaluation and treatment, J. Pall. Care
10:2/1994;31-38.
Cherny, N., Commentary: Sedation in response to Refractory Existential
Distress: Walking the Fine Line, J Pain Symptom Manage, 1998 Dec; 16(6):
404-5.
Charter S et al. Sedation for intractable distress in the dying-a survey
of experts. Pall Med 1998; 12:255-269.
Braun TC et al. Development of a clinical practice guideline for
palliative sedation. J Pall Med 2003; 6:345-350.
Hallenbeck, J., Terminal sedation for intractable distress, West J Med.
1999 Oct; 171(4):222-3.
Muller-Busch, H., etal, Sedation in palliative care ? a critical analysis
of 7 years experience, BMC Palliative Care. 2003 May 13; 2(1):2.
Rousseau, P., Existential suffering and palliative sedation: a brief
commentary with a proposal for clinical guidelines, Am J Hosp Palliat
Care, 2001 May-Jun; 18(3): 151-3.
Copyright/Referencing Information: Users are free to download and
distribute Fast Facts for educational purposes only. Citation for
referencing: Fast Facts and Concepts #104. Salacz M and Weissman DE.
CONTROLLED SEDATION FOR REFRACTORY SUFFERING: PART I February 2004.
End-of-Life Physician Education Resource Center www.eperc.mcw.edu.
Disclaimer: Fast Facts provide educational information, this information
is not medical advice. Health care providers should exercise their own
independent clinical judgment. Some Fast Fact information cites the use of
a product in dosage, for an indication, or in a manner other than that
recommended in the product labeling. Accordingly, the official prescribing
information should be consulted before any such product is use.
Creation Date: 2/2004
Format: Handouts
Purpose: Self-Study Guide
Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical
Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General
Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN,
Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Graduate Students,
Lawyers, Patients/Families, Nurses, Social Workers
ACGME Competencies: Interpersonal and Communication Skills, Medical
Knowledge, Patient Care
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