Clinical and Pharmacological Guidelines

Clinical and Pharmacological Guidelines for Palliative Sedation

To assist in decision-making regarding the use of palliative sedation, guidelines have been proposed, including the concept of respite sedation, a procedure that involves temporary and time-limited sedation (Rousseau 2001).

Although specific criteria for palliative sedation are lacking, basic, but not all-inclusive, criteria include (Table 1):

  • the presence of a terminal illness with a refractory symptom(s);
  • a do-not-resuscitate (DNR) order;
  • exhaustion of all palliative treatments directed at the symptom(s), including treatment for depression, delirium, anxiety, and any other contributing disorders;
  • consideration of ethical and psychiatric consultations;
  • assessment for spiritual issues by a skilled clinician or clergy member;
  • discussion regarding the continuance of nutritional support or intravenous or subcutaneous hydration in patients receiving such treatments;
  • obtaining informed consent; and
  • consideration of a trial of respite sedation in selected cases.

Suggested Guidelines for Palliative Sedation

Basic criteria for choosing palliative sedation:

  • Presence of a terminal illness with a refractory symptom(s)
  • A do-not-resuscitate (DNR) order
  • Exhaustion of all palliative treatments, including treatment for depression, anxiety, delirium, and familial discord
  • Consideration of ethical and psychiatric consultations
  • Consideration of assessment for spiritual issues by a skilled clinician or clergy member
  • Discussion regarding the continuance of nutritional support or intravenous or subcutaneous hydration in patients receiving such treatments
  • Obtaining informed consent
  • Consideration of a trial of respite sedation in selected cases

Once palliative sedation has been agreed upon:

  • Choose appropriate agent and initiate sedation
  • Consider monitoring depth of sedation via Ramsay Sedation Scale or other instrument
  • Titrate sedative dose upward as necessary to maintain desired level of sedation
  • Administer additional bolus doses or add other agents as necessary to maintain desired level of sedation
Source: Adapted, in part, from Rousseau PC. Palliative sedation. AmJ Hosp Palliat Care 2002;19:295-297.

 

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