Definition of Refractory Symptoms

What is a Refractory Symptom?

The importance of defining a refractory symptom is central in utilizing palliative sedation in a safe, efficacious, and ethical manner.

Definitions A refractory symptom is one that cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness (Cherny 1994).
  • A refractory symptom may be subjective and, at times, nonspecific.
  • It is 2007-12-07ot;difficult” symptoms, since many symptoms considered refractory are at times successfully managed by specialized hospice and palliative care programs (Broeckaert 2002).
  • The malignant tumors most often associated with refractory symptoms include those in the lungs, gastrointestinal tract, head and neck, colon, rectum, and breasts, though certainly any malignancy can cause refractory symptoms.
  • Pain, dyspnea, persistent emesis, and agitated delirium are the symptoms most commonly requiring sedation (Rousseau 1999, Braun 2000).
  • Nonmalignant disorders may exhibit refractory symptoms, including congestive heart failure (dyspnea etc), chronic obstructive pulmonary disease, and debilitating neurological ailments, such as dementia and amyotrophic lateral sclerosis.
  • Most patients requiring palliative sedation demonstrate more than one refractory symptom (Cowan 2002; Cowan 2001).
  • Palliative medicine experts reported that 34% of their patients received sedation for nonphysical symptoms (Charter 1994). In patients sedated for nonphysical symptoms, 60% were for neuropsychiatric symptoms, whereas 6% were for “anguish”.
  • In deciding when a symptom is refractory, the clinician must perceive that further invasive and non-invasive interventions are :
  • incapable of providing adequate relief,
  • are associated with excessive and intolerable acute or chronic morbidity, or
  • are unlikely to provide relief within a tolerable time frame.

Interestingly, in a study by Braun and associates (Braun 2000), 50% of patients receiving palliative sedation at the beginning of the study were sedated in response to symptoms that were not considered refractory. Moreover, after the implementation of clinical practice guidelines for palliative sedation, the incidence of palliative sedation was reported to be significantly reduced. Consequently, the importance of defining a refractory symptom is central in utilizing palliative sedation in a safe, efficacious, and ethical manner.

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