Medications of Choice

The medications used for palliative sedation vary, but benzodiazepines and barbiturates are favored agents. Other medications used include the phenothiazine chlorpromazine, the butyrophenonehaloperidol, and the anesthetic agent propofol.

Medications and Suggested Doses for Palliative Sedation

Drug

Suggested Dose (a)

Midazolam 0.5–5 mg bolus IV/SC, then CII/CSI at 0.5–1 mg/h; usual maintenance dose, 20–120 mg/d
Lorazepam 0.5–2 mg PO, SL, or SC every 1–2 hours
or
1–5 mg bolus IV/SC, then CII/CSI at 0.5–1 mg/h; usual
maintenance dose, 4–40 mg/d
Chlorpromazine 10–25 mg PO, IV, or PR every 2–4 hours
Haloperidol 0.5–5 mg PO or SC every 2–4 hours
or
1–5 mg bolus IV/SC, then CII/CSI at 5 mg/d; usual maintenance dose, 5–15 mg/d
Pentobarbital 60–200 mg PR every 2–4 hours
or
2–3 mg/kg bolus IV, then CII at 1 mg/h; titrate upward to maintain sedation
Phenobarbital 200 mg IV/SC bolus, then CII/CSI at 600 mg/d; usual maintenance
dose, 600–1,600 mg/d
Thiopental 5–7 mg/kg bolus IV, then CII at 20 mg/h; usual maintenance dose, 70–180 mg/h
Propofol 10 mg/h as CII; may titrate by 10 mg/h every 15–20 minutes;
bolus of 20–50 mg may be used for emergency sedation
a Clinicians should consult pharmacy textbooks, pharmacists, and other knowledgeable professionals for further dosing suggestions.

PO = oral; PR = per rectum; SL = sublingual; IV = intravenous; SC = subcutaneous; CII
= continuous intravenous infusion; CSI = continuous subcutaneous infusion

Source: Rousseau P. Palliative sedation in the management of refractory symptoms. J Support Oncol. 2004 Mar-Apr;2(2):181-6.

The choice of an agent is dependent, for the most part, upon clinician preference as well as institutional policy and formulary restrictions. Also, in difficult cases, more than one medication may be needed to sedate a patient adequately. Medications may be administered orally (until the patient is sedated), sublingually, rectally, intravenously, or subcutaneously, with the route usually patient and clinician dependent. In addition, since there is no definitive evidence that unconscious patients do not experience pain, opioid administration is usually continued once palliative sedation is initiated, although the dose is usually not increased (Rousseau, 2001).

With respect to dose escalation of sedative medications, no universally accepted guidelines or protocols exist (Rousseau, 2002Wein, 2000); however, the dose of a sedative medication should not be increased unless there is evidence of inadequate sedation. Unfortunately, there are no validated scales to assess depth of sedation in terminally ill patients, so many clinicians use direct visual observation to determine depth of sedation.

However,

* the Ramsay Sedation Scale (Ramsay, 1974),

* the Intra-Operative Sedation Scale (Rudkin, 1992), and

* the Richmond Agitation-Sedation Scale (Ely, 2003)

have all been utilized, although their validation and corroboration with depth of sedation in terminal illness are lacking.

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