Recent Studies

Recent Studies

Reference Brief Summary
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 Feb;10(1):67-85
PST is defined as the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness, using appropriate drugs carefully titrated to the cessation of symptoms. The initial dose of sedatives should usually be small enough to maintain the patients’ ability to communicate periodically. The team looking after the patient should have enough expertise and experience to judge the symptom as refractory. Advice from palliative care specialists is strongly recommended before initiating PST. In the case of continuous and deep PST, the disease should be irreversible and advanced, with death expected within hours to days. Midazolam should be considered first-line choice. The decision whether or not to withhold or withdraw hydration should be discussed separately. Hydration should be offered only if it is considered likely that the benefit will outweigh the harm. PST is distinct from euthanasia because (1) it has the intent to provide symptom relief, (2) it is a proportionate intervention, and (3) the death of the patient is not a criterion for success. PST and its outcome should be carefully monitored and documented. When other treatments fail to relieve suffering in the imminently dying patient, PST is a valid palliative care option.

Legemaate J, Verkerk M, van Wijlick E, de Graeff
A. Palliative sedation in the Netherlands: starting-points and contents of a national guideline. Eur J Health Law. 2007 Apr;14(1):61-73
The objective of palliative sedation is to relieve suffering, and lowering consciousness is a means to achieve this. It is very important that palliative sedation is given for the right indication, proportionally, and adequately. It is the degree of symptom control, not the level to which consciousness is lowered, which determines the dose and combinations of the sedatives used and duration of treatment. The assessment and decision-making processes must focus on adequate relief of the patient’s suffering, so that a peaceful and acceptable situation is created. Palliative sedation is given in the last phase of life, in the imminently dying patient. Palliative sedation raises several legal questions. This article describes the main legal issues involved, like the distinction between palliative sedation and euthanasia and the process of informed consent.
Verkerk M, van Wijlick E, Legemaate J, de Graeff A.
A National Guideline for Palliative Sedation in the Netherlands. J Pain Symptom Manage. 2007 Jul 6
Palliative sedation is defined as the intentional lowering of consciousness of a patient in the last phase of his or her life. The aim of palliative sedation is to relieve suffering, and lowering consciousness is a means to achieve this. The indication for palliative sedation is the presence of one or more refractory symptoms that lead to unbearable suffering for the patient. Palliative sedation is given to improve patient comfort. It is the degree of symptom control, not the level to which consciousness is lowered, which determines the dose and the combinations of the sedatives used and duration of treatment. Palliative sedation is normal medical practice and must be clearly distinguished from the termination of life.
Postovsky S, Moaed B, Krivoy E, Ofir R, Ben Arush MW.
Practice of palliative sedation in children with brain tumors and sarcomas at the end of life. Pediatr Hematol Oncol. 2007 Sep;24(6):409-15
Despite progress in the treatment of pediatric cancer, approximately 25% of these children will die of the disease. The last period of life is characterized by profound physical and psychological suffering, both of the children and their loved ones. Adequate alleviation of this suffering becomes the priority in the management of these patients. The authors retrospectively evaluated the indications, incidence, and characteristics of palliative sedation (PS) in 19 children with brain tumors (BT) and 18 with sarcomas (S) at the end of life. Twelve of the 18 S patients received PS, as did 13 of the 19 BT patients. Indications for initiation of PS for those with BT were seizures and/or pain, for those with S were pain and/or respiratory insufficiency. It was concluded that PS may be the only efficacious and safe treatment for the alleviation of suffering in these children at the end of life, despite differing indications.
Rosland JH, Saunes TK, Bull AN.Treatment of intolerable sufferings in a hospice unit. Tidsskr Nor Laegeforen. 2007 Oct 18;127(20):2661-4 Journals from 47 patients, who died in Sunniva Hospice in Bergen during 2003, were examined retrospectively. All opioid analgesics and sedatives given to the patients during the last two days of life were recorded, as well as additional supportive treatment. The degree of consciousness was evaluated and classified in three levels. All patients were given opioids, and 34 were given sedatives in addition. Midazolam was the most frequently prescribed drug. Seven patients received midazolam in doses that were considered as potentially sedative (> 20 mg/day). All seven had advanced cancer and five of them had metastases to lungs, bone or both. The most common reasons to give high doses of sedatives were intolerable pain and dyspnoea, often combined with an increase in tolerance. One patient required acute sedation. Even though reduced consciousness was observed in some patients, none met the criteria for palliative sedation of dying patients. Drugs that may reduce consciousness are often prescribed to dying patients. As long as the aim is to reduce specific symptoms, this is a natural part of palliative treatment. Documentation with specification for the aim of the treatment is mandatory. This is especially important when consciousness is reduced.
Rietjens JA, Hauser J, van der Heide A, Emanuel L.
Rietjens JA, Hauser J, van der Heide A, Emanuel L. Having a difficult time leaving: experiences and attitudes of nurses with palliative sedation. Palliat Med. 2007 Oct;21(7):643-9
Semi-structured interviews were conducted on 16 nurses about their most memorable cases of palliative sedation. In all of the described cases, palliative sedation was used primarily to address physical suffering in severely ill patients. Concomitant reasons for the use of palliative sedation were nonphysical suffering, the patient’s wish and the family’s distress about the patient’s suffering. The use of palliative sedation for the patient’s nonphysical suffering was often difficult for many of the nurses. Nurses had different perspectives on whether palliative sedation may have had a life-shortening effect on the patient. Some thought that it had not accelerated death; others thought that it may have accelerated death but that this was justified when there was no other way of relieving discomfort. A third group thought that palliative sedation was close to the practice of euthanasia and they often found it difficult to be involved in its use. Nevertheless, palliative sedation was considered by all the nurses to positively contribute to the patient’s quality of dying in all discussed cases. The struggles that nurses in this study cohort experienced indicate the need for further study and may suggest the need for more nursing education and discussion about ethical aspects of palliative sedation.
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