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Palliative Sedation to Alleviate Intractable Distress of the Dying Patient

Feature |
November 16, 2009

Palliative Sedation to Alleviate Intractable Distress of the Dying Patient

  1. Stephanie Grossman, MD, FHM, FAAPM

A review of treatment options

  1. Stephanie Grossman, MD, FHM, FAAPM

Patients who are dying can experience physical and emotional suffering, such as anxiety, agitated depression, or insomnia. Physicians often administer nonopioid drugs to alleviate such symptoms (ordinary sedation). However, in some instances, suffering is severe and refractory to conventional treatment, and further palliative sedation is medically indicated. In a review of palliative sedation options, palliative care specialists distinguish treatment for refractory symptoms as either proportionate palliative sedation (PPS) or palliative sedation to unconsciousness (PSU).

With PPS, sedation at the lowest possible level is administered to relieve suffering, and increases in dosage are tied to persistent signs and symptoms of distress. Unconsciousness is a foreseen but unintended side effect. Patients with refractory symptoms often respond to increasing doses of benzodiazepines, haloperidol, chlorpromazine, barbiturates, or propofol. Because opiates can lead to development of tolerance and neurotoxicity, their use should be restricted to patients in whom pain or dyspnea cannot be controlled with other medications.

With PSU, sedation is increased rapidly until the patient is no longer responsive. Unconsciousness is the intended goal, rather than a side effect. PSU might be applicable for patients with refractory symptoms, such as severe respiratory secretions or severe nausea, or for those with predominantly existential suffering, such as anguish and fear, that often accompany the dying process.

Both types of sedation, although legal, raise ethical concerns and are challenged by those who fear that such practices hasten death. However, unlike physician-assisted suicide or euthanasia, the intent of PPS and PSU is to relieve refractory suffering in patients who are dying. Death is secondary to the underlying disease process, and data show that palliative sedation does not shorten survival. In addition, we must distinguish related questions about provision of or withholding nutrition and hydration as separate and distinct from administration of PPS and PSU: Many patients and their surrogates make informed decisions to discontinue nutritional support when it is not within their goals of care or because of unacceptable side effects, such as nausea or excessive respiratory secretions. Nevertheless, withholding nutrition and hydration is not a requirement for effective palliative sedation.

National policies and guidelines support both conscious and unconscious palliative sedation. Either one can be offered to terminal patients who are experiencing refractory suffering, with safeguards and internal institutional review to guide the practice. Safeguards include peer consultation to confirm that a patient is near death and is experiencing refractory symptoms. Institutional policies and procedures can help standardize practice, remove moral ambiguity that is related to sedation, and, ultimately, improve the quality of symptom management for terminally ill patients.

Dr. Grossman is an Assistant Professor in the School of Medicine at Emory University and Director of Palliative Care at Emory University Hospital and Emory University Hospital Midtown in Atlanta, Georgia.

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