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Palliative Sedation in Hospice and Palliative Care

Palliative Sedation in Hospice and Palliative Care. Instructions for using this presentation: Download and save the file to your computer. Review the speaker notes at the bottom of each slide.

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Palliative Sedation in Hospice and Palliative Care

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  1. Palliative Sedation in Hospice and Palliative Care Instructions for using this presentation: Download and save the file to your computer. Review the speaker notes at the bottom of each slide. If needed, copy the speaker notes into another document for reformatting and ease of use during presentation

  2. Palliative Sedation in Hospice and Palliative Care National Hospice and Palliative Care Organization Ethics Committee July 2012

  3. Goals • Define palliative sedation • Discuss ethical justification • Discuss implementation issues • Review relevant organizational policies and procedures • Explore process using case studies

  4. Define PST • Palliative sedation is • lowering of patient consciousness using sedative medications; with the • intent of limiting patient awareness of suffering; • when suffering is otherwise intractable and intolerable (Morita et al., 2002; Kirk & Mahon, 2010).

  5. Process and Conditions of Sedation • Use of sedatives via evidence-based protocol (Cherny et al.) • Appropriateness considering patient’s trajectory toward death • Proportionate sedation: only to the degree necessary to make suffering tolerable as defined by patient • Reversible

  6. Ethical Justification • Nonmaleficence • Do no harm • Preventing/reducing harm • Beneficence • Benefitting patient/family • Conceive of “benefit” in a way informed by patient/family values/goals • Autonomy • Honoring wishes/preferences of patient/family • Removing barriers/threats to patient’s sense of self

  7. Confusion about Ethical Justification • Assisted suicide debate • Doctrine of double effect • Sedation & the proximate cause of death • Distinct from high-dose opioid use

  8. Ethical Implementation • Thoughtfully and thoroughly developed policy and procedures • Rigorous interdisciplinary assessment • Excellent but unsuccessful interdisciplinary interventions prior to initiation • Clear communication with patient and family • Careful, expert implementation • Accurate and complete documentation

  9. Clinical Use • Far end of palliative care continuum • Part of interdisciplinary plan of care • Revocable • Only for unrelieved symptoms

  10. Pediatric Considerations • Appropriate for children • Unrelieved distress • Inadequately alleviated by other measures

  11. Artificial Nutrition and Hydration • Separate the decision for sedation from ANH and other concomitant therapies • Consider clinical appropriateness for each intervention • Patients have right to refuse invasive procedures • Hospice and palliative care organizations have responsibility to offer only therapies consistent with their mission, scope of practice, expertise, and policies and procedures

  12. Who Decides? • Patient: autonomy and related rights • Family: involved in care planning • Interdisciplinary team: develops care plan with patient and family • Advice from external ethics consultation may be helpful • Advice from external clinicians may be helpful

  13. When Death is not Imminent • Relationship of sedation and voluntary intake of food & hydration • Does sedation preventing intake of food & hydration for >10 days become contributing cause of death? • Questions to consider: • Voluntary intake? • Benefit/burden? • Temporary sedation appropriate?

  14. Organizational Policy and Procedure POLICY • Definition of PST • Indications for PST • Clinical & ethical rationale for PST • Guidelines for patient, family, & team assessment & support during and after PST • Guidelines for annual case review & quality improvement process

  15. Organizational Policy and Procedure PROCEDURES • Checklist for intractable & intolerable symptoms & trialed/failed interventions • Checklist for patient/family education/consent • Plan/rationale for continuing/not continuing ANH • Evidence-based protocol for selection & dosage of sedative medication

  16. Organizational Policy and Procedure PROCEDURES • Checklist for ongoing support of family and team during sedation • Evidence-based protocol for symptom assessment during induction, & regular assessment during sedation to ensure level of suffering is tolerable

  17. Case Studies • Case 1: Mr. Martin, 73-years old, has prostate ca. • Case 2: Ms. North is 68 and has lung ca. • Case 3: Ms. Smith is 22 years old and has a peripheral neuroectodermal tumor that responded poorly to treatment. • Case 4: Mr. George is in his late 50s and has ALS. • Case 5: Ms. Lopez is in her mid-30s and has cervical ca that has become metastatic to multiple organs and to bone.

  18. Bibliography • Cherny, N & Radbruch, L. “European Association for Palliative Care (EAPC) Recommended Framework for the Use of Sedation in Palliative Care.”Palliative Medicine 23, no. 7 (2009): 581-593. • Kirk, T. & Mahon, M. “National Hospice and Palliative Care Organization (NHPCO) Position Statement and Commentary on the Use of Palliative Sedation in Imminently Dying Terminally Ill Patients.”Journal of Pain & Symptom Management 39, no. 5 (2010): 914-923.

  19. Bibliography • Maltoni, M., Scarpi, E., Rosati, M. et al. “Palliative Sedation in End-of-Life Care and Survival: A Systematic Review.”Journal of Clinical Oncology 30, no. 12 (2012): 1378-1383. • Morita, T., Tsuneto, S. & Shima, Y. “Definition of Sedation for Symptom Relief: A Systematic Literature Review and a Proposal of Operational Criteria.”Journal of Pain & Symptom Management 24, no. (2002): 447-453.

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