National Hospice and Palliative Care Organization Palliative Sedation in Hospice and Palliative Care...

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National Hospice and Palliative Care Organization Palliative Sedation in Hospice and Palliative Care Instructions for using this presentation: 1.Download and save the file to your computer. 2.Review the speaker notes at the bottom of each slide. 3.If needed, copy the speaker notes into another document for reformatting and ease of use during presentation

Transcript of National Hospice and Palliative Care Organization Palliative Sedation in Hospice and Palliative Care...

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  • National Hospice and Palliative Care Organization Palliative Sedation in Hospice and Palliative Care Instructions for using this presentation: 1.Download and save the file to your computer. 2.Review the speaker notes at the bottom of each slide. 3.If needed, copy the speaker notes into another document for reformatting and ease of use during presentation
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  • National Hospice and Palliative Care Organization Palliative Sedation in Hospice and Palliative Care National Hospice and Palliative Care Organization Ethics Committee July 2012
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  • National Hospice and Palliative Care Organization Goals Define palliative sedation Discuss ethical justification Discuss implementation issues Review relevant organizational policies and procedures Explore process using case studies
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  • National Hospice and Palliative Care Organization 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).
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  • National Hospice and Palliative Care Organization Process and Conditions of Sedation Use of sedatives via evidence-based protocol (Cherny et al.) Appropriateness considering patients trajectory toward death Proportionate sedation: only to the degree necessary to make suffering tolerable as defined by patient Reversible
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  • National Hospice and Palliative Care Organization 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 patients sense of self
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  • National Hospice and Palliative Care Organization Confusion about Ethical Justification Assisted suicide debate Doctrine of double effect Sedation & the proximate cause of death Distinct from high-dose opioid use
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  • National Hospice and Palliative Care Organization 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
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  • National Hospice and Palliative Care Organization Clinical Use Far end of palliative care continuum Part of interdisciplinary plan of care Revocable Only for unrelieved symptoms
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  • National Hospice and Palliative Care Organization Pediatric Considerations Appropriate for children Unrelieved distress Inadequately alleviated by other measures
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  • National Hospice and Palliative Care Organization 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
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  • National Hospice and Palliative Care Organization 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
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  • National Hospice and Palliative Care Organization 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?
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  • National Hospice and Palliative Care Organization 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
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  • National Hospice and Palliative Care Organization 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
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  • National Hospice and Palliative Care Organization 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
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  • National Hospice and Palliative Care Organization 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.
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  • National Hospice and Palliative Care Organization 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.
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  • National Hospice and Palliative Care Organization 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.