Palliative Sedation in Hospice and Palliative Care
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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
National Hospice and Palliative Care Organization Ethics Committee
July 2012
National Hospice and Palliative Care Organization
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
National Hospice and Palliative Care Organization
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).
National Hospice and Palliative Care Organization
National Hospice and Palliative Care Organization
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
National Hospice and Palliative Care Organization
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 patient’s 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?
National Hospice and Palliative Care Organization
National Hospice and Palliative Care Organization
Organizational Policy and ProcedurePOLICY
Definition of PSTIndications for PSTClinical & ethical rationale for PSTGuidelines for patient, family, & team assessment & support during and after PSTGuidelines for annual case review & quality improvement process
National Hospice and Palliative Care Organization
National Hospice and Palliative Care Organization
Organizational Policy and ProcedurePROCEDURES
Checklist for intractable & intolerable symptoms & trialed/failed interventionsChecklist for patient/family education/consentPlan/rationale for continuing/not continuing ANHEvidence-based protocol for selection & dosage of sedative medication
National Hospice and Palliative Care Organization
National Hospice and Palliative Care Organization
Organizational Policy and ProcedurePROCEDURES
Checklist for ongoing support of family and team during sedationEvidence-based protocol for symptom assessment during induction, & regular assessment during sedation to ensure level of suffering is tolerable
National Hospice and Palliative Care Organization
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.
National Hospice and Palliative Care Organization
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.
National Hospice and Palliative Care Organization
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.