Palliative Sedation at End of Life

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Palliative Sedation at End of Life

• Nessa Coyle NP, PhD
• Pain and Palliative Care Service
• Memorial Sloan-Kettering Cancer Center
• New York, New York

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Objectives

• Define palliative sedation
• Identify situations in which palliative sedation
  may be appropriate
• Discuss ethical issues in palliative sedation
• Review guidelines and drug selection for
  palliative sedation

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Sedation at the End-of-LifeDefinition

• Medical therapy for the imminently dying
• Intended to relieve intractable pain and other
  symptoms
• Reduced level of consciousness anticipated and
  accepted as a necessary part of therapy

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Sedation at the End-of-LifeThe context

• Pain and suffering are intolerable
• The hope of recovery is negligible
• Other interventions have proved inadequate

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Sedation at the End-of-Life

• The goal of symptom control then changes
• from the control of symptoms with the patient
• maintaining an awake status, to allowing the
• patient to sleep as the only way of controlling
• the symptom. Other treatments may continue
• such as antibiotics and hydration

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Patients for whom sedation at end-of-life may be
an option

• Removal of patient from a respirator who is semi
  or fully conscious (e. ALS)
• Control of specific intractable symptoms where it
  is not possible that the patient be awake, alert
  and interactive
• Dying event potentially catastrophic
• Intractable anguish

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Sedation at the End-of-LifePatient screening

• Are refractory symptoms present, if so what are
  they?
• Have other pharmacological, psychological,
  physical measures been used in an attempt to
  manage these symptoms?
• If attempts at managing these symptoms have been
  made what interventions were utilized?
• Drugs(s), doses, frequency, outcomes
• Are these interventions and outcomes documented
  in the patients chart?

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Palliative Sedation Patient screening

• Is this a reversible or irreversible situation?
• Was it expected? (If expected need to have a
  strategy in place to handle situation)
• Was there precipitating event? (e.g., if an
  agitated delirium drug overdose or drug not
  taken infection urinary retention
  hypercalcemia recent fall dehydration and
  accumulation of opioid metabolites?

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Palliative SedationGuidelines

• Level of sedation required to relieve symptoms
  varies from patient-to-patient
• Some may require light sedation whereas others
  may require deep sedation
• Goals of sedation and end points being monitored
  must be clear for patient/family/ staff
• Clinical vigilance is imperative to ensure
  ongoing relief of suffering

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Sedation at the End-of-LifeCurrent Status

• Various drugs used case by case (opioids,
  benzodiazepines, barbiturates, general
  anesthetics)
• Can be temporary, or continuous until time of
  patients death
• Large variations in practice (rarely driven by
  protocol)

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End-of-Life SedationChoice of Drugs

• International survey of palliative care experts
• 37 received one drug
• 30 received two drugs
• 28 received three drugs
• 69 family involved in the decision
• 90 use of sedation believed to be successful
• (Chater S. Palliat Med. 1998)

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Sedation at the End-of-LifeINTENT the critical
issue

• Sedation intent is to produce somulance and
  relieve suffering not hasten death
• Assisted suicide intent is to produce death to
  relieve suffering (agent the patient)
• Euthanasia intent to produce death to relieve
  suffering (agent - another)

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The decision is made to sedate the patient at
end-of-life summary

• The patients has far advanced disease and is
  dying
• The goal of care is no longer to prolong life but
  comfort
• This is the patients/familys desire
• The health care team are in consensus that there
  is no other approach to control the symptom
• The patients disease and treatment history is
  reviewed to date and why this measure is being
  suggested

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The decision is made to sedate the patient at
end-of-life summary

• The pharmacotherapy approach to be used is
  identified
• Discussion with the nursing staff who will be
  monitoring the patient re the goal of treatment
  and the end points to be monitored
• Ongoing monitoring of effectiveness of approach
  and plan in place for titration to achieve
  ongoing comfort

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Palliative Sedation Guidelines

• The selection of sedating drug is largely
  empirical
• Most sedating drugs can be delivered IV if access
  is available
• Alternative routes include s/c, s/l, rectal,
  gastrostomy

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Palliative SedationGuidelines

• Upward titration is often necessary therefore
  frequent patient monitoring is essential to
  ensure desired level of sedation is being
  achieved
• Increments are usual in the 50 100 range

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Palliative SedationGuidelines

• In a patient already on opioids initially
  efforts may be made to titrate to sedative
  effect.
• May be ineffective in the opioid tolerant patient
  or precipitate or exacerbate unwanted side
  effects
• In this case add a 2nd sedating non opioid
  medication

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Three Cases

• Larry (inpatient setting) Lung cancer - SOB
• Morphine IV infusion increased by 50
• Ativan 1mg IV q6h. Rescues of I mg q1h prn. ATC
  dose 2mg IV q4h.
• Jane (at home) Possible carotid blowout
• 25g butterfly needle inserted. Syringe prepared
  with 3mg lorazepam for one time use.
• Tito (at home) GI cancer agitated delirium
• IV Methadone dose increase by 25. Lorazepam 1mg
  and Haloperidol 0.5mg given q6h

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Caring for the patient who requires sedation at
EOL and family and staff

• attention to the patients basic care (bathing,
  turning, mouth care, sitting by the side of the
  patient and being there)
• attention to the needs of the family
• anticipate that the family may ask that the
  sedation be lightened so that they have a
  chance to interact with the patient one more time

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Documentation

• Documentation
• of nature of the symptom/distress for which
  sedation was necessary
• that is not possible to control the symptom and
  the patient be awake and alert
• that the patient/health care proxy are in
  agreement
• that a family meeting was held and there is
  consensus

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Documentation

• Documentation
• the approach to be used and the end point desired
  (i.e. no evidence of distress when the patient is
  at rest or moved or suctioned if that is
  required)
• the monitoring required of evidence of comfort at
  rest and when moved
• the resource people in place for family and
  friends and staff

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Summary

• Palliative sedation is a necessary tool for the
  provision of palliative care
• Expert evaluation from an interdisciplinary team
  that all other reasonable measure to ameliorate
  the patients suffering have been tried
• Physicians remain closely involved with the team
  in monitoring the effectiveness of the approach
• Family and team support is ongoing and attention
  is given to debriefing staff and bereavement care

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Palliative SedationPharmacological considerations

• Midazolam (Versed) most common use agitated
• delirium - Short acting, water soluble, does not
  
• cause s/c skin irritation. Rapid onset of action
• Give initial loading dose of 0.5-5mg IV push over
  3-5 minutes (wait 2-minutes to evaluate the
  sedative effects)
• Start with a continuous IV or S/C infusion of 0.5
  to 1mg/hr and titrate according to agitation.
• Dose range usual from 1-10mg/hr

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Palliative SedationPharmacological considerations

• Lorazepam (Ativan)
• 0.5-2mg PO, S/L/ or IV/S/C q1-2h or
• 1-5mg bolus dose IV/S/C until sedation then bolus
  every 4-6hrs to maintain sedation or
• CII/SCI at 0.5-1mg/hr
• Usual maintenance dose 4-40mg/day may go higher

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Palliative SedationPharmacological considerations

• Diazepam (Valium) (half-life 20-40 hrs)
• Poorly water soluble
• Give IV, PR, PO
• Dose 5-20mg q 6 h.

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Palliative SedationPharmacological considerations

• Chlorpromazine (Thorazine)
• Tranquilizer, antiemetic, antipsychotic
• Route- PO/PR/IV
• Give 20-50mg IV piggyback over 30 mins.
• Haloperidol (Haldol)
• Least sedating
• 0.5-5mg PO,SC/IV every 2-4hrs or
• 1-5mg bolus IV or S/C the CII/CSI at 4-15mg/day

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Palliative SedationPharmacological considerations

• Phenobarbital
• 200mg IV/SC bolus then CII/CSI at 600mg/day
• Usual maintenance dose 600-1600mg/day

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Palliative SedationPharmacological considerations

• Propofol deep sedation, hypnotic, general
• anesthetic
• Rapid onset of action and recovery phase (eye
  opening 20 mins after infusion shut off)
• Hepatic elimination
• Induction dose for anesthesia 1.5-2.5mg/kg
• Maintenance dose 6-9mg.kg/hr
• (consult with anesthesia or ICU colleagues)

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Palliative SedationKetamine

• Ketamine (analgesic low doses 0.1-1.4mg/kg/hr
  anesthetic agent higher doses).
• Has NMDA receptor properties
• Used most commonly for pain crises not responding
  to opioids. Given by IV or SC infus
• Advisable to administer a drug such as
  haloperidol at the same time in case dysphoric
  reactions occur which the patient is unable to
  report
• Concern if used for EOL sedation
• Dysphoric reactions

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Ketamine

• Bolus 0.1- 0.2mg/kg IV.
• Double the dose if no clinical improvement.
• Follow bolus with infusion. (about 1mg/min for a
  70kg person). Decrease opioid by 50.
• Treat for potential dysphoric dreams
• (Fine PG. JPSM 199917296-300)

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Progressive SedationExample step by step
approach

• Terminal agitation
• Mild pain related. Increase the opioid, rotate
  if indicated if hallucinations add haloperidol
  add lorazepam if needed (will not clear pts
  sensorium)
• Moderate increase all of the above or give
  chlorpromazine IV, or PO or PR 25-100mgs q4-6h
• Severe Midazolam by s/c or IV infusion
• Phenobarbital 130mg s/c q30mins until calm (may
  need gt1000mg/day).
• Propofol IV infusion

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Palliative SedationPharmacological considerations

• Benzodiazepines (lorazepam, diazepam, midazolam).
  
• Have little or no analgesic function
• Be alert to paradoxical reactions (e.g.,
  lorazepam)