Palliative Sedation in Hospice and Palliative Care

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 patients 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 patients 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 gt10 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.