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Palliative Sedation Presentation to Manitoba Palliative Care Nursing ...

Palliative Sedation Presentation to Manitoba Palliative Care Nursing ...

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“…the use of sedation in the most problematic clinicalsituations…inevitably draws us in<strong>to</strong> complex, divisive, andcontroversial discussions that will continue <strong>to</strong> have opposingproponents.”


<strong>Presentation</strong> Overview• Definition Challenges• Distinguish between difficult andrefrac<strong>to</strong>ry symp<strong>to</strong>ms• Clinical indications for palliativesedation• Medications Used• Ethical Considerations• Conclusion


Terms Open <strong>to</strong> VariousInterpretations• Terminal• Imminently Dying• Refrac<strong>to</strong>ry• Prolonged• Possible Options• Severe/extreme/profound• Adequately controlled


Terms and Definitions for “<strong>Sedation</strong>”(Subjective Terminology Highlighted in Red)Chater et al.(1998)TerminalsedationThe intention ofdeliberately inducingand maintaining deepsleep, but notdeliberately causingdeath, for the relief of1) one or moreintractable symp<strong>to</strong>mswhen all otherpossible interventionshave failed, or 2)profound anguish.


Terms and Definitions ctdMorita et al.(1999)Quill & Byock(2000)<strong>Sedation</strong>Terminal<strong>Sedation</strong>A medical procedure <strong>to</strong>palliate patients’symp<strong>to</strong>ms refrac<strong>to</strong>ry <strong>to</strong>standard treatment byintentionally diminishingtheir consciousness.The use of high doses ofsedatives <strong>to</strong> relieveextremes of physicaLdistress


<strong>Palliative</strong> <strong>Sedation</strong>(Broeckaert& Nunez, 2002)“<strong>Palliative</strong> sedation is the intentionaladministration of sedative drugs indosages and in combinations required<strong>to</strong> reduce the consciousness of aterminal patient as much as necessary<strong>to</strong> adequately relieve one or morerefrac<strong>to</strong>ry symp<strong>to</strong>ms. (p. 170).”


Broeckaert -Refrac<strong>to</strong>rysymp<strong>to</strong>ms“Any given symp<strong>to</strong>m can be consideredrefrac<strong>to</strong>ry <strong>to</strong> treatment when it cannotbe adequately controlled in spite ofevery <strong>to</strong>lerable effort <strong>to</strong> provide reliefwithin an acceptable time periodwithout compromising consciousness”.


Refrac<strong>to</strong>ry ctdIn deciding that a symp<strong>to</strong>m isrefrac<strong>to</strong>ry, the clinician must perceivethat further invasive and noninvasiveinterventions are either:- incapable of providing adequate relief- excessive / in<strong>to</strong>lerable acute or chronicmorbidity- unlikely <strong>to</strong> provide relief within a<strong>to</strong>lerable time frame (Cherny& Portenoy, , 1994)


Reasons for <strong>Sedation</strong>Symp<strong>to</strong>ms S<strong>to</strong>ne etal. (1997)(n=115)Morita etal. (1999)(n= 157)PortaSales(2001)Delirium 60% 42% 39%Dyspnea 20% 41% 38%Pain 20% 13% 22%H’rrhage- - 9%N/V - 2% 6%Fatigue - - 20%Psych 26% 2% 21%


When is it “<strong>Sedation</strong>”?In an imminently dying person, if there areunintended yet unavoidable sedating effects ofmedication intended <strong>to</strong> relieve:PainNauseaDyspneaIs this “palliative sedation”, , or is it simply treatingpain, nausea or dyspnea?There is no intent or desire <strong>to</strong> sedate; if alternativemeans could be used, they would be.


When is it “<strong>Sedation</strong>”? ctdIn an irreversible delirium with hoursor days <strong>to</strong> live and an agitated,restless state, effective options <strong>to</strong>relieve distress are limited <strong>to</strong> sedatingthe patient and supporting the family.Is this “palliative sedation”, , or treatinga delirium?


What symp<strong>to</strong>ms are “BadEnough” <strong>to</strong> allow sedation as anInescapable outcome ofeffective treatment?


Is it “OK” for… Severe pain? Shortness of breath…choking <strong>to</strong> death Nausea and vomiting… as in a bowelobstruction near death where someone isvomiting up feces, or blood? Anguish…severe severe emotional distress insomeone who is hours <strong>to</strong> days from dying?If not…Whtnot?


<strong>Sedation</strong> for Anguish• Does “pain of the soul” deserve the sameaggressive approach as other types ofdistress in the imminently dying?• Is it wrong <strong>to</strong> “numb the brain” in order <strong>to</strong>address suffering experienced duringwakefulness or should you try <strong>to</strong> force theperson <strong>to</strong> deal with the demons that plaguehim/her?• Is lying on one’s s death bed <strong>to</strong>rtured byfear/regrets/guilt/despair less burdensomethan severe physical pain caused bytumour?


What will you offerOtherwise?• “Journey will you”• “Walk your walk with you”• “Be present”


<strong>Sedation</strong> for AnguishJust as in managing severe pain,dyspnea, nausea, agitated deliriumwhen death is near, before acceptingthat an unconscious state is the onlyoption for comfort, one must…


<strong>Sedation</strong> for Anguish ctd• Consider reversible causes• Explore available treatment options• Consult with expert colleagues (pas<strong>to</strong>ral care, socialwork)• Thorough discussion and documentation; pre-emptive discussion about food and fluids• Ongoing, proactive communication with families• Consider a measured, titrated approach…”…”take theedge off”…not a on/off phenomenon like a light switch


A Specific Considerationin <strong>Palliative</strong> <strong>Sedation</strong>What is the proximity of expecteddeath from the terminalcondition…hours, days, one week, 2weeks, a month, more?‣ How does this compare <strong>to</strong> whensedation itself might result in death?


Medications used inpalliative sedation• Benzodiazepines (lorazepam, midazolam)• Neurolepitics (haloperidol,methotrimeprazine)• Barbiturates (phenobarbital)• Opioids if concomitant pain / dyspnea


<strong>Palliative</strong> <strong>Sedation</strong> vs. EuthanasiaGoalIntentProcessImmediateOutcome<strong>Palliative</strong> <strong>Sedation</strong>Decrease sufferingTo SedateAdministration ofSedatives, titrated <strong>to</strong>effectDecreased level ofconsciousnessEuthanasiaDecreasesufferingTo KillAdministration ofa lethal drugDeath


A common Concern AboutAggressive Use of Opioids inthe Final HoursHow do you know that the aggressiveuse of opioids doesn’t t actually bringabout or speed up the patient’s s death?


Typically, with excessive opioid dosing onewould see:• pinpoint pupils• gradual slowing of the respira<strong>to</strong>ry rate• breathing is deep (though may be shallow) and regular


COMMON BREATHING PATTERNSIN THE FINAL HOURSCheyne-S<strong>to</strong>kesRapid, shallow“Agonal” / Ataxic


Doctrine of Double Effect“Asserts that a bad effect, such as thepatient’s s death, may be permissible ifit is not intended and occurs as a sideeffect of a beneficial action.”(Thorns, 1998)


DOCTRINE OF DOUBLE EFFECTWilkinson J. Oxford Textbook of<strong>Palliative</strong> Medicine 1993: p. 497-498498Where an action,intended <strong>to</strong> have a good effect, canachieve this effect only at risk of producing a harmful/ bad effect, then this action is ethically permissibleproviding:1. The action is good itself.2. The intention is solely <strong>to</strong> produce the good effect (eventhough the bad effect may be foreseen).3. The good effect is not achieved through the bad effect.4. There is sufficient reason <strong>to</strong> permit the bad effect (theaction is undertaken for a proportionately grave reason).


Case Study #1Mrs. B: 76year old – Ca of the Pancreas- Increased weakness and abdominal pain onadmission, previous good pain control- Developed confusion and hypotension- GI Bleeding suspected – very Lucid- Expressing wish <strong>to</strong> die soon, requesting sedation- Discussed with her and family – all in agreementand supportive- Midazolam 5mg q4h s.c.- Sleeping but periods of wakefulness- Congestion and movement pain prior <strong>to</strong> death- Died quietly and comfortably – family present


Case Study #2Mrs. H: 65 year old – end stage MS- very frail, bedridden,- Complaining of pain “all over”- Starts <strong>to</strong> cry when family/visi<strong>to</strong>rs present- Family do not want <strong>to</strong> see her “suffer”- Emotional and psychological component <strong>to</strong> pain- Lengthy discussion with pt, family, spiritual care involved- Started on midazolam 5 mg Q4H and Q1H PRN, fentanylpatch increased and fentanyl S/L pre-turns- Five days later sub-optimal pain control & delirium- Increase fentanyl patch, add nozinan Q4H and sufentanil pre-turns- Died four days later surrounded by family


Similarities• Were the physical symp<strong>to</strong>ms controlled?• Patient initiated request for sedation• Personal Struggle <strong>to</strong> justify the sedation:had we done enough?• Uncertainty as <strong>to</strong> whether it would hastenpatient’s s death• Stigma of <strong>Sedation</strong>: “Slippery Slope”• What constitutes a “good death”


<strong>Sedation</strong> uses in ourpractice• In cases of extreme delirium andagitation• In crises such as severe haemorrhageor acute dyspnea• Refrac<strong>to</strong>ry pain• Short survival


Why?• Perception of “giving up”• No time <strong>to</strong> consult• Negative connotations• Lack of clear guidelines• Lack of clearly supporting researchavailable (this is changing)• Good death = being awake


Ethical considerations –(N.Cherny)“There There is no distinct ethical problem in the use ofsedation <strong>to</strong> relieve otherwise in<strong>to</strong>lerable sufferingfor patients who are dying. Rather, the decisionmaking and application of this therapeutic optionrepresents a continuum of good clinical practice (…)(predicated on careful patient evaluation.(…)Where risks of treatment are involved, the risksmust be proportionate <strong>to</strong> the gravity of the clinicalindication. In these deliberations, clinicianconsiderations are guided by an understanding ofthe goals of care and must be within acceptedmedical guidelines of beneficence and non-maleficence.”• From <strong>Sedation</strong>: uses, abuses and ethics at the endof life

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