Palliative Sedation - Palliative Care
Palliative Sedation - Palliative Care
Palliative Sedation - Palliative Care
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“When I use a word, itmeans just what I chooseit to mean – neither morenor less”
<strong>Palliative</strong> <strong>Sedation</strong>Presentation to Manitoba <strong>Palliative</strong> <strong>Care</strong> NursingCertification Study Group, Jan. 12, 2005Mike Harlos MD, CCFP, FCFPWith liberal use of slides kindly shared with permission by:• Alexandra Beel, <strong>Palliative</strong> <strong>Care</strong> Clinical Nurse Specialist• Dr. Leah MacDonald, <strong>Palliative</strong> <strong>Care</strong> Physician2
Terms Open to Various InterpretationsUnfortunately, those with the• Terminalpower to treat the suffering• Imminently dying• Refractory• Prolonged• Possible options• Severe/extreme/profound• Adequately controlledare also empowered withinterpreting these terms,rather than the personexperiencing the suffering3
Terms and Definitions for “<strong>Sedation</strong>”Subjective Terminology Highlighted In RedChater etal. (1998)TerminalsedationThe intention of deliberatelyinducing and maintaining deepsleep, but not deliberately causingdeath, for the relief of 1) one ormore intractable symptoms whenall other possible interventionshave failed, or2) profound anguish.4
LEARN TO PERFORMChoose from these arts opportunities: Annual DessertTheatre production, Briercrest’s annual Christmas concert,Choir, Touring opportunities, Orchestra, Worship teams,Private music lessons, Access to a professional recordingstudio, Cheesecake Café, Art show, Skits at Youth Quake,and Fine Arts Club.PLAY VARSITY SPORTSThe Cougars practice and compete in collegefacilities, and are often among the top provincialcompetitors each season. We want you, our Cougars,to be Total Champions, which means excelling on thefield, the floor, and the ice—but also in the classroomand in your walk with God.At Hope Chapel he worked his way up from a bookstorevolunteer to the church receptionist—a positionhe said never felt like a good fit for his personality.“The task orientation of that job was burning methin,” he remarked.After a year as receptionist, he jumped at an opportunityto work with the former associate pastor, KitLauer, to lead the church’s Friday evening service.“I spent seven great years working with Kit,” he remembered.“He was like a father figure who mentoredme in all aspects of pastoral care. Most people spendseven years in college and seminary. I spent sevenyears in Kit Lauer’s minivan!”In 2009 Lauer died of leukemia and Prangnell assumedhis leadership position for the Friday eveningservice. He hopes to carry the same passion his mentorhad to reach people who don’t know God.“A person who might not go to church on Sundaymorning might step through the doors on a Fridaynight,” he said.This desire to network with those outside the churchalso inspires Prangnell in his work with BasketballMaui.“I’ve met more people in the community in one yearthan I had in 10 years prior,” he insisted. “I’ve hadpeople come to church on Friday nights just becausethey remember me as the guy who did the basketballcamp.”High profile basketball coaches help Prangnell athis camps. Last year, at his first camp, he had FredThe CHS Cougars: 1998 Provincial Champions. (Prangnell is standingfourth from the right.)Crowell, the founder of Northwest Basketball Camps(NBC) and Lorenzo Romar, head basketball coach forthe Washington Huskies.Prangnell also has a big vision for his camps. He’sestablished the Kit Lauer Memorial Scholarship programto help families who lack the funds to send theirchildren to camp. This summer he is hoping to have350 campers and simultaneous camps running on twodifferent sites on the island.He’s also especially excited for two of the coacheswho are coming to this year’s camp.“Gib Hinz is going to be there this summer,” he said,“along with John Thiessen, who is a former (Briercrest)Clipper.”Hinz is proud of the accomplishments his formerplayer has made.“You always wonder where your players may be in5-10 years after you’ve coached them,” he stated. “Ialways knew Ben would be a success wherever he’d go,but he far exceeded any of the hopes and dreams I hadfor him. Ben has totally changed the basketball cultureon Maui for every young person there.”Prangnell admits that the fact that his basketballcamps are in Hawaii might be a bonus when it comesto luring coaches to help out at the events.“I’m not sure if it would go over as well if it wereBasketball Ohio,” he joked.TUITIONPLANLIVE IN DORMMake friends from around the world in our dormprogram as our leaders care for you—heart, mind,and soul.HOW MUCH? TUITION ROOM AND BOARDSaskatchewan students $2,020 $6,954Out-of-province students $8,450 $6,954Moose Jaw students $2,402(includes transportation)Ask us about our family tuitionplan. Call 1-800-667-5199 orvisit www.briercrest.ca.8 BRIERCREST MAGAZINE HIGH SCHOOL EDITION | ISSUE 1 | SUMMER 2010WWW.BRIERCREST.CA 9
<strong>Palliative</strong> <strong>Sedation</strong>(Broeckaert & Nunez, 2002)“<strong>Palliative</strong> sedation is the intentionaladministration of sedative drugs indosages and in combinations requiredto reduce the consciousness of aterminal patient as much as necessaryto adequately relieve one or morerefractory symptoms. (p. 170).”6
Broeckaert -Refractory symptoms“Any given symptom can be consideredrefractory to treatment when it cannotbe adequately controlled in spite ofevery tolerable effort to provide reliefwithin an acceptable time periodwithout compromising consciousness”.7
Refractory ctdIn deciding that a symptom is refractory,the clinician must perceive that furtherinvasive and noninvasive interventionsare either:• incapable of providing adequate relief• excessive / intolerable acute or chronicmorbidity• unlikely to provide relief within atolerable time frame (Cherny & Portenoy, 1994)8
Reasons for <strong>Sedation</strong>SymptomsStone et al.(1997)(n=115)Morita et al.(1999)(n= 157)Porta Sales(2001)Delirium60%42%39%Dyspnea20%41%38%Pain20%13%22%Bleeding--9%N/V-2%6%Fatigue--20%Psych26%2%21%9
When is it “<strong>Sedation</strong>”?In an imminently dying person, if there are unintendedyet unavoidable sedating effects of medication intendedto relieve‣Pain‣Nausea‣DyspneaIs this “palliative sedation”, or is it simply treating pain,nausea, or dyspnea?There is no intent or desire to sedate; if alternativeeffective means could be used, they would be.10
What symptoms are “BadEnough” to allow sedation as aninescapable outcome ofeffective treatment?12
Is it “OK” for…Severe pain?Shortness of breath… choking to deathNausea and vomiting… as in a bowelobstruction near death where someoneis vomiting up feces, or ongoingvomiting of blood?Anguish… severe emotional distress insomeone who is hours to days fromdying? If not… why not?13
<strong>Sedation</strong> for Anguish• Does “pain of the soul” deserve the same aggressiveapproach as other types of distress in the imminentlydying?• Is it wrong to “numb the brain” in order to addresssuffering experienced during wakefulness, or should youtry to force the person to deal with the demons thatplague him/her?• Is lying on one’s death bed, tortured byfear/regrets/guilt/despair less burdensome than severephysical pain caused by tumour?14
What Will You Offer Otherwise?• “Journey with you”• “Walk your walk with you”• “Share your path”• “Be present”15
<strong>Sedation</strong> for AnguishJust as in managing severe pain,dyspnea, nausea, agitated delirium whendeath is near, before accepting that anunconscious state is the only option forcomfort, one must…16
<strong>Sedation</strong> for Anguish ctd• Consider reversible causes• Explore available treatment options• Consult with expert colleagues (pastoral care, social work)• Thorough discussion and documentation; pre-emptivediscussion about food and fluids• Ongoing, proactive communication with families• Consider a measured, titrated approach… “take the edge off” …not a on/off phenomenon like a light switch17
A Specific Consideration in<strong>Palliative</strong> <strong>Sedation</strong>What is the proximity of expected deathfrom the terminal condition… hours, days,one week, 2 weeks, a month, more?‣ How does this compare to whensedation itself might result in death?18
Medications used in palliativesedation• Benzodiazepines (lorazepam,midazolam)• Neuroleptics (haloperidol,methotrimeprazine [Nozinan®])• Barbiturates (phenobarbital)• Opioids if concomitant pain/dyspnea19
<strong>Palliative</strong> <strong>Sedation</strong> vs. EuthanasiaGoalIntentProcessImmediateOutcome<strong>Palliative</strong> <strong>Sedation</strong>Decrease sufferingTo SedateAdministration ofsedatives, titrated toeffectDecreased level ofconsciousnessEuthanasiaDecrease sufferingTo KillAdministration of alethal drugDeath20
A COMMON CONCERN ABOUT AGGRESSIVEUSE OF OPIOIDS IN THE FINAL HOURSHow do you know that theaggressive use of opioids doesn'tactually bring about or speed up thepatient's death?21
SUBCUTANEOUS MORPHINE INTERMINAL CANCER1009080706050403020100Bruera et al. J Pain Symptom Manage. 1990; 5:341-344Pre-MorphinePost-MorphineDyspnea Pain Resp. Rate(breaths/min)O2 Sat (%)pCO222
Typically, With Excessive Opioid DosingOne Would See:• pinpoint pupils• gradual slowing of the respiratory rate• breathing is deep (though may be shallow) and regular23
COMMON BREATHING PATTERNSIN THE FINAL HOURSCheyne-StokesRapid, shallow“Agonal” / Ataxic24
DOCTRINE OF DOUBLE EFFECTWilkinson J. Oxford Textbook of <strong>Palliative</strong> Medicine 1993: p 497-8Where an action, intended to have a good effect, can achieve thiseffect only at the risk of producing a harmful/bad effect, then thisaction is ethically permissible providing:1. The action is good in itself.2. The intention is solely to 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 to permit the bad effect (theaction is undertaken for a proportionately grave reason).25
Mount B., Flanders E.M.; Morphine Drips, Terminal <strong>Sedation</strong>,and Slow Euthanasia: Definitions and Fact, Not AnecdotesJ Pall <strong>Care</strong> 12:4 1996; p 31-37The principle of double effect is not confined to end-of-lifecircumstancesGood effectsBenefitsBeneficial EffectsBad effectsBurdensSide Effects26
• The difference in aggressive opioid use in end-of-lifecircumstances is that the “bad effect” = Death• The doctrine of double effect exists to support thosehealth care providers who may otherwise withholdopioids in the dying out of fear that the opioid mayhasten the dying process• A problem with the emphasis on double effect is thatthere in an implication that this is a commonscenario…. in day-to-day palliative care it is extremelyrare to need to even consider its implications
Case Presentation• 55 yo man• Multiple myeloma• While covering the ward for the day,asked to talk to him for “just a couple ofminutes” about his wish to be sedatedHow would you approach this situation?28
Thorough Assessment• Total burden of illness• Prognosis, expected proximity of death• Hb 50• Short of breath, congested, bedridden,severely cachectic• Estimated prognosis at most 1 week, likely afew daysWhy is is the medical assessment relevant?29
Why Is This Being Asked For?• Treatable depression?• Fear of dying process – how will it happen?• How do people imagine their death will be?• Uncontrolled symptoms – pain, choking, confusion• Burden on family – “Better off without me”• No meaning/purpose/point in continuedexistenceWhy don’t we talk more often about dyingwith people who are dying?30
What is the ripple effect?• Family• Health <strong>Care</strong> Team31
Consider• Do you have misgivings about this?• Would you have misgivings if this weresevere pain?32
Curve Ball…“Don’t tell my wife…”33