This paper reviews the reported use of nonopioid medications for terminal sedation. To provide a summary of the available literature, an electronic database search was performed. Thirteen series and 1 4 case reports were identified. Various symptoms, including agitation, pain, and confusion, required terminal sedation. Eleven drugs were used in 342 patients. Most patients were also treated with concurrent opioids and received terminal sedation in an inpatient hospice unit. Midazolam was the most common sedative employed. A good response--defined as adequate sedation--ranged between 75% and 100%. The median time to death following the introduction of terminal sedation was greater than 1 day. No agent appears to have superior efficacy or limiting toxicity.

Terminally ill patients want assurance that their symptoms will be controlled as death approaches. Most patients can have a peaceful death with standard palliative care. Some patients approaching death, however, have refractory symptoms such as pain, dyspnea, nausea, and agitated delirium. Palliative sedation (PS), the use of medications to induce sedation in order to control refractory symptoms near death, is a therapeutic option for these patients. The reported frequency of PS use varies greatly, ranging from 5% to 52% of the terminally ill. One concern with PS is its effect on survival. Data suggest that PS does not lead to immediate death, with the median time to death after initiating PS being greater than 1 to 5 days. A number of medications have been used for PS, but midazolam is most commonly reported. PS is distinct from euthanasia because the intent of PS is relief from suffering without death as a required outcome.

Defining financial parameters of palliative care (PC) is important for providing sustainable programming. In our study, we evaluated hospital length of stay (LOS) and charges for the first 164 inpatient PC consultations performed by the Advanced Illness Assistance (AIA) team at Blount Memorial Hospital (BMH). These AIA patients had a median LOS of 11 days (range, 3-114 days), mean total charges per patient of 65,795 dollars, and mean daily charges of 3,809 dollars. Higher mean daily charges (p = 2.74 E-08, chi-square) were associated with patients who received consultation because of nonphysical symptom reasons. Patients were followed in PC consultation (AIA follow-up days) for a median of five days (range, 1-48), and had mean daily charges of 3,117 dollars. These mean daily charges were 414 dollars less than the charges for the five days prior to PC consultation (pre-AIA days) (p = 0.04, t-test). There was a significant decrease in laboratory and imaging charges during AIA follow-up (p = 0.04, t-test). The study included a reference group of patients whose information was obtained retrospectively from the BMH Atlas (MediQual, Marlborough, MA) database. These reference group patients were hospitalized at BMH during the same time, but they were not seen by the AIA team. The reference group was matched by Diagnosis Related Group (DRG), Admission Severity Grade (ASG), and disposition to the AIA patients. The Atlas patients had a shorter median LOS of six days (range, 1-105 days), and significantly greater mean daily charges of 4,105 dollars (p = 0.006, t-test) compared with AIA patients. Mean daily charges decreased for Atlas patients, as their day of discharge approached (p < 0.001). Estimates of potential charge savings were calculated in two ways: 1) by evaluating the effect of decreasing the LOS of Atlas patients with long LOS (more than seven days) to the level of AIA patients with long LOS, and 2) by comparing the actual mean patient charges during AIA follow-up with using the pre-AIA mean daily charges during the AIA follow-up period and correcting for the effect of decreasing charges that occurred as discharge approached. The estimated savings achieved by decreasing long LOS were more than 100,000 dollars per year, and estimated savings achieved using AIA follow-up charges were more than 1,801,930 dollars per year.

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Multiple recommendations were made with most patients surviving long enough potentially to benefit. Consultation in palliative medicine is a sophisticated intervention involving considerable acuity and complexity of care.