Controlled Sedation for Refractory Symptoms in Dying Patients

Abstract

Terminally ill cancer patients near the end of life may experience intolerable suffering refractory to palliative treatment. Although sedation is considered to be an effective treatment when aggressive efforts fail to provide relief in terminally ill patients, it remains controversial. The aim of this study was to assess the need and effectiveness of sedation in dying patients with intractable symptoms, and the thoughts of relatives regarding sedation. A prospective cohort study was performed on a consecutive sample of dying patients admitted to an acute pain relief and palliative care unit within a cancer center. Indications for sedation, opioid and midazolam doses, level of delirium and sedation, nutrition, hydration, rattle, inability to cough and swallow, pharyngeal aspiration, duration of sedation and survival, and use of anticholinergics or other drugs were recorded. Family members were interviewed. Forty-two of 77 dying patients were sedated, and had a longer survival than those who were not sedated (P=0.003). Prevalent indications for sedation were dyspnea and/or delirium. Twelve patients began with an intermediate sedation, and 38 patients started with definitive sedation. The median sedation duration was 22 hours. Opioid doses did not change during sedation. Agitated delirium significantly decreased with increasing doses of midazolam, whereas the capacity to communicate concomitantly decreased. Interviewed relatives were actively involved in the process of end-of-life care, and the decision to sedate, and the efficacy of sedation, were considered appropriate by almost all relatives. Controlled sedation is successful in dying patients with untreatable symptoms, did not hasten death, and yielded satisfactory results for relatives. This study also points to the importance of palliative care and the experience of professionals skilled in both symptom control and end-of-life care.

Nurses’ Perceptions of Palliative Sedation in a Scottish Hospice

“…This study supported previous research that found decisions were collaborative, driven by patient's wishes, and supported by family and the multidisciplinary team. 21,22 Other studies had found that the setting, individual values, and culture could impact decisions, 23,24 but at this site, nurses perceived the culture as supportive and collaborative, and consensus was reached easily, which contradicted some previous findings. 25 …”

“…[1][2][3][4]21,22 The nurses in this study also described how many other treatments and nonpharmacological measures were attempted before a decision was made to go forward with palliative sedation. This study supported previous research that found decisions were collaborative, driven by patient's wishes, and supported by family and the multidisciplinary team.…”

Indirekte Sterbehilfe

“…Zahlreiche Wissenschaftler bezweifeln, dass eine adäquate Schmerztherapie zu einer Lebensverkürzung führen kann [10,14,19,31,32]. Thorns u. Sykes [32] kamen zu dem Schluss: "Appropriate use of opioids for symptom control does not shorten life."…”

Negotiating Uncertain Terrain: A Qualitative Analysis of Clinicians' Experiences of Refractory Suffering

“…6 Over the past decade there has been a growing interest in the use of sedation for the control of refractory symptoms and the suffering it engenders. [7][8][9][10] While the use of sedation has encouraged considerable research and debate in this area, less attention has been paid to the effect on the clinicians involved of witnessing suffering. Research that has been undertaken in this area has generally been on a single disciplinary group, usually nurses.…”