Efficacy and safety of deep, continuous palliative sedation at home: a retrospective, single-institution study

Porzio, Giampiero; Aielli, Federica; Verna, Lucilla; Micolucci, Giovanna; Aloisi, Paolo; Ficorella, Corrado

doi:10.1007/s00520-009-0632-4

Cited by 40 publications

(67 citation statements)

References 27 publications

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“…The principal reason to begin PS was agitated delirium, with dyspnea being the second indication in about 20% of patients. This is in accordance with previous retrospective studies performed at home by our group and other authors, 7,10,11 and in contrast with older data. 12,13 It is likely that a modern approach and greater opioid availability make pain an infrequent indication for PS.…”

Section: Discussionsupporting

confidence: 94%

“…Then, a small number of patients who survived more than 24 hours required further dose increments, with an escalation index of about one in the three patients who survived four days, with doses even lower than those reported in other studies. 11 Of interest, the use of midazolam out of hospital, subcutaneously or intravenously, is off-label, although both home care programs have direct contact with hospitals or hospices and drugs are provided by these institutions.…”

Section: Discussionmentioning

confidence: 99%

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Palliative Sedation in Patients With Advanced Cancer Followed at Home: A Prospective Study

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Porzio

Valle³

et al. 2014

Journal of Pain and Symptom Management

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Context. Home care programs in Italy.Objectives. The aim of this study was to assess a protocol for palliative sedation (PS) performed at home.Methods. A total of 219 patients were prospectively assessed to evaluate a PS protocol in patients with advanced cancer followed at home by two home care programs with different territorial facilities. The protocol was based on stepwise administration of midazolam.Results. A total of 176 of the patients died at home, and PS was performed in 24 of these patients (13.6%). Younger patients received the procedure more frequently than older patients (P ¼ 0.012). The principal reasons to start PS were agitated delirium (n ¼ 20) and dyspnea (n ¼ 4). Mean duration of PS was 42.2 AE 30.4 hours, and the mean doses of midazolam were 23e58 mg/day. Both the home care team and the patients' relatives expressed optimal or good levels of satisfaction with the procedure in all but one case, respectively.Conclusion. This protocol for PS was feasible and effective in minimizing distress for a subgroup of patients who died at home. The characteristics of patients who may be effectively sedated at home should be better explored in future studies. J Pain Symptom Manage 2014;47:860e866. Ó

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Section: Discussionsupporting

confidence: 94%

Section: Discussionmentioning

confidence: 99%

Palliative Sedation in Patients With Advanced Cancer Followed at Home: A Prospective Study

Mercadante

Porzio

Valle³

et al. 2014

Journal of Pain and Symptom Management

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“…9 The principal symptom to be relieved with PS was delirium; alone or in combination with other symptoms, it was the indication for PS in about 70% of patients. This confirms recent data in the home care setting 3,7,17 and in a pioneer study, 8 and is similar to data reported in a palliative care unit population. 16 Dyspnea was the second most frequent reason to start PS (about 43% of patients).…”

Section: Discussionsupporting

confidence: 92%

“…16 It is likely that hospitalized patients tend to have a greater symptom burden than those who remain at home or patients are admitted to hospital as an emergency because of the development of refractory symptoms close to death. 7,8 Finally, the different environment at home could potentially influence the decision to start PS; factors include lack of a continuous bedside presence, family cooperation, time for planning, and decision making in case of an emergency. 9 The principal symptom to be relieved with PS was delirium; alone or in combination with other symptoms, it was the indication for PS in about 70% of patients.…”

Section: Discussionmentioning

confidence: 99%

“…6 Although in one study the frequency of PS at home was higher than that reported in hospital (36% vs. 21%), only 36% of patients who were followed by the palliative care team died at home. 7 In another study of advanced cancer patients followed at home, more patients were sedated when moved to hospital than when remaining at home (32% vs. 23%). 8 In a systematic review of PS at home, only six papers reported data regarding patients who were sedated at home.…”

Section: Introductionmentioning

confidence: 99%

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Palliative Sedation in Advanced Cancer Patients Followed at Home: A Retrospective Analysis

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Porzio

Valle³

et al. 2012

Journal of Pain and Symptom Management

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Context. Data regarding palliative sedation at home in dying patients are lacking.Objectives. To describe the frequency, indication, and modality of palliative sedation (PS) in patients followed at home.Methods. A retrospective analysis of home care cancer patients was performed. Patients who received PS before dying were selected and information about epidemiologic characteristics, indications, duration, drugs, and outcomes was collected.Results. Of 370 medical charts of patients who died at home, 49 patients received PS before dying. PS was proposed by the team, relatives, or both in 63.3%, 4.1%, and 32.6% of cases, respectively. Delirium alone or in combination with other symptoms was the most frequent indication to begin PS. Midazolam was the most frequently used drug to initiate PS (98%), at a mean dose of 28.1 mg/day, in combination with parenteral morphine (84.7%) at a mean dose of 25.4 mg/day. At the time of death, midazolam was administered in 98% of patients (mean dose 22.3 mg/day), combined with parenteral morphine in 87.8% of patients (mean dose 28.1 mg/day). Satisfaction for physicians and principal caregivers after PS was good in 46 and 48 cases, respectively.Conclusion. PS at home seems to be a feasible treatment option among selected patients and makes a potentially important contribution to improving care for those who choose to die at home. J Pain Symptom Manage 2012;43:1126e1130.

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Palliative pharmacological sedation for terminally ill adults

Beller

Driel

McGregor

et al. 2015

Cochrane Database of Systematic Reviews

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BackgroundTerminally ill people experience a variety of symptoms in the last hours and days of life, including delirium, agitation, anxiety, terminal restlessness, dyspnoea, pain, vomiting, and psychological and physical distress. In the terminal phase of life, these symptoms may become refractory, and unable to be controlled by supportive and palliative therapies specifically targeted to these symptoms. Palliative sedation therapy is one potential solution to providing relief from these refractory symptoms. Sedation in terminally ill people is intended to provide relief from refractory symptoms that are not controlled by other methods. Sedative drugs such as benzodiazepines are titrated to achieve the desired level of sedation; the level of sedation can be easily maintained and the effect is reversible. ObjectivesTo assess the evidence for the benefit of palliative pharmacological sedation on quality of life, survival, and specific refractory symptoms in terminally ill adults during their last few days of life. Search methodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 11), MEDLINE (1946 to November 2014, and EMBASE (1974 to December 2014), using search terms representing the sedative drug names and classes, disease stage, and study designs. Selection criteriaWe included randomised controlled trials (RCTs), quasi-RCTs, non-RCTs, and observational studies (e.g. before-and-after, interruptedtime-series) with quantitative outcomes. We excluded studies with only qualitative outcomes or that had no comparison (i.e. no control group or no within-group comparison) (e.g. single arm case series). Data collection and analysisTwo review authors independently screened titles and abstracts of citations, and full text of potentially eligible studies. Two review authors independently carried out data extraction using standard data extraction forms. A third review author acted as arbiter for both stages. We carried out no meta-analyses due to insufficient data for pooling on any outcome; therefore, we reported outcomes narratively.

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Efficacy and safety of deep, continuous palliative sedation at home: a retrospective, single-institution study

Abstract: A midazolam-based protocol for PSH is feasible and effective. Our results need to be confirmed by prospective, multicentric, controlled studies.

Cited by 40 publications

References 27 publications

Palliative Sedation in Patients With Advanced Cancer Followed at Home: A Prospective Study

Palliative Sedation in Patients With Advanced Cancer Followed at Home: A Prospective Study

Palliative Sedation in Advanced Cancer Patients Followed at Home: A Retrospective Analysis

Palliative pharmacological sedation for terminally ill adults

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