Patient and/or family controlled palliative sedation with midazolam for intractable symptom control: a case series

Abstract

IntroductionOur case series prospectively evaluate the concept of Patient/Family-Controlled Sedation with midazolam, as an alternative to sedation by continuous infusion in terminal cancer patients.Cases presentationOur method was applied in 8 pts. Midazolam was administered in a Patient Control Analgesia mode. The infusion pump was activated "as-needed" by the pt or a caretaker. Sedation was rated as: 1) awake 2) arousable to voice 3) arousable to light pain or 4) unarousable. Family satisfaction was rated as: 1) good, 2) fair, 3) poor, or 4) unacceptable. Mean midazolam consumption was 12 – 40 mg/24 hours. We did not observe respiratory depression. Death occurred 1–6 days after sedation started. Family satisfaction was mainly good and median sedation was in the range 2 – 3.ConclusionPatient/Family-Controlled Sedation with midazolam was effective in providing comfort, by allowing titration of sedation to each patient's needs.

The use of observational scales to monitor symptom control and depth of sedation in patients requiring palliative sedation: A systematic review

“…32 On symptom level, the Visual Analogue Scale (VAS) was used in two studies to measure pain, nausea and drowsiness, whereby data based on patient-administered VAS were used for conscious patients, whereas a trained nurse performed the assessments during sedation. 27,30 The Edmonton Symptoms Assessment System (ESAS) was used in one study. 35 In one study single items for measuring hypo-or hyperactivity on the Agitation Distress Scale (Agitation Scale) and the Memorial Delirium Assessment Scale (MDAS) were used.…”

“…25 In addition to these established instruments, the use of an ad hoc scoring system was reported in six studies. 27,28,31,33,34,42 Finally, we found one study monitoring the effects of sedation by unspecified observation. 39 In studies evaluating physicians' experiences (see Table 2), consumption of benzodiazepines was described as a way to measure symptom management.…”

“…In addition, six guidelines and two reviews advised to monitor the effects of sedation without providing reference to specific tools or methods. 3,9,10,12,13,17 Assessors of the scales In most patient-based pro-or retrospective studies (n = 10) monitoring was performed by trained personnel (physicians, n = 6; 25,27,31,33,35,42 nurses, n = 5; 31,33,35,39,42 members of a treatment team, n = 1 28 ; or palliative care specialist, n = 1 8 ) (see Table 1). In two prospective patient-based studies, and three studies in which physicians' experiences were assessed, no information was provided with regard to the assessors.…”

“…4,17,40 Timing and frequency of monitoring In 10 pro-or retrospective studies information was provided with regard to frequency of monitoring (see Table 1): daily monitoring (n = 3), 28,31,34 twice a day 30,35 or four times a day. 27 In one study, assessments were performed just before the start of sedation, and at four and 24 hours after sedation. 25 In another study, measurements were reported to take place 'regularly' in the first hour after the start of sedation, and at two and six hours following onset of sedation.…”

Medication and Monitoring in Palliative Sedation Therapy: A Systematic Review and Quality Assessment of Published Guidelines

“…In addition, drugs such as propofol just recently emerged in the palliative care context 17. Small observational studies assessing the effect of different drugs have recently been published,[18][19][20] but these as well as results from earlier published studies 21-23 need to be confirmed by larger prospective, ideally studies. This evidence is urgently required to develop recommendations on drugs…”