Pediatrician Ambiguity in Understanding Palliative Sedation at the End of Life

Abstract

Responses point to ambiguity surrounding the concept of palliative sedation. Pediatricians were concerned with a decreased level of consciousness as the goal of palliative sedation. Respondents were split on whether they view palliative sedation as a distinct entity or as one broad continuum of care, equivalent to aggressive symptom management. Institutional-based policies are essential to clarify acceptable practice, enable open communication, and promote further research.

Should Pediatric Euthanasia be Legalized?

“…Then, either their pain will be relieved or, in rare cases, the patients go on to respiratory failure and death. 13 Children generally don't fear becoming a burden to others. They don't worry about the loss of future autonomy.…”

Palliative Sedation With Propofol for an Adolescent With a DNR Order

“…Although the concept of PST is well described in the adult palliative care and oncology literature, it has received less attention in the pediatric literature, with publications primarily limited to case series and case reports. 7 Numerous position statements and clinical guidelines for the consideration of PST have been published by experts in adult palliative care 1 ; however, there is a dearth of pediatric-specific guidance. Given the particularly complex medical and social situation that often surrounds a dying child, particularly a child with refractory physical symptomatology, there is a great need for new approaches to pain and symptom control.…”

The role of the pediatric anesthesiologist in relieving suffering at the end of life: when is palliative sedation appropriate in pediatrics?

“…Palliative sedation therapy with infusions of opioids, benzodiazepines, dexmedetomidine, or propofol can provide deep sedation and symptom relief, allowing the child to die with less pain, suffering and distress . While this concept is well described in the adult palliative care and oncology literature and position statements and clinical guidelines are available, it has received less attention in pediatrics, and literature is limited to case series and case reports . Expert consultation from pediatric anesthesiologists and pain and palliative care specialists is crucial to determine if symptoms are truly refractory (i.e.…”

“…The goal of palliative sedation therapy is to address intolerable and refractory suffering by a purposeful reduction in patient awareness, to the point of unconsciousness; the goal is never to hasten death, but to relieve distress from refractory and distressing physical symptoms . The medical team and the family should reach consensus that (i) the child is imminently dying (having a terminal diagnosis, unlikely to recover from the current illness, and unlikely to survive more than several days or weeks); and (ii) pain and suffering are deemed intolerable by the patient and the parents, despite maximization of symptom‐directed interventions, including rapid opioid escalation, rotation to an alternative opioid, nonopioid adjuvant medications, nonpharmacologic approaches, or interventional approaches .…”

“…Clear and comprehensive communication with the patient and the family is essential, and should include the purpose and the risks and benefits. The doses needed for adequate relief of suffering may be high enough that some risk of respiratory depression (and death) may exist as a double effect; however, these risks are rare with appropriate use by clinicians trained in palliative sedation therapy . Documentation in the medical record should clearly state that the purpose is relief of refractory suffering and not to hasten death (i.e., euthanasia).…”