Sedation for Delirium and Other Symptoms in Terminally Ill Patients in Edmonton

Abstract

The use of sedation and the management of delirium and other difficult symptoms in terminally ill patients in Edmonton has been reported previously. The focus of this study was to assess the prevalence in the Edmonton region of difficult symptoms requiring sedation at the end of life. Data were collected for 50 consecutive patients at each of (a) the tertiary palliative care unit, (b) the consulting palliative care program at the Royal Alexandra Hospital (acute care), and (c) three hospice inpatient units in the city. Patients on the tertiary palliative care unit were significantly younger. Assessments confirmed the more problematic physical and psychosocial issues of patients in the tertiary palliative care unit. These patients had more difficult pain syndromes and required significantly higher doses of daily opioids. Approximately 80% of patients in all three settings developed delirium prior to death. Pharmacological management of this problem was needed by 40% in the acute care setting, and by 80% in the tertiary palliative care unit. The patients sedated varied from 4% in the hospice setting to 10% in the tertiary palliative care unit. Of the 150 patients, nine were sedated for delirium, one for dyspnea. The prevalence of delirium and other symptoms requiring sedation in our area is relatively low compared to others reported in the literature. Demographic variability between the three Edmonton settings highlights the need for caution in comparing results of different palliative care groups. It is possible that some variability in the use of sedation internationally is due to cultural differences. The infrequent deliberate use of sedation in Edmonton suggests that improved management has resulted in fewer distressing symptoms at the end of life. This is of benefit to patients and to family members who are with them during this time.

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

“…As reported for in-hospice patients, a more frequent indication was agitated delirium followed by dyspnea [15,16,27]. In our experience, as well as in Bruera's data, we did not evidence uncontrolled pain as indication to PSH [13].…”

“…Our rate of PSH is in the range of sedation rate among in-hospice patients reported in the literature [15,19,31]. As regard patients at home, the two large, Italian studies reported a rate of sedation between 12% and 25% [4,26].…”

Two Remarkable Dyspneic Men: When Should Terminal Sedation be Administered?

“…[1][2][3][4][5][6][7][8][9][10][11][12] Descriptions of various parameters surrounding the use of sedation in multiple centers has provided valuable information regarding the prevalence of sedation, refractory symptoms that require sedation, expert's attitudes regarding sedation, as well as the influence of cultural differences. 4,5,8 Nevertheless, ethical concerns as to when terminal sedation is justified can be controversial. 1,2,6 In addition, the definition of refractory symptoms is complex and the role that sedation has in the management of these symptoms is not inherently clear.…”

Delirium: An important (but often unrecognized) clinical syndrome

“…It may foreshadow impending death in as many as 25% of hospitalized inpatients [2][3][4][5] and may be a source of significant morbidity in those who present with this syndrome [6]. The disorder may go unrecognized by hospital staff as well as those close to an affected individual, and this oversight may lead to poorer outcomes including longer lengths of stay in acute care hospitals, the need for nursing home placement, prolonged cognitive disturbances, and protracted disability [7][8][9][10][11][12][13].…”