Palliative Sedation: A Review of the Research Literature

Abstract

The overall aim of this paper is to systematically review the following important aspects of palliative sedation: prevalence, indications, survival, medication, food and fluid intake, decision making, attitudes of physicians, family experiences, and efficacy and safety. A thorough search of different databases was conducted for pertinent research articles published from 1966 to June 2007. The following keywords were used: end of life, sedation, terminal sedation, palliative sedation, refractory symptoms, and palliative care. Language of the articles was limited to English, French, German, and Dutch. Papers reporting solely on the sedatives used in palliative care, without explicitly reporting the prevalence or intensity of sedation, and papers not reporting on primary research (such as reviews or theoretical articles) were excluded. Methodological quality was assessed according to the criteria of Hawker et al. (2002). The search yielded 130 articles, 33.8% of which were peer-reviewed empirical research studies. Thirty-three research papers and one thesis were included in this systematic review. This review reveals that there still are many inconsistencies with regard to the prevalence, the effect of sedation, food and fluid intake, the possible life-shortening effect, and the decision-making process. Further research to clarify all of this should be based on multicenter, prospective, longitudinal, and international studies that use a uniform definition of palliative sedation, and valid and reliable instruments. Only through such research will it be possible to resolve some of the important ethical issues related to palliative sedation.

Palliative sedation: Why we should be more concerned about the risks that patients experience an uncomfortable death

“…However, in case of refractory symptoms leading to 20 unbearable suffering such as intolerable pain, dyspnea, and delir- 21 ium, a more drastic option may be chosen, known as palliative 22 sedation (Table 1). In these cases, comfort is sought by reducing 23 the patient's level of consciousness [12,23]. Although palliative 24 sedation is ethically controversial and some studies have ques- 25 tioned its efficacy and safety [29], this practice has substantially in- 26 creased.…”

“…Paradoxically, the inability to report distress might also be 159 aggravated or even blocked by the use of drugs that might abolish 160 potential further communication and even facial expressions [9]. Palliative sedation is normal medical practice and must be clearly distinguished from the termination of life [35] Proportionality: the degree of sedation must not be deeper than necessary to relieve suffering [11,12,23,35] Palliative sedation will not (usually) hasten death (and that is certainly not the intention) [ [24] o ''Monitoring (observational) scales exist but the usefulness of these scales has not been proven'' [16] o ''Presently no particular scale can be recommended'' [16,24] ''Scales involving administration of painful stimuli are not acceptable'' [16] Frequency of monitoring: every 20 minutes until adequate sedation has been reached and then at least once a day [15,16] Nurses have the explicit task to observe, measure, and report [24] 161 Hence, some patients might have subjective phenomenological …”

Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments

“…4 Several studies have reported use of PS for fatigue and malaise 6,16 ; however, whether these symptoms represent existential or physical suffering is debatable. A few studies have directly addressed the use of PS for existential or psychological suffering.…”

“…During the late 1990s, several important court cases in the United States brought the issue of PS to the forefront and clarified the legality of the right to palliation at end of life. 2,3 Studies have shown that PS is effective, with efficacy rates ranging from 71% to 92%, 4 usually defined as the patient, family, or physician's perceived relief of refractory physical symptoms. In many settings, PS is uncommon, although a recent review revealed considerable variability in the prevalence of PS in the United States and other countries.…”

“…In many settings, PS is uncommon, although a recent review revealed considerable variability in the prevalence of PS in the United States and other countries. 4 When PS is used, it is a measure of last resort rather than general care. Although required infrequently, PS is an important palliative tool with which clinicians should be familiar.…”