Palliative Sedation Therapy Practice Comparison – A Survey of Pediatric Palliative Care and Pain Management Specialists

Abstract

Context: Palliative sedation therapy (PST) can relieve suffering at end-of-life (EOL) in children with intolerable and refractory symptoms. However, updated and consistent guidance on PST practices are imperative. Objectives: We investigate current variations in clinical practice and PST implementation among pediatric palliative care (PPC) and pain management (PM) specialists. Methods: We distributed an IRB-exempt electronic anonymous survey via email through the Society of Pediatric Pain Medicine, and the American Academy of Hospice and Palliative Medicine. Survey responses were collated and descriptively reported. Results: Of 83 survey responses, the majority (75%) represented large academic children’s hospitals. The distribution between PPC and pediatric pain management specialists’ responses was 60% and 40%, respectively. Most respondents reported having designated pain management and/or palliative care teams (70% and 90%, respectively). Approximately half (48%) reported following an institutional PST protocol, most not requiring formal ethics consult (69%). Only 54% of respondents noted that the Do Not Resuscitate (DNR) order was required prior to PST initiation. PST was primarily utilized for children with oncologic diagnoses (76%). The primary and secondary medications of choice for PST implementation were reported to be opioids (39%) and benzodiazepines (36%) by pain management specialists, and benzodiazepines (52%) and barbiturates (28%) by palliative care specialists. Conclusions: Our study highlights the variability in the practice and implementation of PST. Further educational efforts are key for establishing PST practices and efficient protocol development.

Palliative Sedation Therapy in Pediatrics: An Algorithm and Clinical Practice Update

“…In a recent survey study completed by pediatric palliative care (PC) physicians and pain management specialists, significant variability was identified in the implementation of PST and which medications were chosen [ 26 ]. Among PC physicians, the most common class of drug used for PST implementation was benzodiazepines, followed by barbiturates [ 26 ]. In contrast, pain medicine specialists opted for opioids as a first line drug for PST initiation, followed by benzodiazepines [ 26 ].…”

“…Among PC physicians, the most common class of drug used for PST implementation was benzodiazepines, followed by barbiturates [ 26 ]. In contrast, pain medicine specialists opted for opioids as a first line drug for PST initiation, followed by benzodiazepines [ 26 ]. This survey study highlighted additional variations in PST practice including lack of standardized protocols or guidelines for PST procedures, inconsistent involvement of ethics committees, and varying need for scope of physician orders (i.e., do not resuscitate orders) prior to PST initiation [ 26 ].…”

“…In contrast, pain medicine specialists opted for opioids as a first line drug for PST initiation, followed by benzodiazepines [ 26 ]. This survey study highlighted additional variations in PST practice including lack of standardized protocols or guidelines for PST procedures, inconsistent involvement of ethics committees, and varying need for scope of physician orders (i.e., do not resuscitate orders) prior to PST initiation [ 26 ]. Overall, this study highlights the current variability in the clinical practice of PST and suggests targetable aspects for practice improvement.…”