Palliative Sedation With Propofol for an Adolescent With a DNR Order

Johnson, Liza‐Marie; Frader, Joel; Wolfe, Joanne; Baker, Justin N.; Anghelescu, Doralina L.; Lantos, John D.

doi:10.1542/peds.2017-0487

Cited by 23 publications

(24 citation statements)

References 18 publications

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“…Evidence throughout the literature suggests several opportunities for interfacing and collaboration between intensivists and PC team, to improve the EOL experience of patients, their families, and even medical teams, through assistance with advanced-care planning, shared medical decision making, particularly when faced with decisions about de-escalation of care and symptom management, which may include palliative sedation therapy (PST) (3,7,32,39). PST is defined as, "the use of sedative medications to relieve intolerable and refractory distress by the reduction in patient consciousness" (40)(41)(42)(43)(44). Over the last several years, acceptance of early integration of PC in the realm of pediatric oncology and PICU care has grown with institutions using the PICU admission as a trigger for PC consultation (38,(45)(46)(47)(48)(49).…”

Section: Discussionmentioning

confidence: 99%

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Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration

Cuviello

Pasli²,

Hurley³

et al. 2022

Front. Oncol.

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ContextApproximately 40%-60% of deaths in the pediatric intensive care unit (PICU) are in the context of de-escalation of life-sustaining treatments (LSTs), including compassionate extubation, withdrawal of vasopressors, or other LSTs. Suffering at the end of life (EOL) is often undertreated and underrecognized. Pain and poor quality of life are common concerns amongst parents and providers at a child’s EOL. Integration of palliative care (PC) may decrease suffering and improve symptom management in many clinical situations; however, few studies have described medical management and symptom burden in children with cancer in the pediatric intensive care unit (PICU) undergoing de-escalation of LSTs.MethodsA retrospective chart review was completed for deceased pediatric oncology patients who experienced compassionate extubation and/or withdrawal of vasopressor support at EOL in the PICU. Demographics, EOL characteristics, and medication use for symptom management were abstracted. Descriptive analyses were applied.ResultsCharts of 43 patients treated over a 10-year period were reviewed. Most patients (69.8%) were white males who had undergone hematopoietic stem cell transplantation and experienced compassionate extubation (67.4%) and/or withdrawal of vasopressor support (44.2%). The majority (88.3%) had a physician order for scope of treatment (POST – DNaR) in place an average of 13.9 days before death. PC was consulted for all but one patient; however, in 18.6% of cases, consultations occurred on the day of death. During EOL, many patients received medications to treat or prevent respiratory distress, pain, and agitation/anxiety. Sedative medications were utilized, specifically propofol (14%), dexmedetomidine (12%), or both (44%), often with opioids and benzodiazepines.ConclusionsPediatric oncology patients undergoing de-escalation of LSTs experience symptoms of pain, anxiety, and respiratory distress during EOL. Dexmedetomidine and propofol may help prevent and/or relieve suffering during compassionate de-escalation of LSTs. Further efforts to optimize institutional policies, education, and collaborations between pediatric intensivists and PC teams are needed.

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Section: Discussionmentioning

confidence: 99%

“…In rare cases, suffering persists despite all interventions, and PST is an effective tool for refractory suffering at the EOL (40)(41)(42)(43)(44). PST practices are variable in pediatric oncology, and medication choices for implementation of PST are evolving (40,68,69).…”

Section: Discussionmentioning

confidence: 99%

Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration

Cuviello

Pasli²,

Hurley³

et al. 2022

Front. Oncol.

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“…In the same year, a similar case and protocol was reported in Italy [ 32 ]. Since then, propofol infusions in end‐of‐life care have been described regularly, albeit infrequently, in the palliative care literature [ 33 , 34 , 35 ].…”

Section: General Anaesthesia In End‐of‐life Care In Practice: Rediscovering the Moyle Protocolmentioning

confidence: 99%

General anaesthesia in end‐of‐life care: extending the indications for anaesthesia beyond surgery

et al. 2021

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Summary In this article, we describe an extension of general anaesthesia – beyond facilitating surgery – to the relief of suffering during dying. Some refractory symptoms at the end of life (pain, delirium, distress, dyspnoea) might be managed by analgesia, but in high doses, adverse effects (e.g. respiratory depression) can hasten death. Sedation may be needed for agitation or distress and can be administered as continuous deep sedation (also referred to as terminal or palliative sedation) generally using benzodiazepines. However, for some patients these interventions are not enough, and others may express a clear desire to be completely unconscious as they die. We summarise the historical background of an established practice that we refer to as ‘general anaesthesia in end‐of‐life care’. We discuss its contexts and some ethical and legal issues that it raises, arguing that these are largely similar issues to those already raised by continuous deep sedation. To be a valid option, general anaesthesia in end‐of‐life care will require a clear multidisciplinary framework and consensus practice guidelines. We see these as an impending development for which the specialty should prepare. General anaesthesia in end‐of‐life care raises an important debate about the possible role of anaesthesia in the relief of suffering beyond the context of surgical/diagnostic interventions.

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“…Consultation with radiation oncology, neurosurgery, pain medicine, and/or hospice and palliative medicine specialists is prudent in patients with recalcitrant pain. In the rare case where pain control cannot be achieved, the goals-of-care may be consistent with palliative sedation, which necessitates consultation with palliative care specialists [71,76,77,78].…”

Section: Painmentioning

confidence: 99%

Palliative Care for Children with Central Nervous System Malignancies

Baenziger

Moody

2018

Bioengineering

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Children with central nervous system (CNS) malignancies often suffer from high symptom burden and risk of death. Pediatric palliative care is a medical specialty, provided by an interdisciplinary team, which focuses on enhancing quality of life and minimizing suffering for children with life-threatening or life-limiting disease, and their families. Primary palliative care skills, which include basic symptom management, facilitation of goals-of-care discussions, and transition to hospice, can and should be developed by all providers of neuro-oncology care. This chapter will review the fundamentals of providing primary pediatric palliative care.

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Palliative Sedation With Propofol for an Adolescent With a DNR Order

Cited by 23 publications

References 18 publications

Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration

Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration

General anaesthesia in end‐of‐life care: extending the indications for anaesthesia beyond surgery

Palliative Care for Children with Central Nervous System Malignancies

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