Pediatric Palliative Sedation Therapy with Propofol: Recommendations Based on Experience in Children with Terminal Cancer

Abstract

Background: The use of propofol for palliative sedation of children is not well documented. Objective: Here we describe our experience with the use of propofol palliative sedation therapy (PST) to alleviate intractable end-of-life suffering in three pediatric oncology patients, and propose an algorithm for the selection of such candidates for PST. Patients and Methods: We identified inpatients who had received propofol PST within 20 days of death at our institution between 2003 and 2010. Their medical records were reviewed for indicators of pain, suffering, and sedation from 48 hours before PST to the time of death. We also tabulated consumption of opioids and other symptom management medications, pain scores, and adverse events of propofol, and reviewed clinical notes for descriptors of suffering and/or palliation. Results: Three of 192 (1.6%) inpatients (aged 6-15 years) received propofol PST at the end of life. Consumption of opioids and other supportive medications decreased during PST in two cases. In the third case, pain scores remained high and sedation was the only effective comfort measure. Clinical notes suggested improved comfort and rest in all patients. Propofol infusions were continued until the time of death. Conclusions: Our experience demonstrates that propofol PST is a useful palliative option for pediatric patients experiencing intractable suffering at the end of life. We describe an algorithm that can be used to identify such children who are candidates for PST.

Palliative Sedation With Propofol for an Adolescent With a DNR Order

“…In adult studies on PST, achievement of adequate analgesia may be associated with life prolongation rather than hastening of death. 6 Objective criteria for monitoring children on PST may help families and clinicians evaluate the level of sedation and, in some circumstances, a trial of sedation may be indicated to determine if it is still indicated.…”

Should Euthanasia Be Considered Iatrogenic?

“…It is important to note that, although major American medical associations and academies reject euthanasia [57,58], palliative sedation (PS) to unconsciousness is considered an appropriate intervention of last resort for patients in very specific situations (e.g., patients with terminal illness or symptoms that are severe, refractory, and not responding to aggressive palliation) [63,64]. Concretely, PS involves administering medication to patients with severe and refractory symptoms with the goal of lowering a patient's level of consciousness so that she or he is not aware of pain and discomfort [65,66].…”

Dexmedetomidine for Sedation during Withdrawal of Support

“…Opioids, benzodiazepines, 1 ketamine, propofol, 2 barbiturates, 3 and neuroleptics are agents utilized to provide sedation to manage refractory pain and symptoms at the end of life. A recent retrospective analysis based on data from the Pediatric Health Information System and Premier Perspective Database between 2007 and 2011 confirmed this, and also noted an increasing use of dexmedetomidine.…”