Palliative Sedation. B. Craig Weldon, MD. That sweet, deep sleep, so close to tranquil death. The Aeneid, Virgil [70-19 B.C.E]
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![The Aeneid, Virgil [70-19 B.C.E] B.](/docs-images/76/73993882/images/1-1.jpg "Craig Weldon, MD 5 th Annual UNC-Duke-Wake Forest")
1 Palliative Sedation That sweet, deep sleep, so close to tranquil death. The Aeneid, Virgil [70-19 B.C.E] B. Craig Weldon, MD 5 th Annual UNC-Duke-Wake Forest Pediatric Anesthesiology Conference 25 August 2012
2 J.D.: A Child Dying in Severe Pain JD, 5 year old with terminal abdominal neuroblastoma Tx d for the past 3 years with chemo, surgery Continued local invasion (spine) and metastasis (liver) Tumor-related neuropathic and visceral pain for 18 mos Treated with escalating doses of opioids Gabapentin, ketamine used without much relief Failed epidural opioid/l.a. due to catheter infection
3 The Current Situation Pain still poorly controlled with high dose hydromorphone infusion and methadone Gaba, lorezapam, low dose ketamine by mouth Opioid-induced delirium and myoclonic jerks Child screaming, confused, writhing in bed Rapid, labored breathing Abdomen distended, diffusely tender
4 Can you help JD? Parents distraught over child s suffering Problems Intractable Pain Delirium/Myoclonus Dyspnea Primary service confirms he has only days to live Palliative Care consultation
5 Objectives Define Palliative Sedation Ethical Concerns The Conduct of Palliative Sedation
6 Palliative Sedation (PS) Dear spell of sleep, assuager of disease. Orestes, Euripides [ B.C.E.]
7 Hypnos and Thanatos John William Waterhouse, 1874 Sleep and his half brother Death
8 Palliative Sedation: The progressive use of sedatives to relieve otherwise intractable symptoms in terminally ill patients Only in the context of palliative care team consultation End of Life Level of consciousness is important Conscious vs Unconscious Sedation Titration of agent(s) to lowest effective dose Physician Intent is Critical! Symptom relief, not death, is intended
9 The Principle of Double Effect Thomas Aquinas ( ) Sometimes it is permissible to bring about as a merely foreseen side effect a harmful event that it would be impermissible to bring about intentionally. Thus, the intent is to relieve suffering at the end of life with the understanding that one s efforts might shorten that life.
10 Physician Assisted Death (PAD) The use of physician prescribed medication to facilitate death Drug administration not physician administered or supervised Legal in Oregon, Washington and Montana
11 Euthanasia Physician administered/supervised lethal dose of medication(s) With patient s consent (Netherlands and Belgium) Without patient s consent (Nazi Doctors) Illegal in US
12 Treatments of last resort Euthanasia/PAD Palliation through death Ethically questionable for some Silent PAD illegal outside OR, WA, MT Abrogates palliative care and symptom relief regimen Palliative Sedation Palliation alongside death Ethically Acceptable Legal in US Logical extension of symptom relief regimen Hastings Center Report. 2010; 40: 32-38
13 Arguments for PS Individual autonomy justifies PS Each individual has the right to pursue their own view of what kind of life is best Beneficence supports PS Ending a painful life will actually relieve more suffering and thereby produce more good PS is no different than withdrawing life-sustaining treatments PS shown NOT to hasten death
14 Multicenter, observational, nonrandomized study 518 hospice patients: 267 PS vs 215 routine hospice care Median duration of sedation - 2 days (0-42) Kaplan-Meyer Plot Double effect need NOT be invoked to justify Palliative Sedation
15 Arguments Against PS Autonomy does not justify PS By ending life, the individual can no longer exercise autonomy Beneficence can be achieved with quality care The distinction between terminating life-sustaining treatments and PS is clear Some patients who have these treatments discontinued may continue to live
16 Other Issues in Pediatric PS Is End of Life Near? Patient s Consent vs Parental Wishes? Is conscious PS possible in children? Home Death? Paucity of Published Data in Children
17 How do we conduct PS? ALWAYS in the context of the best palliative care
18 Palliative Sedation Planning What Symptoms are we trying to relieve? What Agents is the child currently receiving? What is our Endpoint of symptom management? Family s Expectations?
19 Palliative Sedation: The Basics NO Physiologic Monitoring Individualized Spiritual Support Quiet, Easily Accessible Location Physician Immediately Available Frequent visits to assess effectiveness Consultation with nursing Rapid intervention for inadequate symptom control
20 Indications for Palliative Sedation: Intractable Terminal Suffering Pain that is unrelieved with opioids and adjuvants Dyspnea Nausea/Vomiting Agitated Delirium Seizures Existential Suffering? When sleep puts an end to delirium, it is a good symptom. Aphorisms, Hippocrates [ B.C.E.]
21 Concomitant Polypharmacy High Dose Opioids tolerance, delirium Analgesic Adjuvants: Ketamine, Gabapentin, Amitriptyline Benzodiazepines tolerance, delirium Antidepressants/Antipsychotics SSRIs, Haloperidol
22 Agents Commonly Used for PS Opioids Sedatives/Hypnotics/Antipsychotics Anesthetic Agents
23 Opioid Analgesics for PS Morphine, hydromorphone as continuous infusion Methadone mu agonist-nmda antagonist Sedative effects, euphoria Dysphoria/delirium with very large doses Respiratory depression Tolerance
24 Sedative Agents used for PS Midazolam Rapid onset of action + short half-life = continuous infusion Sedative, anxiolytic, and anticonvulsive effects Paradoxical agitation and delirium possible Ketamine analgesic + sedative, dysphoria/salivation Barbiturates phenobarbital, pentobarbital as infusion Haldol for delirium, little experience in children
25 Anesthetic Agents used for PS Propofol Anesthesia or ICU provider Easy titratability moderate sedation possible? Anti-emetic, anti-convulsant Provides sedation, amnesia, and anxiolysis
26 Propofol No inherent analgesic properties Cardiorespiratory depression Requires ICU setting and properly trained staff Frequent dose adjustments Journal of Palliative Med. 2009; 13:
27 Dexmedetomidine Central α2 agonist, simulates normal sleep Analgesic properties compliment opioids Currently used to treat/prevent: Postoperative delirium in children and adults ICU therapeutic sedation AM J Hosp Palliat Care. 2011; 28:
28 PS Management Plan for JD JD transferred to PICU Dexmedetomidine infusion titrated to unconsciousness Hydromorphone infusion decreased Lorezapam dose decreased Oral meds held
29 Denouement Occasional arousal without agitation or evidence of pain Work of breathing and myoclonus reduced JD dies 96 hours after PS begun Parents express gratitude for the relief of his suffering
30 Suggested Reading Berger, J. Rethinking Guidelines for the Use of Palliative Sedation. Hastings Center Report. 2010; 40: Bennett, R Givens, D. Easing Suffering for a Child with Intractable Pain at the End of Life. Jour Ped Health Care. 2011; 25: Postovsky, S et al. Practice of Palliative Sedation in Children with Brain Tumors and Sarcomas at the End of Life. Pediatric Hem and Onc. 2007; 24: Prommer, E. Dexmedetomidine: Does it Have Potential in Palliative Medicine? AM J Hosp Palliat Care. 2011; 28: McWilliams, K et al. Propofol for Terminal Sedation in Palliative Care: A Systematic Review. Journal of Palliative Med. 2009; 13: Tobias, J. Propofol Sedation for Terminal Care in a Pediatric Patient. Clinical Pediatrics. 1997; 36:
31 Questions, Discussion
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