Frederic Jackson, DO, MPH, FAAFP Veronica Giron-Stone, RN, MSN, CHPN Suzanne Mitchell, RN, CHPN. (Who, What, When, Where, Why and How)

Transcription

1 9/5/2012 SUZIE S STORY PALLIATIVE SEDATION IN PRACTICE Frederic Jackson, DO, MPH, FAAFP Veronica Giron-Stone, RN, MSN, CHPN Suzanne Mitchell, RN, CHPN Angela Akbarian, LCSW Dee Crimmel, MDiv, MA OBJECTIVES 1. Define e the Purpose of Palliative at Sedation (PS) 2. Describe Standard of Practice (Who, What, When, Where, Why and How) 3. Name 3 challenges staff may voice when introducing Palliative Sedation at your agency 4. Explain the Importance of the Debrief Meeting following a Palliative Sedation case 1

2 9/5/2012 OVERVIEW o The Elizabeth Hospice, a Community Based Not for Profit Founded 1978 Census 485 o Palliative Sedation IDT Task Force Created Research & Develop POC Board Approved Staff Education 3 Palliative Sedation Cases o Topics of Discussion / Challenges Assisted suicide, hastening death, existential suffering, staff discomfort, euthanasia, one team, ethical questions 2

3 9/5/2012 PALLIATIVE SEDATION IS o The monitored use of medications (sedatives, barbiturates, neuroleptics, hypnotics, benzodiazepines or anesthetic medications) o To relieve refractory and unendurable physical, spiritual and/or psychosocial distress. Refractory: Symptoms that cannot be adequately controlled despite aggressive efforts by the IDT to provide timely, tolerable therapies that do not compromise consciousness. o For patients with a terminal diagnosis, inducing varied degrees of unconsciousness. PURPOSE AND INTENT o Purpose: Provide comfort and relieve suffering and not to hasten death. o Intent: Relief of suffering and not to end the patient s life. 3

4 9/5/2012 ETHICAL ISSUES AND JUSTIFICATION Four Pillars of Medical Ethics A U T O N O M Y B E N E F I C E N C E N O N M A L E F I C E N C E J T U Y S T I C E / F I D E L I AUTONOMY o An individual has the right to decide their course of treatment for themselves according to their values, beliefs or life plan. o Informed consent is required in order to make autonomous decisions based upon the risks and benefits of any intervention. 4

5 9/5/2012 BENEFICENCE o Ethical duty to do well as it relates to promoting well being o The action in itself is morally right o Intent of the healthcare provider is to do good NONMALEFICENCE o Not doing anything intentionally bad, not causing harm o Only good effects are directly intended o Distinction between the means and the effects must be envisioned (death must not be the means to the good effect) e.g. drugs relieve severe symptoms even though indirectly producing undesired bad effects such as deprivation of mental properties 5

6 9/5/2012 JUSTICE/FIDELITY o When a patient no longer has the capacity to make decisions for him/herself, the principle of fidelity, which includes the promise not to abandon another, allows a designated health care proxy or patient representative who knows the patient s wishes, to make informed decisions regarding the patient s care. DESIRED OUTCOME o Congruent to the intent of palliative sedation; the outcome is the patient is made unaware of unendurable suffering through sedation. o Sedation is titrated to the minimum level of consciousness reduction necessary to render symptoms tolerable. o For some patients, this may be total unconsciousness; for most it will be less than total unconsciousness, allowing the patient to rest comfortably but to be aroused. 6

7 9/5/2012 FOUR BOX METHOD - J ONSEN ONSEN,, A.R. ET.AL. MEDICAL INDICATIONS Beneficence and Nonmaleficence: 1. Disease and prognosis 2. Goals of treatment 3. Probabilities of success in achieving goals 4. How can patient be benefitted and harm avoided PATIENT PREFERENCES Respect for Patient Autonomy: 1. What has the patient expressed? 2. Is the patient capable of understanding consequences of treatments? 3. Prior preferences such as an advanced directive. QUALITY OF LIFE Beneficence, Nonmaleficence, and Respect for Patient Autonomy: 1. Prospects for return to normal life. 2. Possible personal prejudices about QOL. CONTEXTUAL FEATURES Loyalty and Fairness: 1. Are there any conflicts of interest. 2. Are there any religious considerations? 3. Are there other interested parties? 4. Are there institutional pressures? 5. Are there questions of allocation of resources? SUZIE S SITUATION 47 year old single woman admitted to hospice upon discharge from the hospital for pain and symptom management. She had advanced ovarian cancer and was s/p pelvic exenteration, colostomy, ileostomy, ureterostomy, and with an intrathecal opioid pump in place. She had been hospitalized for bleeding from a fungating lesion of the vagina, receiving transfusions, surgical and palliative consultations. On admission her PPS was 40%, dependent for 5/6 ADLs, oriented to time, place and person, and having constant pain of about 4/10 despite oral and intrathecal opioids. Shortly after admission her intrathecal pump became infected and had to be removed, leaving her with only IV and PO routes of medication. She was highly tolerant of opioids and required steadily increasing doses. Despite that she was in such pain that she refused to be moved, even for hygiene. She developed massive stage 4 wounds that became infected and necrotic. 7

8 9/5/2012 BEGINNING THE PROCESS o A decision to initiate palliative sedation must be preceded by a comprehensive interdisciplinary team assessment of the patient and a discussion of treatment expectations and options. 8

9 9/5/2012 TIMELINE MONTH 1 10/08/11 Admitted to hospice. Full Code. Pain 4-5 Goal 2. PPS 40% 10/10/11 Initial MSW visit discussed self-determined life goals. Hospice Chaplain declined by pt. 10/14/11 PO Dilaudid increased from 8mg to 16mg every 1-2 hours for pain. 10/26/11 She has episodes of either severe sweating or clear anal discharge. 10/28/11 Giant seroma around implanted pump. Explosive drainage when pressed by MD. 11/02/11 Staph aureus in wound. Doxycycline started. Dressing changes 3-4 /QD. Pain increasing TIMELINE MONTH 2 11/11/11 Significant emesis 3x bile-colored. Unable to tolerate PO meds. Haldol not effective for nausea. IV Dilaudid started, IV Compazine Q 4 hours. Discussion re: need for hospitalization i to remove infected pump. 11/15/11 Surgeon recommends taking pump out ASAP 11/16/11 POLST completed to remain full code during hospitalization 11/17-18/1118/11 Admitted d to hospital- Intrathecal pump removed, wound vac placed 11/21/11 NP discussion with patient s mother and sister regarding patient s status and s/s of actively dying. 11/29/11 Now open to chaplain visits Not her time yet 9

10 9/5/2012 TIMELINE MONTH 3 12/07/11 Chaplain confession session 12/15/11 Patient transitioning from healing to reality of decline, hoping to make it to Christmas 12/22/11 Mother inquired about patient s fear of dying 12/27/11 Flat on back for two weeks, heavy foul odor from infected wound, unbearable pain (9-10), talked with Mom about dying 12/28/11 DNR signed, tired of fighting, worried about parents coping after her death. ORAL MORPHINE EQUIVALENT/ / DAY MILLIGRAMS ALL OPIOIDS PRIOR TO PALLIATIVE SEDATION 10

11 9/5/2012 FOUR BOX METHOD (SUZIE) - J ONSEN ONSEN,, A.R. ET.AL. MEDICAL INDICATIONS Beneficence and Non-maleficence: 1. Ovarian cancer s/p pelvic li exenteration 2. Necrosis of entire backside 3. Constant pain unable to be moved 4. Tolerant of opioids 5. Failed intrathecal pump PATIENT PREFERENCES Respect for Patient Autonomy: 1. Ahi Achieve pain relief lif 2. Achieve a natural death 3. Wake up in the arms of Jesus 4. Ready to go NOW! QUALITY OF LIFE Beneficence, Non-maleficence, and Respect for Patient Autonomy: 1. Immobile 2. No chance of cure, absent miracle 3. Odor 4. Family burden of care CONTEXTUAL FEATURES Loyalty and Fairness: 1. Spiritual preparation 2. Family support 3. Availability of Palliative Sedation protocol 4. Hospice team prepared FIRST COURSE OF ACTION o The patient maintains a DNR, full No-code status and a physician s s order o The patient, or if lacking capacity, the patient s representative, family, physician, hospice medical director, and interdisciplinary team collaborate regarding the appropriate utilization of palliative sedation. 11

12 9/5/2012 AUTHORIZED DETAILS o Informed consent is obtained from the patient, or, if lacking capacity, the pt.'s designated representative. o A discussion of the risks and benefits of palliative sedation will be part of the informed consent process. o The written consent for palliative sedation will be ordered by the physician. Informed Consent/Palliative Sedation Program Goals: Provide relief for suffering unrelieved by other measures. Documentation of suffering unrelieved by other measures: Palliative measures previously attempted and outcome: PATIENT HEALTH CARE PROXY/PATIENT REPRESENTATIVE (check one) ( ) Able to respond intelligibly to queries ( ) Able to participate rationally in decision-making ( ) Able to articulate the decision Information Presented: ( ) Nature and progress of stage of terminal illness (prognosis) ( ) Verified DNR status and expected outcome from proposed Palliative Sedation ( ) Effects limitation, side effects, and risks of the proposed Palliative Sedation ( ) I am aware that Dr. agrees with the plan to initiate Palliative Sedation. With knowledge of the risks discussed by the physician(s), I consent to Palliative Sedation for refractory suffering. Date Patient or Authorized Representative Signature Relationship Date Physician Signature Patient Name: Clinical Record # 12

13 9/5/2012 MANAGING AT THE ONSET o For sedation that is instituted in a patient s home, continuous care registered nursing must be provided for at least 24 hours. o In all cases of palliative sedation at any location, the hospice physician will be present during the initiation of sedation AND A registered nurse will assess the patient continuously during the initiation of therapy ESSENTIAL SPECIFICS o Continuous Care staffing availability o Establish IV access o Foley consideration o Daily MD/NP visits o MSW/Chaplain visits to support caregivers o Adequate supply of medications~weekend and weekdays o Verbal reports between triage nurses and nurse at bedside o Documentation~ RN shift summary in clinical notes o Notify Bereavement of initiation of PS o Debrief Meeting 13

14 9/5/2012 Palliative Sedation Checklist RN Visit / Notify hospice physician / Conventional treatment attempted Aggressive measures fail to provide relief Care Team including MD, Chaplain, MSW, RNCM meet to discuss optional PS Interdisciplinary Team and Hospice MD joint visit to discuss palliative sedation, discuss plan of care, risk and benefits Physician to fully assess previous drug history Notify primary physician (if any) that palliative sedation is considered Hospice MD to collaborate with a second Hospice physician regarding use of palliative sedation CORE IDG (including entire Care Team) Managers verify staffing availability Patient or DPOA agree to palliative sedation/consent form signed Signed DNR verified / Verify copy of power of attorney (if available) Establish IV access, PICC line preferred Insert Foley catheter Palliative sedation to be implemented at home or facility/crisis care with RN staffing for 24 hours minimum (If in a facility, discuss financial responsibility with patient/family) Daily Physician Visits Review efficacy and goals of treatment as part of physician visit MSW and Chaplain visits as needed to support caregivers PALLIATIVE SEDATION MEDICATIONS 14

15 9/5/2012 TIMELINE MONTH 4 01/04/12 NP talked with patient and Mom about palliative sedation related to pain, offered to abstain from food and fluids, but this was not acceptable alternative to patient 01/06/12 Core IDG meeting, interdisciplinary agreement to support patient decision for PS 01/09/12 3 rd day of PS, has awakened twice. Dilaudid now at 50 mg/hr with Ativan 35 mg/hr, after Versed ran out at all pharmacies 01/11/12 Helicopter flyover and the family went outside to see them and returned to find patient had died. Chaplain condolence calls. 01/27/12 Debriefing Oral Morphine Equivalent/ Day Milligrams All Opioids /8/11 10/26/11 11/18/11 12/3/11 12/23/11 12/27/11 1/2/12 1/5/12 1/6/12 1/7/12 1/8/12 1/9/12 1/10/12 1/11/12 15

16 9/5/2012 SUZIE S ESCORT TO HEAVEN LESSONS LEARNED - DEBRIEF o Checklist is essential ~ following the steps may vary o Do not promise that the patient will not wake up o Schedule Debrief Meeting soon after case ends ~ edit checklist based on findings from this meeting o Be flexible o IDT input by everyone is essential for success o Daily communication between IDT and afterhours staff important ~ staff emotions can run high o Broaden the spectrum of medications. o Realize there is a continuum of healing 16

17 9/5/2012 RESOURCES o AAPHM~Position Statements. Statement on Palliative Sedation, html o NHPCO Policy statement on Palliative Sedation o EPERC~Fast Facts and Concepts: Salacz M, Weissman D. Controlled sedation for refractory suffering. Fast Facts #106 and o HPNA Position statement paper on palliative sedation. J of HPN, Vol 5, No. 4, October-December, 2003 and revised March 2008 o AMA Oks palliative sedation for terminally ill. July 7, 2008 o o Albert R. Jonsen, Mark Siegler, and William J. Winslade, Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 4th edition. New York: McGraw-Hill, Inc., Hospice and Palliative Care Formulary USA, Palliativedrugs.com, Nottingham UK, 2006; Drug Protocol for Palliative Sedation QUESTIONS? 17

18 9/5/ W. CREST STREET ESCONDIDO, CA (760) SERVING OUR COMMUNITIES AS A NOT-FOR-PROFIT SINCE

19 Informed Consent/Palliative Sedation Program Goals: Provide relief for suffering unrelieved by other measures. Documentation of suffering unrelieved by other measures: Palliative measures previously attempted and outcome: PATIENT HEALTH CARE PROXY/PATIENT REPRESENTATIVE (check one) ( ) Able to respond intelligibly to queries ( ) Able to participate rationally in decision-making ( ) Able to articulate the decision Information Presented: ( ) Nature and progress of stage of terminal illness (prognosis) ( ) Verified DNR status and expected outcome from proposed Palliative Sedation ( ) Effects limitation, side effects, and risks of the proposed Palliative Sedation ( ) I am aware that Dr. agrees with the plan to initiate Palliative Sedation. With knowledge of the risks discussed by the physician(s), I consent to Palliative Sedation for refractory suffering. Date Patient or Authorized Representative Signature Relationship Date Physician Signature Patient Name: Clinical Record # T:\Forms\Master Documents\Informed Consent - Palliative Sedation RV.doc

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30 Palliative Sedation Checklist RN Visit Notify Hospice physician Conventional treatment attempted Aggressive measures fail to provide relief Care Team including MD, Chaplain, MSW, RNCM meet to discuss optional PS Interdisciplinary Team and Hospice MD joint visit to discuss palliative sedation, discuss plan of care, risk and benefits Physician to fully assess previous drug history Notify primary physician (if any) that palliative sedation is considered Hospice MD to collaborate with a second Hospice physician regarding use of palliative sedation CORE IDG (including entire Care Team) Managers verify staffing availability Patient or DPOA agree to palliative sedation/consent form signed Signed DNR verified / Verify copy of power of attorney (if available) Establish IV access, PICC line preferred Insert Foley catheter Palliative sedation to be implemented at home or facility/crisis care with RN staffing for 24 hours minimum (If in a facility, discuss financial responsibility with patient/family) Daily Physician Visits Review efficacy and goals of treatment as part of physician visit MSW and Chaplain visits as needed to support caregivers Daily verbal report between Triage RNs and CC RNs Adequate medication supply over the weekend Notify Bereavement Department of initiation of PS case Refer to Standards of Practice for Palliative Sedation 08/27/12

31 Palliative Sedation Medications Anxiolytic Antipsychotic +/- +/- Analgesic Midazolam 1-5 mg load IV/SC then mg/hr IV/SC Haloperidol 1 mg bolus IV/SC then mg/hr IV/SC Morphine 1-5 mg/hr IV/SC titrate to effect* or or or Hydromorphone mg/hr IV/SC titrate to effect* Lorazepam mg/hr IV/SC Zaprisadone (Geodon) 5-10 mg IM q 2-4 h *No maximum dose unless patient experiences opioid toxicity not controlled by adjuvants Goal is relief of refractory symptoms of terminal agitation, resistant delirium, nausea/vomiting, pain or respiratory distress. Sedation for agitation or delirium may be reversed if inciting factors mitigated. Sedation for pain or respiratory distress is usually disease related and not reversible. Parenteral access is preferred for reliability and predictability of medication dosing. Low flow pumps are preferable and medication concentrations may need to be increased to avoid over hydration If the patient is also delirious and not calmed with anxiolytics a phenothiazine may be added. If atropine/hyoscyamine/scopolamine/glycopyrrolate are anticipated for tracheal secretions they should be initiated as soon as tracheal rattle is detected. Source: Hospice and Palliative Care Formulary USA, Palliativedrugs.com, Nottingham UK, 2006; Drug Protocol for Palliative Sedation 1/13/10

32 Cat#: PC-129 Effective Date: 08/2010 Reviewed/Revised: 08/2010 Palliative Sedation Purpose: The purpose of palliative sedation is to relieve suffering from refractory symptoms, but not to hasten death. The intent is the relief of unendurable suffering and not to end the patient s life. Background: A refractory symptom is one that cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness. Whenever a patient experiences refractory symptoms, palliative sedation may be considered as an intervention to control unendurable suffering. It may be initiated in a clinical setting or the patient s home. Procedure: 1. Whenever a patient experiences refractory symptoms, and all conventional treatments have been exhausted and fail to provide relief, palliative sedation may be considered as an intervention to control unendurable suffering. It may be initiated in a clinical setting or the patient s home. 2. The patient maintains a DNR, FULL NO CODE physician s order 3. Sedation need not be requested by the patient and family, but can be suggested by hospice staff as part of the care plan. This procedure is flexible enough to allow for staff to respond to a crisis change in patient s symptoms on a 24-hour basis. 4. If a staff member feels palliative sedation should be considered, an RN assessment followed by a physician consult should take place prior to discussing with the patient. 5. The decision to initiate palliative sedation must be preceded by a comprehensive interdisciplinary team assessment of the patient and a discussion of treatment expectations and options. 6. All members of the team are essential to the discussion and provision of palliative sedation. A joint visit by the core care team and the hospice physician should occur to discuss the plan of care, risks and benefits. 7. Review by the interdisciplinary team is required to assure the following criteria have been met: A. Presence of a terminal diagnosis B. A do-not-resuscitate (DNR) order C. Verify copy of DPOA (if available) D. Assessment by hospice physician of previous drug history PC-129/Page 1 of 3

33 E. Exhaustion of all palliative treatments, including treatment for depression, anxiety, delirium, and familial discord F. Assessment for spiritual issues by a chaplain or clergy member. 8. The patient s primary care/attending physician, if any, is informed of the decision to initiate palliative sedation. A consultation with a second hospice certified physician must occur and both must agree on the decision to implement palliative sedation. 9. In addition, a CORE IDG discussion is required. Regional managers verify staffing availability. 10. Informed consent is obtained from the patient, or, if lacking capacity, the patient s designated representative. A discussion of the risks and benefits of palliative sedation will be part of the informed consent process. The written consent for palliative sedation will be obtained by the physician. 11. IV access via PICC line is preferred, if possible. Foley catheter inserted to avoid patient arousal to void. 12. With the initiation of palliative sedation, continuous care registered nursing must be provided for at least 24 hours. A registered nurse will assess the patient closely during the initiation of therapy until the medication(s) is titrated to the desired effect. The registered nurse will monitor and collaborate with the hospice physician for any adverse effect, or change in dosing. Ongoing monitoring will be determined according to the clinical needs of the patient. 13. If patient resides in a facility, financial responsibility for room and board to be clarified with patient/family. 14. Once the patient is sedated, medications are titrated per physician s order. The goal of palliative sedation is to relieve symptoms by decreasing the level of consciousness. The eyelash reflex is used to assess level of sedation. A soft tactile stroke over a closed eyelid should cause a reduced flicker/reflex in a first stage anesthesia. A lack of flicker (reflex) indicates deep sedation. 15. RN to assure a sufficient supply of medications are present in the home to manage symptoms through the weekend, including boluses and potential increases of the basal rate. 16. Decrease in sedatives will be considered if the patient experiences heavy snoring unusual to baseline or abrupt onset of apnea. Gradual deterioration of respirations is expected in terminal patients and should not alone constitute a reason to decrease sedation. 17. Hospice providers will provide education regarding hydration and nutrition as a separate intervention with the patient and family/dpoa. 18. Sedation will not be attempted solely by increasing opioid dosages, however, opioids will be continued in order to ensure pain management and to prevent opioid withdrawal. 19. Daily physician visits will be made to review the efficacy and goals of the treatment plan. 20. MSW and Chaplain visits as needed to support caregivers should be provided. PC-129/Page 2 of 3

34 21. A debriefing session will be scheduled following the conclusion of the treatment. Reference: Medicare CoP: n/a State Licensure: n/a Palliative Sedation, Maureen Lynch, Clinical Journal of Oncology Nursing, Vol. 7, No. 6, Nov/Dec 2003 Palliative Sedation in End-of-Life Care, Journal of Hospice and Palliative Nursing, Vol. 8, No. 6, Nov/Dec 2006 Palliative Sedation in the Management of Refractory Symptoms, Rousseau, P. J of Supp Onc. Vol. 2, no.2, March/April PC-129/Page 3 of 3

35 Informed Consent/Palliative Sedation Program Goals: Provide relief for suffering unrelieved by other measures. Documentation of suffering unrelieved by other measures: Palliative measures previously attempted and outcome: PATIENT HEALTH CARE PROXY/PATIENT REPRESENTATIVE (check one) ( ) Able to respond intelligibly to queries ( ) Able to participate rationally in decision-making ( ) Able to articulate the decision Information Presented: ( ) Nature and progress of stage of terminal illness (prognosis) ( ) Verified DNR status and expected outcome from proposed Palliative Sedation ( ) Effects limitation, side effects, and risks of the proposed Palliative Sedation ( ) I am aware that Dr. agrees with the plan to initiate Palliative Sedation. With knowledge of the risks discussed by the physician(s), I consent to Palliative Sedation for refractory suffering. Date Patient or Authorized Representative Signature Relationship Date Physician Signature Patient Name: Clinical Record # T:\Forms\Master Documents\Informed Consent - Palliative Sedation RV.doc

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46 Palliative Sedation Checklist RN Visit Notify Hospice physician Conventional treatment attempted Aggressive measures fail to provide relief Care Team including MD, Chaplain, MSW, RNCM meet to discuss optional PS Interdisciplinary Team and Hospice MD joint visit to discuss palliative sedation, discuss plan of care, risk and benefits Physician to fully assess previous drug history Notify primary physician (if any) that palliative sedation is considered Hospice MD to collaborate with a second Hospice physician regarding use of palliative sedation CORE IDG (including entire Care Team) Managers verify staffing availability Patient or DPOA agree to palliative sedation/consent form signed Signed DNR verified / Verify copy of power of attorney (if available) Establish IV access, PICC line preferred Insert Foley catheter Palliative sedation to be implemented at home or facility/crisis care with RN staffing for 24 hours minimum (If in a facility, discuss financial responsibility with patient/family) Daily Physician Visits Review efficacy and goals of treatment as part of physician visit MSW and Chaplain visits as needed to support caregivers Daily verbal report between Triage RNs and CC RNs Adequate medication supply over the weekend Notify Bereavement Department of initiation of PS case Refer to Standards of Practice for Palliative Sedation 08/27/12

47 Palliative Sedation Medications Anxiolytic Antipsychotic +/- +/- Analgesic Midazolam 1-5 mg load IV/SC then mg/hr IV/SC Haloperidol 1 mg bolus IV/SC then mg/hr IV/SC Morphine 1-5 mg/hr IV/SC titrate to effect* or or or Hydromorphone mg/hr IV/SC titrate to effect* Lorazepam mg/hr IV/SC Zaprisadone (Geodon) 5-10 mg IM q 2-4 h *No maximum dose unless patient experiences opioid toxicity not controlled by adjuvants Goal is relief of refractory symptoms of terminal agitation, resistant delirium, nausea/vomiting, pain or respiratory distress. Sedation for agitation or delirium may be reversed if inciting factors mitigated. Sedation for pain or respiratory distress is usually disease related and not reversible. Parenteral access is preferred for reliability and predictability of medication dosing. Low flow pumps are preferable and medication concentrations may need to be increased to avoid over hydration If the patient is also delirious and not calmed with anxiolytics a phenothiazine may be added. If atropine/hyoscyamine/scopolamine/glycopyrrolate are anticipated for tracheal secretions they should be initiated as soon as tracheal rattle is detected. Source: Hospice and Palliative Care Formulary USA, Palliativedrugs.com, Nottingham UK, 2006; Drug Protocol for Palliative Sedation 1/13/10

48 Cat#: PC-129 Effective Date: 08/2010 Reviewed/Revised: 08/2010 Palliative Sedation Purpose: The purpose of palliative sedation is to relieve suffering from refractory symptoms, but not to hasten death. The intent is the relief of unendurable suffering and not to end the patient s life. Background: A refractory symptom is one that cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness. Whenever a patient experiences refractory symptoms, palliative sedation may be considered as an intervention to control unendurable suffering. It may be initiated in a clinical setting or the patient s home. Procedure: 1. Whenever a patient experiences refractory symptoms, and all conventional treatments have been exhausted and fail to provide relief, palliative sedation may be considered as an intervention to control unendurable suffering. It may be initiated in a clinical setting or the patient s home. 2. The patient maintains a DNR, FULL NO CODE physician s order 3. Sedation need not be requested by the patient and family, but can be suggested by hospice staff as part of the care plan. This procedure is flexible enough to allow for staff to respond to a crisis change in patient s symptoms on a 24-hour basis. 4. If a staff member feels palliative sedation should be considered, an RN assessment followed by a physician consult should take place prior to discussing with the patient. 5. The decision to initiate palliative sedation must be preceded by a comprehensive interdisciplinary team assessment of the patient and a discussion of treatment expectations and options. 6. All members of the team are essential to the discussion and provision of palliative sedation. A joint visit by the core care team and the hospice physician should occur to discuss the plan of care, risks and benefits. 7. Review by the interdisciplinary team is required to assure the following criteria have been met: A. Presence of a terminal diagnosis B. A do-not-resuscitate (DNR) order C. Verify copy of DPOA (if available) D. Assessment by hospice physician of previous drug history PC-129/Page 1 of 3

49 E. Exhaustion of all palliative treatments, including treatment for depression, anxiety, delirium, and familial discord F. Assessment for spiritual issues by a chaplain or clergy member. 8. The patient s primary care/attending physician, if any, is informed of the decision to initiate palliative sedation. A consultation with a second hospice certified physician must occur and both must agree on the decision to implement palliative sedation. 9. In addition, a CORE IDG discussion is required. Regional managers verify staffing availability. 10. Informed consent is obtained from the patient, or, if lacking capacity, the patient s designated representative. A discussion of the risks and benefits of palliative sedation will be part of the informed consent process. The written consent for palliative sedation will be obtained by the physician. 11. IV access via PICC line is preferred, if possible. Foley catheter inserted to avoid patient arousal to void. 12. With the initiation of palliative sedation, continuous care registered nursing must be provided for at least 24 hours. A registered nurse will assess the patient closely during the initiation of therapy until the medication(s) is titrated to the desired effect. The registered nurse will monitor and collaborate with the hospice physician for any adverse effect, or change in dosing. Ongoing monitoring will be determined according to the clinical needs of the patient. 13. If patient resides in a facility, financial responsibility for room and board to be clarified with patient/family. 14. Once the patient is sedated, medications are titrated per physician s order. The goal of palliative sedation is to relieve symptoms by decreasing the level of consciousness. The eyelash reflex is used to assess level of sedation. A soft tactile stroke over a closed eyelid should cause a reduced flicker/reflex in a first stage anesthesia. A lack of flicker (reflex) indicates deep sedation. 15. RN to assure a sufficient supply of medications are present in the home to manage symptoms through the weekend, including boluses and potential increases of the basal rate. 16. Decrease in sedatives will be considered if the patient experiences heavy snoring unusual to baseline or abrupt onset of apnea. Gradual deterioration of respirations is expected in terminal patients and should not alone constitute a reason to decrease sedation. 17. Hospice providers will provide education regarding hydration and nutrition as a separate intervention with the patient and family/dpoa. 18. Sedation will not be attempted solely by increasing opioid dosages, however, opioids will be continued in order to ensure pain management and to prevent opioid withdrawal. 19. Daily physician visits will be made to review the efficacy and goals of the treatment plan. 20. MSW and Chaplain visits as needed to support caregivers should be provided. PC-129/Page 2 of 3

50 21. A debriefing session will be scheduled following the conclusion of the treatment. Reference: Medicare CoP: n/a State Licensure: n/a Palliative Sedation, Maureen Lynch, Clinical Journal of Oncology Nursing, Vol. 7, No. 6, Nov/Dec 2003 Palliative Sedation in End-of-Life Care, Journal of Hospice and Palliative Nursing, Vol. 8, No. 6, Nov/Dec 2006 Palliative Sedation in the Management of Refractory Symptoms, Rousseau, P. J of Supp Onc. Vol. 2, no.2, March/April PC-129/Page 3 of 3