end of life best practice guidelines HPC hpcconnection.ca interdisciplinary suffering collaborative Palliative Sedation Therapy sedation agitation

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1 HPC family hpcconnection.ca consensus end of life collaborative agitation best practice guidelines support interdisciplinary criteria dignity ethical decision making sedation documentation standards suffering expert consultation Palliative Sedation Therapy quality of life refractory symptoms Waterloo Wellington HPC Protocol clinical support The Waterloo Wellington Palliative Sedation Protocol A Case Based Review of the WW PST Protocol Education Facilitation Guide

2 Printed in Canada, March

3 This education facilitation guide is intended as a resource to accompany the PowerPoint: Palliative Sedation Therapy: A Case-based Panel Review of the Waterloo Wellington Protocol. The facilitation guide and PowerPoint were designed as educational components to the. Slide 2: Title Slide On behalf of the Waterloo Wellington Interdisciplinary Palliative Education Committee, this PowerPoint Presentation has been revised to support the adoption and implementation of the WW Palliative Sedation Protocol. It is recommended that this education be supported with the following documents: 1 The WW Palliative Sedation Protocol 2 The PST Criteria Handout 3 The Richmond Agitation Sedation Scale Handout Palliative Sedation Therapy A case-based panel review of the Waterloo Wellington Protocol Revised and Adapted from PST Launch December, 2014 The waterloo wellington interdisciplinary palliative education committee Slide 3: Purpose of the PST Protocol There are many issues related to end of life care that are appearing in the media: Bill 52 in Quebec Dr. Donald Low and the dying with dignity movement Purpose of the PST Protocol To provide clinicians in the Waterloo Wellington region with an approach to PST that has been reviewed by peers with experience in this area. To be used as an aide in clinical practice and to clarify the purpose, key definitions, and process of PST To ensure effective, safe and appropriate use of PST To open dialogue and promote communication 3 Education Facilitation Guide 3

4 Slide 4: Contents of the PST Protocol Please turn to the table of contents. We will review many of the items listed above However, we do want to draw your attention to Appendix B. This outlines the extensive consensus process that was followed in order to finalize the document. Contents of the PST Protocol Purpose and Definitions Indications for Use and Criteria for Initiation Process and Documentation Medications Monitoring How Can Family and the Clinical Team be supported 4 Slide 5: Case 1 Review Slide contents Case 1 Susan is a 54 yo woman with end-stage COPD. She has been admitted to hospital with pain all over. Her Bayshore nurse had noted increased anxiety and hopelessness in past week. Susan says she is tired of being sick and exhausted, and wants to be put to sleep. She is angry that terminal sedation hasn t been offered. Adapted from cases.pallimed.org/2008/11/palliative-sedation-therapy.html 5 Slide 6: Case 1 continued Review Slide contents Case 1 Susan lives with her spouse and adult children, all who work full-time. Susan experiences dyspnea with activity but is able to transfer independently to commode or wheelchair. She is alert with no evidence of confusion. She is not suicidal. She is cachectic and tachypnic. Her prognosis is estimated in months. She takes medication erratically for symptom control. 6 4

5 Slide 7: Questions for Case 1 What is palliative sedation therapy? - answer directly from/draw reference to the protocol PST is defined in the protocol on page 5 (read the first paragraph) It is important to highlight what is NOT PST as outlined as well on page 5 (read list) Emphasize nursing perspective struggle with what is and is not PST having a protocol and being familiar with it will help support these tough questions that we face. We need to be able to as a nurse advocate for patients/families as well as help educate patients/families. Slide 8: Questions for Case 1 continued Does Susan meet the indications and criteria for palliative sedation? Consider: The indications and criteria are outlined in detail on pages 6 7 of the protocol We will use next slide to walk everyone through this answer Slide 9: PST Criteria This slide summarizes the criteria in what is hopefully and easy way to walk through the decision making process. It is important to first determine if the patient finds the symptom unbearable or intolerable Intolerable suffering has been defined as a sense of helplessness or loss in the face of a seemingly relentless and unendurable threat to quality of life or integrity of self QUESTIONS FOR CASE 1 What is palliative sedation therapy? QUESTIONS FOR CASE 1 What is palliative sedation therapy? Dose Susan meet the indications and criteria for palliative sedation? 7 8 It is important to review the values and wishes of the patients and reflect on exactly who finds the symptoms intolerable patient versus family Susan is asking for terminal sedation and thus one can assume the answer is YES Reflect on whether or not the patient is near the end of life Susan s prognosis is felt to be a matter of months and thus technically she would not meet the criteria Let s go through the rest of the questions anyway Assuming Susan is near the end of life the next question we would ask then is Is this symptom refractory? Refractory symptoms are also defined on page 5 but issues to address are summarized on this slide Susan is experiencing dyspnea, anxiety and hopelessness There is likely much more we can do to alleviate symptoms before considering them refractory Thus, once again Susan does not meet the criteria for PST It is helpful to take advantage of palliative expertise when contemplating this issue, even if it is just a phone call to ensure no other ideas come to mind PST Criteria Is symptom intolerable for patient? Consider impact on quality of life, suffering, demoralization, lack of dignity Consider patient goals, hopes, wishes, plans in light of symptom Is patient near end of life (days to weeks)? Is symptom refractory?* Are further treatment options available? Can treatment be given without unacceptable side effects? Can treatment be given in an acceptable care setting? Will treatment be effective within an acceptable time frame? (*a symptom is considered refractory if the answer is no to any one of the above questions) Non-controversial indications include intractable dyspnea, delirium, seizure, pain, nausea. Controversial indications include existential/spiritual suffering, psychological suffering) Criteria are met for consideration of PST 9 Education Facilitation Guide 5

6 Slide 10: Questions for Case 1 continued What should we do for Susan? Optimize medical management of dyspnea and pain She isn t taking regular around the clock or long acting meds Address reason behind taking meds sporadically Address hopelessness and anxiety Acknowledge her request for terminal sedation and review criteria Take this as an opportunity to provide education to the patient and open dialogue on other issues related to end of life care QUESTIONS FOR CASE 1 What is palliative sedation therapy? Dose Susan meet the criteria for palliative sedation? What should we do for Susan? 10 Slide 11: Case 1 Outcome Ongoing review of this plan is crucial f/u, f/u, f/u (follow up) Case 1 - Outcome A family meeting is held where Susan expresses her frustration that no one can stay at home with her during the day. The request for terminal sedation is acknowledged and the PST process is explained Susan is informed that her symptoms can be treated more effectively Around the clock opioids are initiated instead of as needed for relief of dyspnea and pain and a comprehensive plan is put in place for her anxiety, depression and sense of isolation 11 Slide 12: Case 2 Review Slide contents Case 2 Sarosh is 30 years old with a diagnosis of end-stage osteosarcoma and has exhausted all treatment options He has been battling severe pain and dyspnea and has made use of aggressive opioid and adjuvant therapies along with attempts at management with interventional pain techniques Sarosh has severe myoclonus refractory to standard therapy and ongoing poorly controlled pain 12 6

7 Slide 13: Case 2 continued Review Slide contents Case 2 Sarosh is groggy from medication and while pain improves with increasing narcotics the myoclonus continues to get worse Sarosh s PPS is 20% to 30% and his prognosis has been estimated to be days to a couple of weeks Sarosh is able to articulate the severity of his pain and physical signs of poorly controlled pain are visible when attempting personal care Sarosh is currently at a residential hospice and is well supported by his immediate family and numerous friends 13 Slide 14: Case 2 Questions Does Sarosh meet the criteria for PST? Go through next slide Case 2 - Questions Does Sarosh meet the criteria for PST? 14 Slide 15: PST Criteria It is important to first determine if the patient finds the symptom unbearable/intolerable Sarosh is experiencing uncontrolled pain; we would need to ask the question but for the sake of brevity will assume the answer is YES--- Reflect on whether or not the patient is near the end of life Sarosh s prognosis is estimated to be a matter of days to weeks so YES Is this symptom refractory? Based on the case description and for the sake of time we will assume that all treatment options have been explored However in general, it is recommended as part of the process that palliative physician/interdisciplinary team member consultation be explored to help ensure there are not any other feasible treatment options Sarosh is also experiencing unacceptable side-effects with myoclonus Thus he would meet the criteria for having a refractory symptoms PST Criteria Is symptom intolerable for patient? Consider impact on quality of life, suffering, demoralization, lack of dignity Consider patient goals, hopes, wishes, plans in light of symptom Is patient near end of life (days to weeks)? Is symptom refractory?* Are further treatment options available? Can the treatment be given without unacceptable side effects? Can treatment be given in an acceptable care setting? Will treatment be effective within an acceptable time frame? (*a symptom is considered refractory if the answer is no to any one of the above questions) Non-controversial indications include intractable dyspnea, delirium, seizure, pain, nausea. Controversial indications include existential/spiritual suffering, psychological suffering) Criteria are met for consideration of PST 15 Education Facilitation Guide 7

8 Slide 16: Case 2 Questions The process and documentation pieces are outlined on page 7 of the protocol We will use the next slide to summarize this and answer the questions Slide 17: PST Criteria As already mentioned, it is crucial to take advantage of expertise from colleagues to help finalize a determination that criteria are met It would actually be helpful to then re-evaluate patients medication list and be prepared with treatment plan that can be discussed at family meeting Hold a family meeting and include members of the health care team that will be involved Case 2 - Questions Does Sarosh meet the criteria for PST? How would you finalize a decision to pursue PST? What documentation would be involved prior to initiation of PST? 16 Sarosh has not requested sedation and thus the conversation will really need to reflect on patients values and wishes It is especially important to ensure cultural aspects are addressed It will be important to help patient/family understand the goal would be CONTINUOUS SEDATION but PROPORTIONAL to the relief of the refractory symptom A plan of care could potentially include an attempt to decrease sedation at some point if it seems to make sense Discussion about managing hydration, oral, eye, skin care is important Documentation as outlined in the slide. Emphasize that this is not meant to be an essay and the note can be brief but careful attention should be made to ensure that there is informed consent, that the intent of sedation is to relieve suffering and a plan of action is I place Further documentation issues will arise when we discuss monitoring PST Process Consider palliative expertise consultation to ensure no other options then. Evaluate patient s medication list and decide on medications that may be used then. Hold a family meeting with interdisciplinary team members to establish Patient s goals of care including resuscitation wishes Clear understanding of the risks, benefits and process of PST and alternate options Informed consent Management of nutrition and hydration, oral, eye, skin care Timing of initiation and how (subcutaneous continuous infusion, stopping unnecessary meds) Expected changes in LOC, respiratory patterns, sounds and ongoing monitoring then Document PST criteria, decision making process, details of family meeting and medications to be administered and plan for ongoing monitoring 17 Slide 18: Case 2 Questions continued What medication would you use? For the sake of simplicity, let s assume Sarosh is on a fentanyl patch and pump for pain control. The amount isn t important per se but the important teaching point is that we need to carry on with his pain meds - these don t get stopped. Another teaching point is stopping all oral medications and changing anything essential to subcutaneous delivery if possible. The medication choices are outlined in the document on pages 7 to 8 Briefly summarize first line vs subsequent lines of treatment options emphasize that opioids should not be used for PST (i.e. don t just keep increasing the narcotics) Pharmacy input beforehand is always helpful Pharmacy input are there any reasons why you would choose one option from the protocol over another, I.e. drug interactions, personal experience/ comfort/availability Case 2 - Questions Does Sarosh meet the criteria for PST? How would you finalize a decision to pursue PST? What documentation would be involved prior to initiation of PST? What medication would you use? 18 8

9 Slide 19: Case 2 Questions continued What orders would you write? see next slide Case 2 - Questions Does Sarosh meet the criteria for PST? How would you finalize a decision to pursue PST? What documentation would be involved prior to initiation of PST? What medication would you use? What orders would you write? 19 Slide 20: Sample PST Orders While this is not our usual practice locally re hypodermoclysis some centres i.e. Edmonton will routinely start hypodermoclysis on patients who were taking in fluids prior to initiation of PST to ensure that cause of death is underlying illness and not dehydration due to PST.This is a point that should be raised so no one feels forced to not give fluids or vice versa etc. Sample PST Orders This is palliative sedation therapy DNR (if not already documented) Continue with (specify narcotic orders) Stop (meds to be discontinued) Midazolam 5mg subq stat then, start midazolam 1mg/hr subq infusion and may increase by 1mg/hr q30 minutes to achieve comfort Foley catheter PRN, routine bowel care, routine skin care Oral balance gel QID and prn Moisture drops to eyes BID and prn Hypodermoclysis normal saline 250 cc daily PRN 20 Slide 21: Case 2 Questions continued What monitoring would be involved? Monitoring part of protocol starts on page 9 A validated tool should be used to chart: level of sedation level of comfort airway patency/comfort Monitoring of vitals as indicated on a case-by case basis emphasize this issue and draw reference to the issue of monitoring respirations we know they are going to slow down it doesn t mean the patient is too sedated necessarily RASS is a good example go through next slide Case 2 - Questions Does Sarosh meet the criteria for PST? How would you finalize a decision to pursue PST? What documentation would be involved prior to initiation of PST? What medication would you use? What orders would you write? What monitoring would be involved? 21 Education Facilitation Guide 9

10 Slide 22: Richmond Agitation Sedation Scale The RASS is an example of a validated tool that can be used for monitoring A copy of this tool is found in the protocol under Appendix A Walk through the RASS Discuss the documentation piece associated with ongoing monitoring Emphasize the importance of communication with team members good documentation to facilitate smooth transition between staff at shift changes etc. 22 Emphasize the value of monitoring for family members. Consider family fears that we are just wanting to sedate someone to make our job easier Each time we monitor and document, it provides an opportunity to support family; thus talking with family should be an important part of the communication and monitoring piece The frequency of monitoring will likely vary dramatically based on location home, vs, hospice, versus hospital Slide 23: Case 2 Outcome Review Slide contents Case 2 Outcome Sarosh and family appreciate the thorough discussion and proceed with a plan for PST at home Sarosh is started on midazolam infusion and the dose is adjusted q15 minutes until a a comfortable level of sedation is reached and then is monitored q4h Sarosh passes away peacefully 48 hours after initiation of PST. 23 Slide 24: Case 3 Review Slide contents Case 3 Carson is a 70 yo man who has been diagnosed with ALS and is experiencing difficulty with muscle control/weakness and has required intermittent respiratory support A psychiatrist has determined that he is not clinically depressed and is able to understand and appreciate his current medical condition Carson fears that he has reached a point of impending loss of dignity. After receiving spiritual counseling and ongoing psychological support, Carson repeatedly asks for the right to die with dignity Adapted from PPT on PST 24 10

11 Slide 25: Case 3 Questions Let s walk through the next slide again to evaluate the situation Case 3 - Questions Does Carson meet the criteria for PST? Slide 26: PST Criteria Carson is asking repeatedly for the right to die with dignity, he thus demonstrated that he finds the symptoms/fear of symptom progression intolerable Is Carson near the end of life? This is not clearly outlined for us in the case description In ALS as in many other situations, esp. non-malignant diagnoses, prognostication is challenging Carson is not at present requiring the need for intubation/invasive resp support (just anticipating), so one could say NO However, for the purpose of discussion, let say that he does have a prognosis of days to weeks Is symptom refractory? Carson is experiencing physical symptoms with breathing/muscle control Assume episodes of aspiration/ respiratory distress to this point have been managed but with hospitalization, invasive measures If he no longer agrees to intubation, antibiotics etc. and just wants palliative respiratory symptoms to be managed with opioids and/or other medications, one could say his symptoms of dyspnea are not refractory at this point His sense of emotional distress and loss of dignity however would not be addressed with the use of opioids alone It is possible he is experiencing some existential suffering and thus we would really want to be careful to fully assess in this circumstance Answer could be different depending on clinician, comfort, resources, patient values and wishes PST Criteria Is symptom intolerable for patient? Consider impact on quality of life, suffering, demoralization, lack of dignity Consider patient goals, hopes, wishes, plans in light of symptom Is patient near end of life (days to weeks)? Is symptom refractory?* Are further treatment options available? Can the treatment be given without unacceptable side effects? Can treatment be given in an acceptable care setting? Will treatment be effective within an acceptable time frame? (*a symptom is considered refractory if the answer is no to any one of the above questions) Non-controversial indications include intractable dyspnea, delirium, seizure, pain, nausea. Controversial indications include existential/spiritual suffering, psychological suffering) Criteria are met for consideration of PST Slide 27: Case 3 Questions See next 3 slides Slide 30: Existential Suffering Please draw reference to the definition in the protocol, state that it can be found on page 5 Please be brief and highlight that this could be a CME topic all on its own. Case 3 - Questions Does Carson meet the criteria for PST? What is existential suffering? 27 Education Facilitation Guide 11

12 Slide 28: Existential Suffering Review slide contents Existential Suffering Existential Suffering: Angst or anguish Meaning, purpose and fulfillment Quality of living Concerns personhood (what makes me me ) Questions/statements that may arise: Why is this happening to me? What happens after I die? It s not death I fear but the dying part Will I be eternally dammed for the bad things I have done? 28 Slide 29: Existential Suffering Review slide contents Existential Suffering What is happening: Personal integrity is threatened Existential or spiritual suffering Inherently subjective, unique (Cassell) Manifestation: 4 core issues: death, isolation, freedom and meaning (Yalom) Could manifest in somatic, psychological and emotional ways Total Pain body, mind and spirit (Dame Saunders) Transcending suffering 29 Slide 30: Existential Suffering Review slide contents Existential Suffering Issues: Troubling for caregivers Suffering needs to be acknowledged and validated Empathic listening and staying with the person in their suffering References: Balfour Mount and Eric Flanders. Existential suffering and the determinants of healing. European Journal of Palliative Care, 2003, 10(2) Supplement. George P. Smith "Refractory Pain, Existential Suffering, and Palliative Care: Releasing an Unbearable Lightness of Being" Available at: Cassell EJ. The nature of suffering and the goals of medicine. N Eng J Med 1982; 306: Yalom ID. Existential Psychotherapy. NY: Basic Books,

13 Slide 31: Case 3 Questions What is the difference between euthanasia, physician assisted death and PST? Already defined PST at the beginning of this presentation: emphasize that goal is not to accelerate death and that studies have shown this to be true (situational dependent however) Euthanasia: an intentional termination of life by another at the explicit request of the person who wishes to die. Euthanasia is generally defined as the act of killing an incurably ill person out of concern and compassion for that person s suffering. PAD: physician supplies information and/or the means of committing suicide (e.g., a prescription for lethal dose of sleeping pills, or a supply of carbon monoxide gas) to a person, so that that individual can successfully terminate his or her own life. Case 3 - Questions Does Carson meet the criteria for PST? What is existential suffering? What is the difference between euthanasia, physician assisted death and PST? 31 Slide 32: Euthanasia and PAD QUICKLY go through these two definitions next slide to compare PST vs PAD Euthanasia and PAD Euthansia: an intentional termination of life by another at the explicit request of the person who wishes to die an act done out of concern and compassion for the person who is suffering Physician Assisted Death (PAD): a physician supplies information and/or the means of committing suicide to a person, so that the individual can successfully terminate his or her own life 32 Slide 33: PST vs PAD Review slide contents PST vs PAD PST PAD Intent Relieve suffering Accelerate death Cause of Death Underlying disease process Intervention prescribed by physician 33 Education Facilitation Guide 13

14 Slide 34: Case 3 Outcomes Review slide contents Case 3 - Outcome Carson s request for physician assisted death is discussed and its underlying meaning in the presence of his family Palliative Sedation Therapy is explained A plan is put in place not to pursue aggressive treatment when he develops another respiratory event and a treatment plan using morphine and midazolam is put in place to ensure rapid and adequate management of dyspnea and anxiety can be achieved, including a plan for PST should his dyspnea become refractory 34 Slide 35: Case 4 Review slide contents Case 4 Joan is 89 years old and was diagnosed with Alzheimer s disease five years ago She has severe osteoarthritis and multiple compression fractures contributing to her experience of chronic pain She resides in a LTC facility and her advance care plan includes a DNR with palliation alone Agitation has been progressive to the point she frequently strikes out and threatens staff Joan is no longer eating or drinking 35 Slide 36: Case 4 continued Review slide contents Case 4 Joan is often heard screaming and staff attribute much of her behaviour to poor pain control (assume no other contributing factors) Several different options are trialed for pain management over a period of weeks to months Family has become quite distressed as her agitation has only become worse with attempts to address her pain issues Medication for agitation is gradually increased and Joan becomes progressively more sedated from these measures and passes away 3 days later 36 14

15 Slide 37: Case 4 Questions Did Joan meet the criteria for PST? One more time, let s go through the list on the next slide Case 4 - Questions Did Joan meet the criteria for PST? 37 Slide 38: PST Criteria Getting Joan s pain under control had certainly been a challenge Joan s behaviour could indicate that she was experiencing symptoms that were intolerable to her Prognostically, If there has been a bit of time where Joan has not been eating or drinking then one could say a prognosis of less than 2 months is reasonable It is however challenging in patients dying of chronic disease to prognosticate well (difficult even in the cancer population) It is unclear whether or not all treatment options have been explored but it certainly has taken longer than what family would have perceived as an acceptable time frame to get symptoms under control Intractable delirium or pain are non-controversial indications for PST One could argue that assuming palliative expert consultation was explored to optimize pain management, that Joan symptoms were refractory Perhaps the setting of LTCH created barriers to alternative pain management options such as an infusion pump or monitoring sedation? PST Criteria Is symptom intolerable for patient? Consider impact on quality of life, suffering, demoralization, lack of dignity Consider patient goals, hopes, wishes, plans in light of symptom Is patient near end of life (days to weeks)? Is symptom refractory?* Are further treatment options available? Can the treatment be given without unacceptable side effects? Can treatment be given in an acceptable care setting? Will treatment be effective within an acceptable time frame? (*a symptom is considered refractory if the answer is no to any one of the above questions) Non-controversial indications include intractable dyspnea, delirium, seizure, pain, nausea. Controversial indications include existential/spiritual suffering, psychological suffering) Criteria are met for consideration of PST 38 Slide 39: Case 4 Questions Did Joan receive PST or simply side-effects from medication (double-effect)? There was no family meeting or documentation to define the management plan as PST However, the progressive increase in the use of medication for agitation (i.e. likely Methotrimiprazine or Nozinan), led to sedation The INTENT is crucial here the intent was to control the agitation and was not necessarily to sedate her There are however cases like this where because of poor communication with family members regarding these types of decisions has led to complaints It highlights that while in this case PST was not the intent, that having a conversation with family members about the potential consequences beforehand is always beneficial Case 4 - Questions Did Joan meet the criteria for PST? Did Joan receive PST or simply consequential sedation secondary to medication/ side-effects from medication (double-effect)? 39 Education Facilitation Guide 15

16 Slide 40: Case Summaries Through all of these case reviews, we hope you became familiarized with the contents of the protocol and the issues to consider when contemplating a decision to offer PST. Case Summaries Case 1: Susan with COPD too soon for consideration of PST Case 2: Sarosh with osteosarcoma PST was appropriate in this case Case 3 : Carson with ALS PST, PAD, Euthanasia and Existential issues Case 4: Joan with Dementia Understanding the nuances of when PST is being administered 40 Slide 41: Acknowledgments In development of the protocol, we would like to specially acknowledge these sources: Pallimed Case Conferences: cases.pallimed.org Mississauga Halton PST Sample Policy Education PPT Blair Henry, Bioethicist from Sunnybrook Hospital Acknowledgements Blair Henry Pallimed Case Conferences: cases.pallimed.org Mississauga Halton PST Sample Policy Education PPT 41 Slide 42: References References Alberta Health Services, Calgary Zone. (2009). CLINICAL PRACTICE GUIDELINE FOR: PALLIATIVE SEDATION. Calgary, Alberta: Author. Arevalo, J.J. et al. (2012). Palliative Sedation: Reliability and Validity of Sedation Scales. Journal of Pain and Symptom Management. 44(5) p Canadian Society of Palliative Care Physicians (CSPCP) Taskforce: Dean, M.M., Cellarius, V., Henry, B., Oneschuk, D. & Librach, L. (2012). Framework for Continuous Palliative Sedation Therapy (CPST) in Canada. Journal of Palliative Medicine, 15(8), THE CHAMPLAIN REGION PALLIATIVE SEDATION THERAPY CLINICAL PRACTICE GUIDELINES AND PROTOCOLS (2010). [Internet] Available from: resources/palliative%20sedation%20protocol%20for%20champlain%20region%20june % pdf De Graeff,A. & Dean, M. (2007). Palliative sedation therapy in the last weeks of life: A literature review and recommendations for standards. Journal of Palliative Medicine, 10(1), Slide 43: References References continued Fraser Health Hospice Palliative Care Program. Refractory Symptoms and Palliative Sedation Therapy Guideline. Approved by: End of Life Care, Practice Advisory Council, May 9, [Internet] Available from: %2009.pdf Khan, B. A. et al. (2012). Comparison and Agreement between the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale in Evaluating Patients Eligibility for Delirium Assessment in the ICU. Chest. 142(2), p Latimer, E.J. (1998). Ethical Care at the end of life. CMAJ, 158(13); Latimer, E.J. (1991). Ethical decision-making in the care of the dying and its applications to clinical practice. J Pain Symptom Management, 6(5): Sessler, C.N., Gosnell, M., Grap, M.J., Brophy, G.T., O'Neal, P.V., Keane, K.A. et al. (2002). The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med, 166(10),