To sleep or not to sleep? PALLIATIVE SEDATION FOR REFRACTORY SYMPTOMS

Size: px

Start display at page:

Download "To sleep or not to sleep? PALLIATIVE SEDATION FOR REFRACTORY SYMPTOMS"

Cody Waters
5 years ago
Views:

1 To sleep or not to sleep? PALLIATIVE SEDATION FOR REFRACTORY SYMPTOMS

2 What is it? Intentional lowering of awareness to mitigate the experience of suffering at the end of life (AAHPM) Can include sedating to unconsciousness for patients with severe and refractory symptoms Does not have to be to unconsciousness HPNA adds monitored use of medications intended to induce varying degrees of unconsciousness without hastening death.

Criteria Must have a specific clinical indication Must have a target outcome Must have a benefit/risk ratio that is acceptable It is reserved for extreme situations Only considered after all

3 Criteria Must have a specific clinical indication Must have a target outcome Must have a benefit/risk ratio that is acceptable It is reserved for extreme situations Only considered after all available expertise to manage the target symptom has been accessed Level of sedation should be proportionate to the patient's level of distress When able patients should participate in the decision to use palliative sedation Treatment of other symptoms should be continued alongside palliative sedation

4 Ethical Considerations Patient is unable to substantially interact with others Patient does not have the ability or opportunity to change his mind Patient is unable to eat and drink (thus potentially shortening survival in particular circumstances).

5 Ethically justified if Careful interdisciplinary evaluation and treatment of the patient has occurred Treatments have failed Side effects of treatment too great Use is not expected to shorten the patient's time to death Used only for the actual or expected duration of symptoms

$palliative sedation usually does not alter the timing or mechanism of a patient's death refractory symptoms = very advanced terminal illness.$

6 Are we euthanizing? palliative sedation usually does not alter the timing or mechanism of a patient's death refractory symptoms = very advanced terminal illness. be clear in their intent to palliate symptoms Address artificial nutrition and hydration should be addressed prior to sedation

7 Refractory?? Exhausted all options Optimized use of adjuvants Interventional pain has been consulted Incapable of providing adequate relief Associated with excessive and intolerable acute or chronic adverse effects Unlikely to provide relief within a tolerable time frame. Cherney and Portenoy

8 Approach to patient/family Address patient and family distress Address the distinction from euthanasia Emphasize that uncontrolled suffering at the end of life constitutes a critical situation

$Ethically problematic practices Sedation as a means of hastening death Sedation applied inappropriately like non-refractory symptoms.$

9 Ethically problematic practices Sedation as a means of hastening death Sedation applied inappropriately like non-refractory symptoms. Need expert palliative care involved. Sedation given in response to the family s not patient s desire Sedation withheld when it is appropriate

10 Approach to staff Witness to suffering Concerns about euthanasia Struggles with family emotions Compassion fatigue

11 Patient assessment Bring up early Review failed treatment options Unacceptable side effects from treatments? Mutli-discipline involvement Will intervention be effective in reasonable time frame

12 Obtaining Consent Outline general condition Acknowledge failed attempts at controlling symptoms Discuss prognosis and give survival prediction Discuss rationale and methods Discuss alternative options Explain lack of communication/oral intake Discuss possible paradoxical agitation and lack of relief

13 Planning for sedation Artificial hydration and nutrition Lifting sedation Manage expectations Anticipate regrets Reassure prior and during sedation that we are not euthanizing Describe process and signs of decline Focus on relief of suffering

14 Sedative medications Midazolam Short half life Rapid onset-2 minutes Water soluble Helpful with seizures/spasms/nausea/central pruritus Risk of paradoxical agitation/delirium Risk of apnea Accumulation and tolerance

15 Sedative Medications Chlorpromazine Rapid onset Effective sedation Anxiolytic Helps with delirium, agitation, nausea/vomiting/hiccups Can get anticholinergic SE, akathisia, acute dystonic reaction, seizures and arrhythmia

16 Sedative medications Phenobarbital Second line for agitation Use when tolerance occurs to benzos and antipsychotics It will control seizures Can get paradoxical excitement (mostly older adults) May worsen nausea Drug/drug interactions Skin reactions Rebound seizures

$Sedative Medications Propofol Ultra-rapid on/off Reliable and rapid unconsciousness Typically second line for refractory or those with tolerance$

17 Sedative Medications Propofol Ultra-rapid on/off Reliable and rapid unconsciousness Typically second line for refractory or those with tolerance Helps with refractory nausea, vomiting and seizures Infusion sight pain Bacterial overgrowth Apnea with bolus Hypertension/allergic reactions/bradycardia

18 Pearls ICU monitoring for some drugs Vitals only if not imminently dying Don t downward titrate unless SE Discuss AHN Continue opiates if already on them Emergency sedation Hemorrhage, asphyxiation, severe terminal dyspnea or overwhelming pain Respite sedation

19 Existential Suffering There is no consensus around the ability to define, assess, and gauge existential suffering There is no way to measure the efficacy of treatments for existential distress Is this in the realm of medicine? Less likely to be imminently dying

I Wanna Be Sedated: Palliative Sedation March 30, 2017 Emily L. Riegel, MD

I Wanna Be Sedated: Palliative Sedation March 30, 2017 Emily L. Riegel, MD 1 NATION'S LARGEST HOSPICE DID NOT PROVIDE A YOUNG MOTHER WITH A 'PEACEFUL DEATH NOV. 19, 2010 The family of a young Los Gatos