Terminal sedation how long

Existential distress is an experience characterised by feelings of hopelessness, isolation and being a burden on others that often affects people with an advanced terminal illness. Figure 2 provides an algorithm for initiating palliative sedation in a hospital setting.

Figure 2. A suggested algorithm to the approach of initiating palliative sedation in a patient with physical and refractory symptoms in their advanced terminal illness.

To relieve this burden, it may be beneficial to employ a team approach to resolving conflicting opinions and coordinating early family meetings and adequate education and training relating to palliative sedation.

Primary care doctors may be involved in MDT meetings discussing palliative sedation for their patients in a hospital setting. Alternatively, family members whose loved ones have required palliative sedation may need to be followed up and monitored for psychological and moral distress, which is why it is important for general practitioners to be aware of this therapy. Palliative sedation is complex. Implementation in rural settings and other low-resource environments would require careful adaptation of the current guidelines including reference to the potential role of telehealth.

Palliative sedation is an important, evidence-based, effective therapy. Guidelines are available to healthcare professionals on when and how to initiate this therapy in an acute care setting. However, it remains a vastly complex form of therapy with significant ethical, emotional and professional issues. Did you know you can now log your CPD with a click of a button? Palliative sedation: A safety net for the relief of refractory and intolerable symptoms at the end of life.

Background Evidence exists for the use of palliative sedation for people approaching the last days of life with refractory and intolerable symptoms. It is a third-line intervention that deliberately lowers the conscious state to relieve intolerable and refractory symptoms.

This level of intervention is not routinely used in primary care, and there is a lack of guidelines for palliative sedation in this context. Objective This article provides some key information about palliative sedation and global issues faced by all individuals involved. A tertiary centre case study is used to illustrate the key points. Given this form of therapy may be required for palliative patients in the community, another aim of this article is to provide an overview for primary care practitioners to raise their awareness of such therapy and the issues related to it.

Case AW, aged 74 years, was an independent retired long-distance truck driver who lived with his wife. An algorithm to aid in determining whether a symptom is refractory Preparation prior to initiation Ideally, palliative sedation is well planned and executed following detailed discussion with the patient or their family members, if the patient is cognitively impaired.

Table 1. Details of suggested pharmacological options for palliative sedation 57 Medication Comments Midazolam Tolerance to the sedative effects of midazolam may occur. The dosage may need to be increased over time. If there is inadequate symptom control or incomplete sedation with maximum doses, then additional agents may be of greater benefit rather than further increases to the dose of midazolam.

Levomepromazine This medication is useful if the individual has significant nausea or delirium. It may lower seizure threshold. Extrapyramidal side effects may appear. It is listed on the Special Access Scheme and requires specific paperwork.

Phenobarbitone This medication requires individualised dosing because of considerable variability in pharmacokinetics. Injection site reactions such as tissue necrosis can occur. It can be used in cases of inadequate response to benzodiazepines and levomepromazine. Propofol 56 Intravenous access is required. Propofol may need input from intensive care anaesthetists or general practitioner anaesthetists. It should only be considered if all options have failed and the patient has reached their last days of life.

Table 2. Practical considerations Palliative sedation is a procedure that renders the patient completely dependent, which is why it is important that it is carried out in an appropriate environment with adequate supports in place. Ethical issues Ethical issues in palliative sedation are complex, such that in some literature, palliative sedation is still described as controversial. Conclusion Palliative sedation is an important, evidence-based, effective therapy.

Summary Palliative sedation is a method of sedation used for patients in the terminal phase that induces a state of reduced or complete consciousness to minimise the distress caused by refractory and intolerable symptoms.

The intent of palliative sedation differs from euthanasia or PAS in that its goal is symptom relief without hastening death. Obtaining informed consent through adequate discussions and documentation relating to the aims, benefits and goals is necessary prior to initiating palliative sedation.

Monitoring relief of distress, depth of sedation and side effects should be tailored to the clinical setting. Those involved in palliative sedation should be monitored for psychological and moral distress. Provenance and peer review: Not commissioned, externally peer reviewed. Create Quick log. Preferences of the Dutch general public for a good death and associations with attitudes towards end-of-life decision-making.

Palliat Med ;20 7 — In search of a good death: Observations of patients, families, and providers. Ann Intern Med ; 10 — Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA ; 19 — Symptom severity of patients with advanced cancer in palliative care unit: Longitudinal assessments of symptoms improvement. BMC Palliat Care ; The symptoms of advanced cancer: Relationship to age, gender, and performance status in 1, patients. Supportive care in cancer ;8 3 — Palliative sedation in nursing homes: A good death?

J Am Med Dir Assoc ;15 8 — The practice of continuous palliative sedation in elderly patients: A nationwide explorative study among Dutch nursing home physicians.

J Am Geriatr Soc ;58 9 — Palliative sedation in terminal cancer patients admitted to hospice or home care programs: Does the setting matter? Results from a national multicenter observational study. J Pain Symptom Manage ;56 1 — Development of a clinical guideline for palliative sedation therapy using the Delphi method. J Palliat Med ;8 4 — The ethics of palliative sedation as a therapy of last resort.

Am J Hosp Palliat Care ;23 6 — Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American College of Physicians. Ann Intern Med ; 2 — Palliat Med ;23 7 — Framework for continuous palliative sedation therapy in Canada.

J Palliat Med ;15 8 — Caring for adults in their last days of life. London: NICE, Sedation in the management of refractory symptoms: Guidelines for evaluation and treatment. J Palliat Care ;10 2 — A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients. Palliat Med ;14 4 — Sedation for intractable distress of a dying patient: Acute palliative care and the principle of double effect. Oncologist ;5 1 — Practice and documentation of palliative sedation: A quality improvement initiative.

Sedated, terminal cancer patients usually live about 1 day. We identified risk factors for a shorter sedation period. This study is limited by its retrospective design and by the frequent use of opioids as the main sedative medications. In this article, we describe the extent to which these claims are reflected in the empirical data that are available on medical end-of-life decisions in the Netherlands.

Cases of euthanasia and terminal sedation are compared for characteristics of the physicians and patients involved, of the decision-making process, and of the clinical course that followed the decision.

Insight into the extent to which these practices can be distinguished based on their clinical characteristics may contribute to the debate about whether terminal sedation resembles euthanasia. We interviewed a nationwide stratified sample of physicians: general practitioners, 77 nursing home physicians, and clinical specialists cardiologists; surgeons; and specialists in internal medicine, pulmonology, and neurology.

The sample size was determined by the likelihood that these specialists had attended deaths and the likelihood that they had been involved with different types of end-of-life decisions. The respondents were selected according to the following criteria: They had to be in active practice at the time of the interview and to have actively practiced medicine within the registered specialty for the past 2 years in the same setting. All addresses were taken from the professional registries of the relevant specialties.

To arrive at the desired number of physicians the number that proved to yield sufficient numbers of cases of euthanasia in previous studies 10 , 11 , we sampled physicians. Face-to-face interviews were conducted by experienced part-time working or recently retired physicians who were trained to use the structured questionnaires.

All interviews took place between March and October We applied strict rules to ensure the anonymity of all physicians and patients studied. The interview schedule addressed experiences with end-of-life decision-making processes.

Terminal sedation was defined as the administration of drugs to keep the patient in deep sedation or coma until death, without giving artificial nutrition or hydration. Euthanasia was defined as the administration of drugs with the explicit intention of ending the patient's life at his or her explicit request. Type of physician was a proxy for place of death.

Euthanasia is always provided at the request of the patient; for cases of terminal sedation, we asked the physicians whether they had discussed their decision to apply terminal sedation with the patient and relatives and whether the patient had requested terminal sedation.

Discussion about and requests for terminal sedation could concern deep sedation, the forgoing of artificial nutrition or hydration, or both. For both practices, the most important reasons for the request of the patient were asked. The presence of 15 symptoms, despite treatment, was evaluated on a 5-point Likert scale. Furthermore, we asked whether other treatments aimed at curing or prolonging life were available at the time of the decision-making process, the physician's intention concerning the hastening of death, which drugs were used, the time interval between administering the drugs and the death of the patient, and the estimated degree of shortening of life.

Our questionnaire was largely based on questionnaires that were used in previous studies. Of the physicians interviewed, 96 reported that they had experience with both practices; , with terminal sedation only; and 97, with euthanasia only. The remaining physicians did not have experience with either of these practices.

Of the physicians' most recent cases, patients who received terminal sedation were, on average, older mean age, 72 years than patients who received euthanasia mean age, 63 years Table 1. Euthanasia was by definition requested by the patient.

Euthanasia is by definition administered with the explicit intention to hasten death. Similarly, we performed all analyses only for patients with cancer to determine whether differences between both practices are mainly attributable to differences in diagnosis.

These analyses resulted in similar distributions of the data. The bottom line of both practices, terminal sedation and euthanasia, obviously is a patient who suffers severely from a fatal disease. However, there are marked differences. By definition, patients receiving euthanasia were actively involved in the decision-making process. This is true of only slightly more than half of the patients receiving terminal sedation, although relatives were almost always involved.

Compared with the patients receiving euthanasia, patients who were terminally sedated were, on average, older, less often suffered from cancer and more often from cardiovascular disease, and less often died at home. Terminal sedation was more often used in patients with unclear consciousness, anxiety, and confusion and in the absence of other treatment options. Furthermore, patient requests for terminal sedation were more often based on pain than were requests for euthanasia, which were more often based on a sense of suffering without chance of improving and on a perceived loss of dignity and independence.

The intent of the physician in cases of terminal sedation was less often to shorten life, and the shortening of life due to terminal sedation was limited. Thus, patients who are terminally sedated are generally sicker and closer to death than patients receiving euthanasia. Two findings may seem to contradict this conclusion: patients receiving euthanasia more often suffered from nausea and vomiting.

However, terminal sedation is not obviously a medically appropriate answer to these symptoms. Furthermore, these symptoms may be closely connected to a sense of loss of dignity, which was a common reason for requesting euthanasia and not for requesting terminal sedation. The finding that requests for euthanasia are often inspired by a sense of loss of dignity is described by others as well. Haverkate et al 12 found that avoiding loss of dignity is one of the most important reasons to request euthanasia.

In addition, during the first year of legalized, physician-assisted suicide in Oregon, the decision to request and use a prescription for lethal medication was associated with concern about loss of autonomy or control of bodily functions, not with fear of intractable pain. In a study 14 within the Japanese population it was shown that respondents who reject continuous deep sedation at the end of life were significantly more likely to regard dignity and preparation for death as important compared with respondents who would appreciate continuous deep sedation at the end of life.