Fast Fact and Concept #106: Controlled Sedation for Refractory Suffering - Part I

Author(s): Mike Salacz; David E. Weissman

Controlled Sedation for Refractory Suffering (a.k.a. total, palliative, terminal) can be defined as: "sedation for intractable distress in the dying". The use of sedation has been reported to be anywhere from 2%-50% of hospice patients. Muller-Busch reported the indications for sedation included: anxiety/psychological distress (40%), dyspnea (35%) and delirium/agitation (14%).

While there exists objective criteria for quantifying and treating physical distress, evaluating psychological distress (a.k.a. existential suffering) is more difficult; there are no simple and clinically oriented tools to evaluate spiritual and psychosocial components of mental suffering. Many clinicians find the idea of sedation for existential suffering to be ethically more challenging than similar treatment for physical suffering. In either case, the decision to begin a trial of sedation is always difficult for clinicians, requiring thorough patient assessment and discussions with the patient, family and other team members.

Ethical/Legal Basis
In the United States, Supreme Court rulings (Vacco v Quill (1997), Washington v Glucksberg (1997)) supported the concept of sedation when used to relieve intractable suffering. However, controversy still surrounds the use of sedation due to confusion with euthanasia. From an ethical and legal standpoint, the key difference is intent. In euthanasia the intent is to produce a hastened death. In sedation, the intent is to relieve intractable suffering, not hasten death. Of note, recent studies have found no difference in survival between hospice patients who required sedation for intractable symptom control during their last days and those who did not.

What is a refractory/intractable symptom?
Cherney and Portenoy clarified the distinction between a difficult vs. a refractory symptom. A refractory symptom, that is, one in which total sedation may be appropriate, should have the following three attributes:

• Aggressive efforts short of sedation fail to provide relief
• Additional invasive/non-invasive treatments are incapable of providing relief
• Additional therapies are associated with excessive/unacceptable morbidity, unlikely to provide relief with a reasonable time frame.

Guidelines
Several similar sedation guidelines have been published; listed below are Rousseau ?s guidelines for sedation in patients with existential suffering; these guidelines would also be appropriate for decisions concerning physical symptoms.

• The patient must have a terminal illness
• All palliative treatments must be exhausted, including treatment for depression, delirium, anxiety, etc
• Psychological assessment by a skilled clinician
• Spiritual assessment by a skilled clinician or clergy
• A DNR order must be in effect and informed consent obtained and documented
• Nutrition/hydration issues need to be addressed prior to sedation
• One additional consideration proposed by Rousseau and others is the concept of Respite Sedation -- a time limited trial (usually 24 - 48 hours) in an attempt to break a cycle of psychological suffering. Fast Fact #107 will review the techniques of sedation.
  

References

1. Cherny NI. The use of sedation in the management of refractory pain. Principles and practice of supportive oncology Updates. 2000 3:1-11
2. Cherny NI and Portenoy RK. Sedation in the management of refractory symptoms: guidelines for evaluation and treatment, J. Pall. Care 10:2/1994 ;31-38.
3. Cherny, N., Commentary: Sedation in response to Refractory Existential Distress: Walking the Fine Line, J Pain Symptom Manage, 1998 Dec; 16(6): 404-5.
4. Charter S et al. Sedation for intractable distress in the dying-a survey of experts. Pall Med 1998; 12:255-269.
5. Braun TC et al. Development of a clinical practice guideline for palliative sedation. J Pall Med 2003; 6:345-350.
6. Hallenbeck, J., Terminal sedation for intractable distress, West J Med. 1999 Oct; 171(4):222-3.
7. Muller-Busch, H., etal, Sedation in palliative care ? a critical analysis of 7 years experience, BMC Palliative Care. 2003 May 13; 2(1):2.
8. Rousseau, P., Existential suffering and palliative sedation: a brief commentary with a proposal for clinical guidelines, Am J Hosp Palliat Care, 2001 May-Jun; 18(3): 151-3.
   

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Fast Facts and Concepts #104. Salacz M and Weissman DE. CONTROLLED SEDATION FOR REFRACTORY SUFFERING: PART I February 2004. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is use.

Creation Date: 2/2004

Purpose: Self-Study Guide

Audience(s)

ACGME Competencies: Interpersonal and Communication Skills, Medical Knowledge, Patient Care

Keyword(s): Non pain symptoms & syndromes; Ethics, law, policy, health systems