Fast Fact and Concept #107: Controlled sedation for refractory symptoms: Part II

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

Fast Fact #106 reviewed the decision process and clinical guidelines for sedation. This Fast Fact will review sedation techniques.

Prior to Initiating Sedation

• Ensure thorough discussion of proposed treatment plan and expected outcomes with patient (if able), all family members and all medical staff (physicians, nurses, therapists, nursing aides, chaplain, etc.).
• Review plans for use of artificial nutrition/hydration?ensure treatment plan has been discussed (either stopping or continuing) and documented with patient/family and medical
• Document informed consent discussion and write DNR order.
• Assure a peaceful, quiet setting, with a minimum of intrusions.
• Confirm any specific goals that need to be met prior to starting sedation (e.g. visit from distant relative).
• Confirm patient/family desire for chaplain/spiritual support prior to starting sedation.
• Review medication and treatment orders ?discontinue orders not contributing to comfort (e.g. vital sign monitoring, blood glucose checks).

Starting Sedation
Many drugs have been used to provide effective sedation; there are no controlled trials comparing efficacy. Midazolam, other benzodiazepines, barbiturates and propafol all have efficacy as sedatives. Although many patients are on opioids prior to the initiation of palliative sedation, opioids are not effective at producing sustained sedation. However, opioids should be continued, along with the sedating drug, to avoid opioid withdrawal and to treat unobserved pain. The following table lists starting doses for the use of sedating drugs including the bolus dose, and a starting continuous infusion (CI) rate; the CI rate can be increased as needed to achieve the desired level of sedation.

• Midazolam (sq,iv) - 5 mg bolus; 1 mg/hr gtt
• Lorazepam (sq,iv) - 2-5 mg bolus; 0.5-1.0 mg/hr gtt
• Thiopental (iv) - 5-7 mg/kg/hr bolus; then 20-80 mg/hr gtt
• Pentobarbital (iv) - 2-3 mg/kg bolus; 1mg/kg/hr gtt
• Phenobarbital (iv,sq) - 200 mg bolus (can repeat q10-15 min); then 25 mg/hr gtt
• Propofol (iv) - 20-50 mg bolus (may repeat); 5-10 mg/hr gtt

Continued Sedation
Current hospital monitoring standards for conscious sedation are inappropriate in the dying patient. A general rule is that the depth of sedation can vary, depending on the symptoms being palliated, and prior discussions with the family regarding goals of treatment. Generally, the infusion is initiated and then titrated to a point where the patient appears to be comfortable. Care should be taken to make further adjustments when necessary to facilitate palliative nursing care. Other reported strategies include varying the depth of sedation during the day, providing deeper sedation at night to ensure peaceful rest. Once total sedation is initiated, survival can be quite variable, but generally is brief. Muller-Busch reports survival of 63 +/- 58 hrs after initiation of sedation, Sykes reports 56% of patients survived less than 48 hrs.

References

1. Berger, AM, Ed, et al, Principles and Practice of Palliative Care and Supportive Oncology, Philadelphia, PA: Lippincott Williams & Wilkins, 2002.
2. Hallenbeck, J, Terminal sedation for intractable distress, West J Med. 1999 Oct; 171(4): 222-3.
3. Muller-Busch, H., et.al., Sedation in palliative care ? a critical analysis of 7 years experience, BMC Palliative Care, 2003 May 13; 2(1): 2.
4. Quill, TE, Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids, Ann Intern Med, 2000; 132: 408-414.
5. Sykes, N., Sedative Use in the Last Week of Life and the Implications for End-of-Life Decision Making. Arch Intern Med, 2003 Feb 10; 163: 341-344.

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 #107. Salacz M and Weissman DE. CONTROLLED SEDATION FOR REFRACTORY SUFFERING: PART II 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: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non pain symptoms & syndromes