Recent news stories relating to the “end of life” have brought public attention to palliative sedation (PS), a therapeutic procedure about which unfortunately little is known in the healthcare world and among the public. This lack of knowledge stems from the fact that, thus far, university courses have almost never provided for the systematic teaching of palliative care. This shortcoming leads to a certain resistance to its implementation or, even worse, confusion of PS with medically assisted death (MAD), a term that includes euthanasia and medically assisted suicide. Media debate has often contributed to this confusion, although there has been a higher quality of information and a reduction of semantic and conceptual ambiguity in the most recent news stories. The Italian Palliative Care Society (SICP) has published numerous press releases concering PS. To understand the difference between PS and MAD, it is necessary to know the constituent elements of the two procedures.
In the document titled, “SICP Recommendations on Terminal Sedation/Palliative Sedation,” this practice is defined as “the intentional reduction of alertness, up to a loss of consciousness, by pharmacological means to reduce or abolish the perception of a symptom that is otherwise intolerable for the patient, despite the most adequate means having been put in place to control the symptom, which is therefore refractory.”
The refractoriness of a symptom means the impossibility of adequately controlling it with traditional treatments (ie, those that do not depress the state of alertness) that are tolerable, effective, and viable in the conditions and in the time available by a healthcare professional expert in palliative care.
Another important defining element is the time frame in which palliative sedation is considered lawful: the phase of imminent death, which can refer to the last 15 days of life. The imminent phase of death is also referred to in the literature as “last hours–last days.”
According to the literature, palliative sedation is mainly carried out in the last 2 to 3 days of life.
The percentage of cases in which it is practiced varies significantly (10% to 43% of deceased patients), depending on many factors (case mix of patients, setting, professional skills, cultural attitudes, etc). The average values are 12% to 16%. As regards continuous deep sedation, the incidence reported in the literature is 5% to 15%.
The indications for starting PS include the onset of acute events that involve a situation of impending death and the progressive worsening of the psychophysical symptom that becomes refractory to the best possible treatments.
Acute events with impending risk of death are mainly respiratory distress due to suffocation (eg, massive pulmonary embolism, pulmonary edema, respiratory tract hemorrhage, massive inhalation of gastroenteric material, superior vena cava syndrome, etc); massive bleeding judged to be affecting the digestive and respiratory tracts, the large vessels of the neck or groin, or vegetating tumor masses; and states of epileptic disease.
In these cases, PS can be employed as an emergency treatment, owing to the inevitability of death and the extreme psychophysical suffering of the patient. The settings in which this emergency PS takes place are obviously manifold and include the home environment, the hospice, or other places of hospitalization, such as nursing homes, hospital wards, urgent and emergency care departments, and intensive care units.
Progressively refractory physical symptoms are represented in both oncologic and chronic-degenerative diseases due to dyspnea (35% to 50% of cases), terminal psychomotor agitation (delirium, 30% to 45% of cases), incoercible nausea and vomiting from intestinal occlusion (25%), and status epilepticus. Pain is rarely reported (5%). Symptoms can become refractory in any oncologic disease, although they occur more frequently in lung, gastrointestinal, head and neck, and breast cancers.
Among nononcologic diseases, the appearance of refractory symptoms is more frequent in association with neurologic pathology (such as amyotrophic lateral sclerosis, muscular dystrophy, Parkinson’s disease, multiple sclerosis, dementia, etc) and in chronic respiratory disease, cardiomyopathy, nephropathy, and metabolic pathology. Contrary to what is generally thought, in the final phase of nononcologic pathology, the suffering induced by refractory symptoms (especially dyspnea and delirium) is of similar, if not higher, intensity, compared with that present in a cancer patient.
Psychological symptoms are psychoexistential suffering, which in many cases is directly proportional to the severity of the physical symptoms, but there are rare cases in which psychoexistential distress is present without being associated with physical suffering. In cases in which this distress is refractory to available treatments (pharmacologic or psychotherapeutic treatment, socioeducational and spiritual support), there is an indication for PS.
The types of PS are emergency sedation, relief sedation or temporary sedation, intermittent sedation, and deep continuous sedation.
Emergency sedation is carried out in the immediately preterminal phases in patients suffering from catastrophic events such as asphyxia, massive hemorrhage, epileptic status, and so on.
Respite sedation or transient sedation may be indicated in earlier termination stages to induce temporary relief, pending the benefit of treatments aimed at symptom control or, more frequently, to control psychoexistential suffering when it is predicted that survival will be greater than 2 weeks.
Intermittent sedation is a relief sedation that is repeated several times or cyclically (eg, in nocturnal phases) as agreed upon with the patient to interrupt the phases of deepest and most intolerable distress.
Deep continuous sedation is most frequently applied in palliative care and involves a progressive increase in the level of sedation due to the increase in suffering upon the worsening of the refractory symptom. Indeed, some authors use the term “proportionate palliative sedation” to emphasize this important concept of proportionality.
The drugs used to implement PS are sedatives, especially benzodiazepines (midazolam as a first-choice drug), variously in association with neuroleptics (primarily haloperidol). More rarely, barbiturates or propofol is used in particular conditions. Opiates should not be used for sedative purposes but can be combined for the control of dyspnea and pain.
The types of sedative drugs that can be used are described in the literature.
Since the fundamental objective of PS is to obtain and maintain adequate control of suffering induced by psychophysical symptoms, there are theoretically no maximum doses of sedatives.
The empirical and moral distinction between PS and MAD is based on the constituent elements of the procedure: aim (or intention), types of drugs, dosages and route of administration, and final result.
Indeed, the aim of the procedure in PS is the control of suffering and not the induction of death in the patient, as in MAD.
The types of drugs, dosages, and routes of administration used in PS are intended to reduce the perception of suffering (through a proportionate reduction in alertness), not for the rapid induction of death, as is the case in MAD.
The result in PS is the reduction of the perception of suffering through sedative drugs, while in MAD it coincides with the death of the patient. Therefore, it can be concluded that PS is different from MAD, since the latter has the aim of causing the patient’s death by using lethal drugs, dosages, and suitable routes of administration.
In recent years, it has become evident that the hypothesized anticipation of death linked to PS is disproved by studies that, starting from the Cochrane review, confirm the absence of respiratory depression and an anticipation of death in sedated patients, compared with those not sedated. Conversely, there are even studies that report a longer survival among sedated patient groups.
It should be noted that the legal legitimacy of PS is sanctioned by Italian Law 21/17 which article 2, paragraph 2, indicates that PS is for the treatment of refractory suffering (Law 219).
This article was translated from Univadis Italy.
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