17 Although beyond the scope of this review, further research regarding in-home PS is needed.ĭistinction of PS from Physician-Assisted Suicide and Euthanasiaĭistinguishing PS from physician-assisted suicide and euthanasia calls on the ethical principles of beneficence (duty to alleviate suffering) and non-maleficence (duty to prevent or avoid harm). Palliative sedation can be used in the home setting, and studies have demonstrated promising results using intravenous midazolam infusion protocols safely and effectively in that setting. Cardiac monitoring is not helpful for achieving the goals of patients receiving PS and should be avoided, because it adds stress and expense for families and distracts loved ones from attending to the dying patient.Īlthough a variety of parenteral (intravenous or subcutaneous), oral, or rectal medications can be used for PS, not all patients requiring PS are in the inpatient hospital or hospice setting. Palliative sedation should be conducted in general care areas or inpatient palliative care or hospice settings, with monitoring of observed levels of comfort and signs of untoward adverse effects.
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If, however, goals of care shift from life prolongation to comfort and a short interval to death precludes transfer from the intensive setting, PS can be effectively implemented in this setting. For those who prioritize comfort at the time of inevitable death, intensive care units are generally a suboptimal setting for PS. Furthermore, the intensive care setting can be hectic and uncomfortable for families. 14 Because intensive care units are specially equipped and attended by highly specialized staff with the goal of preserving life, these rooms are in high demand and should be reserved for the critically ill whose primary goal is survival. Thus, sedation without cardiac monitoring on general hospital services represents a paradigm shift and may be met with resistance.
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In many institutions, sedation is confined to intensive care units and operating rooms for purposeful transient unawareness during noxious procedures, and is accompanied by cardiac monitoring. Opiates should not be used for the primary purpose of sedation, but rather should be continued adjunctively during PS for analgesic purposes and to prevent opiate withdrawal. 12- 14 Our institution (Mayo Clinic, Rochester, MN) supports the use of ketamine or propofol in patients whose condition is refractory to opioids and midazolam.
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5, 9- 11 Other programs that use primarily barbiturates, either alone or in combination with other agents, have also reported good results. Most centers use a midazolam-based regimen for PS because of the drug's short half-life, relatively benign adverse effects, ease of intravenous or subcutaneous administration, and generally good efficacy. When studying the aftermath of Hurricane Katrina, reviewers concluded that physicians' choice of benzodiazepines instead of barbiturates indicated a goal of palliation rather than euthanasia, citing that barbiturates were more “deadly.” 8 Negative press may contribute to restrictive institutional policy and difficulty in accessing these medications for therapeutic use. Some medications have recently received negative attention in the press, including use of propofol in the death of popular singer Michael Jackson, 7 and use of barbiturates in physician-assisted suicide and capital punishment. When choosing pharmacological agents for PS, the physician faces a number of considerations. Although required infrequently, PS is an important palliative tool with which clinicians should be familiar. 4 When PS is used, it is a measure of last resort rather than general care. In many settings, PS is uncommon, although a recent review revealed considerable variability in the prevalence of PS in the United States and other countries. 2, 3 Studies have shown that PS is effective, with efficacy rates ranging from 71% to 92%, 4 usually defined as the patient, family, or physician's perceived relief of refractory physical symptoms.
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During the late 1990s, several important court cases in the United States brought the issue of PS to the forefront and clarified the legality of the right to palliation at end of life. In 1994, Cherny and Portenoy 1 first offered an algorithm for determining appropriate indications for use of PS. The practice of PS has gained attention in the literature during the past 20 years. Palliative sedation (PS) refers to the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. ANH = artificial nutrition and hydration PS = palliative sedation