Palliative sedation therapy in a bone marrow transplant unit

Abstract

To the Editor, Despite the relatively high transplant-related mortality, the management of the end-life care is a poorly understood issue and the problems of providing palliative care to patients submitted to stem cell transplantation (SCT) may be underestimated. Therefore, the SCT environment, focusing on cure rather than relieve sufferance, may not be conducive to the optimal care of dying patients. In this regard, the use of palliative sedation therapy (PST) [1] in the SCT setting remains a major concern [2, 3]. In order to address this issue, a retrospective study on the use of PST in our tertiary SCT unit was performed. Therefore, we reviewed the clinical records of 117 patients who were admitted in our ward between January 2004 and June 2008 to receive SCT or because of SCT-related complications. According to institutional protocols, all patients received the best supportive care (red blood cell and platelet transfusions, parenteral nutrition, diuretics, antibiotics, analgesics and so on) and all available active treatments for complications. Out of 117 patients, 15 (13%) died. The pertinent features and the outcome of these patients are summarised in Table 1. Near death, ten of 15 (66%) patients experienced a total of 14 refractory symptoms (Table 1). Among the ten patients, intractable symptoms were represented by excruciating dyspnoea in eight (80%), agitated delirium in four (40%), severe pain in one (10%) and massive bleeding in one (10%). The decision to label a specific symptom as refractory requires exhausting all interventions known to control that symptom [1, 4]. In this regard, the medical staff comprehensively reviewed the patient’s clinical conditions and the results of adopted measures and discussed the indications to PST compared to other applicable and alternative interventions. Therefore, when the PST emerged as the last measure to relieve the patient’s sufferance, this measure was proposed to the patient, whenever possible, and to the family providing psychological support. Therefore, the patient’s symptoms, the reasons of the failure of the adopted measures in relieving them, the patient’s prognosis as well as ethical and spiritual issues were addressed and the consent to the PST was required. No PST refusal by patients or family was reported. PST was started at a median of two (1–4) days before death. The most used sedative drug was midazolam, which was administered to seven of ten (70%) patients as single agent and in two cases in association with promazine; the remaining patient received the latter agent alone. At the start of PST, five pain patients were receiving parenteral morphine. Midazolam and promazine were given intravenously and their dosages were titrated to the patient’s comfort. Midazolam were given at the dosage of 0, 07 mg/kg (3– 5 mg) as PST induction followed by a continuous infusion of 0.03 mg/kg/h (30–60 mg/die) as maintenance. Symptom control was considered adequate when it became tolerable as described by conscious patient or when sedation resulted on patient’s unconsciousness. To guide monitoring of patients whilst sedated, we used the Glasgow coma scale [5]. The mean dosage for midazolam was 45 mg/24 h (range 30–60 mg) and for promazine 150 mg/24 h (range Support Care Cancer (2009) 17:107–108 DOI 10.1007/s00520-008-0525-y