Palliative Sedation In Patients Research Articles

Successful Use of Propofol After Failed Palliative Sedation in Patients With Refractory Symptoms.

Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.

Successful Use of Propofol After Failed Palliative Sedation in Patients With Refractory Symptoms.

Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.

The clinical practice of palliative sedation in patients dying from COVID-19: a retrospective chart review

BackgroundClinical experts experienced challenges in the practice of palliative sedation (PS) during the COVID-19 pandemic. Rapid deterioration in patients’ situation was observed while the indications for starting PS seemed to differ compared to other terminal patients. It is unclear to which extent clinical trajectories of PS differ for these COVID patients compared to regular clinical practice of PS.ObjectivesTo describe the clinical practice of PS in patients with COVID versus non-COVID patients.MethodsA retrospective analysis of data from a Dutch tertiary medical centre was performed. Charts of adult patients who died with PS during hospitalisation between March ’20 and January ‘21 were included.ResultsDuring the study period, 73 patients received PS and of those 25 (34%) had a COVID infection. Refractory dyspnoea was reported as primary indication for starting PS in 84% of patients with COVID compared to 33% in the other group (p < 0.001). Median duration of PS was significantly shorter in the COVID group (5.8 vs. 17.1 h, p < 0.01). No differences were found for starting dosages, but median hourly dose of midazolam was higher in the COVID group (4.2 mg/hr vs. 2.4 mg/hr, p < 0.001). Time interval between start PS and first medication adjustments seemed to be shorter in COVID patients (1.5 vs. 2.9 h, p = 0.08).ConclusionPS in COVID patients is characterized by rapid clinical deterioration in all phases of the trajectory. What is manifested by earlier dose adjustments and higher hourly doses of midazolam. Timely evaluation of efficacy is recommended in those patients.

Palliative Sedation in COVID-19 End-of-Life Care. Retrospective Cohort Study.

Background and Objectives: Descriptions of end-of-life in COVID-19 are limited to small cross-sectional studies. We aimed to assess end-of-life care in inpatients with COVID-19 at Alicante General University Hospital (ALC) and compare differences according to palliative and non-palliative sedation. Material and Methods: This was a retrospective cohort study in inpatients included in the ALC COVID-19 Registry (PCR-RT or antigen-confirmed cases) who died during conventional admission from 1 March to 15 December 2020. We evaluated differences among deceased cases according to administration of palliative sedation. Results: Of 747 patients evaluated, 101 died (13.5%). Sixty-eight (67.3%) died in acute medical wards, and 30 (44.1%) received palliative sedation. The median age of patients with palliative sedation was 85 years; 44% were women, and 30% of cases were nosocomial. Patients with nosocomial acquisition received more palliative sedation than those infected in the community (81.8% [9/11] vs 36.8% [21/57], p = 0.006), and patients admitted with an altered mental state received it less (20% [6/23] vs. 53.3% [24/45], p = 0.032). The median time from admission to starting palliative sedation was 8.5 days (interquartile range [IQR] 3.0–14.5). The main symptoms leading to palliative sedation were dyspnea at rest (90%), pain (60%), and delirium/agitation (36.7%). The median time from palliative sedation to death was 21.8 h (IQR 10.4–41.1). Morphine was used in all palliative sedation perfusions: the main regimen was morphine + hyoscine butyl bromide + midazolam (43.3%). Conclusions: End-of-life palliative sedation in patients with COVID-19 was initiated quite late. Clinicians should anticipate the need for palliative sedation in these patients and recognize the breathlessness, pain, and agitation/delirium that foreshadow death.

Palliative sedation in patients with advanced cancer in a specialized unit in a middle-income country: A retrospective cohort study.

To describe the 5-year practice on palliative sedation in a specialized palliative care unit in a deprived region in Brazil, and to compare survival of patients with advanced cancer who were and were not sedated during their end-of-life care. Retrospective cohort study in a tertiary teaching hospital. We described the practice of palliative sedation and compared the survival time between patients who were and were not sedated in their last days of life. We included 906 patients who were admitted to the palliative care unit during the study period, of whom, 92 (10.2%) received palliative sedation. Patients who were sedated were younger, presented with higher rates of delirium, and reported more pain, suffering, and dyspnea than those who were not sedated. Median hospital survival of patients who received palliative sedation was 9.30 (CI 95%, 7.51-11.81) days and of patients who were not sedated was 8.2 (CI 95%, 7.3-9.0) days (P = 0.31). Adjusted for age and sex, palliative sedation was not significantly associated with hospital survival (hazard ratio = 0.93; CI 95%, 0.74-1.15). Palliative sedation can be accomplished even in a deprived area. Delirium, dyspnea, and pain were more common in patients who were sedated. Median survival was not reduced in patients who were sedated.

Palliative Sedation in Patients Hospitalized in Internal Medicine Departments

ContextPalliative sedation is used to relieve end-of-life refractory symptoms. ObjectiveThe objective of this study was to describe the use of palliative sedation in patients who die in internal medicine departments. MethodsAn observational, cross-sectional, retrospective, and multicenter clinical audit study was conducted in 145 hospitals in Spain and Argentina. Each hospital included the first 10 patients who died in the internal medicine department, starting on December 1, 2015. ResultsWe included 1447 patients, and palliative sedation was administered to 701 patients (48.4%). Having a terminal illness (odds ratio [OR] 2.469, 95% CI 1.971–3.093, P < 0.001) and the length of hospital stay (OR 1.011, 95% CI 1.002–1.021, P = 0.017) were independently associated with the use of palliative sedation. Consent was granted by the families of 582 (83%) patients. The most common refractory symptom was dyspnea, and the most commonly used drugs for sedation were midazolam (77%) and morphine (89.7%). An induction dose was administered in 25.7% of the patients. Rescue doses were scheduled for 70% of the patients, and hydration was maintained in 49.5%. Pain was more common in patients with cancer, whereas dyspnea was more common in those without cancer. Rescue doses were used more often for the patients with cancer (77.8% vs. 67.7%, P = 0.015). Monitoring the palliative sedation with a scale was more frequent in the patients with cancer (23.7% vs. 14.3%, P = 0.008). ConclusionsPalliative sedation is used more often for terminal patients. There are differences in the administration of palliative sedation between patients with and without cancer.

Clinical Patterns of Continuous and Intermittent Palliative Sedation in Patients With Terminal Cancer: A Descriptive, Observational Study

ContextLimited information is available regarding the detailed clinical patterns of palliative sedation (PS), that is, the symptom control rate, salvage medication, and the effectiveness of intermittent PS (IPS) versus continuous PS (CPS). ObjectivesThe primary aim was to investigate clinical outcomes of PS in a real clinical setting. MethodsClinical information was prospectively collected for patients who were treated according to a prescribed protocol and assessment tools in a hospice unit affiliated with a tertiary cancer center between September 2015 and March 2017. Data were analyzed retrospectively. Midazolam was used as the first medication for PS, and propofol and phenobarbital were subsequently used as salvage medications. Indications of PS, the depth of sedation, the quality of sleep, and the level of consciousness were assessed. ResultsA total of 306 patients were enrolled, 89 of whom (29.1%) received PS. No difference in survival time was found between patients with and without PS (median survival, 34.0 vs 25.0 days, P = 0.109). Delirium was the most common indication of PS. The symptoms of 73 (82.0%) of 89 patients with PS were relieved with midazolam. Twelve (75.0%) of 16 midazolam-failure patients responded to propofol, five of whom (31%) exhibited respiratory depression. Of the 89 patients receiving PS, 61 (68.5%) received IPS and 28 patients (31.5%) received CPS. The median survival times from PS initiation to death were six days in the IPS group and one day in the CPS group (P < 0.001). Interestingly, consciousness levels were significantly improved after IPS in the delirium group compared with those in the other group (41.7% vs 16.7%, P = 0.002). ConclusionThe refractory symptoms of end-of-life patients with cancer can ultimately be relieved with various medications for PS. IPS may improve the consciousness level of patients with delirium.

Palliative Sedation in Patients With Cancer.

Palliative sedation involves the use of sedative medication to relieve refractory symptoms in patients by reducing their level of consciousness. Although it is considered an acceptable clinical practice from most ethical points of view, palliative sedation is still a widely debated procedure and merits better understanding. The relevant medical literature pertaining to palliative sedation was analyzed and reviewed from various technical, relational, and bioethical perspectives. Proportionate palliative sedation is considered to be the most clinically appropriate modality for performing palliative sedation. However, guidelines must be followed to ensure that it is performed correctly. Benzodiazepines represent the first therapeutic option and careful monitoring of dosages is essential to avoid oversedation or undersedation. Proportionate palliative sedation is used to manage and relieve refractory symptoms in patients with cancer during their last days or hours of life. Evidence suggests that its use has no detrimental effect on survival. A different decision-making process is used to manage the withdrawal of hydration than the process used to determine whether proportionate palliative sedation is appropriate. Communication between patients, their relatives, and the health care staff is important during this medical intervention.

Palliative Sedation in Patients With Advanced Cancer Followed at Home: A Prospective Study

ContextHome care programs in Italy. ObjectivesThe aim of this study was to assess a protocol for palliative sedation (PS) performed at home. MethodsA total of 219 patients were prospectively assessed to evaluate a PS protocol in patients with advanced cancer followed at home by two home care programs with different territorial facilities. The protocol was based on stepwise administration of midazolam. ResultsA total of 176 of the patients died at home, and PS was performed in 24 of these patients (13.6%). Younger patients received the procedure more frequently than older patients (P=0.012). The principal reasons to start PS were agitated delirium (n=20) and dyspnea (n=4). Mean duration of PS was 42.2±30.4 hours, and the mean doses of midazolam were 23–58mg/day. Both the home care team and the patients' relatives expressed optimal or good levels of satisfaction with the procedure in all but one case, respectively. ConclusionThis protocol for PS was feasible and effective in minimizing distress for a subgroup of patients who died at home. The characteristics of patients who may be effectively sedated at home should be better explored in future studies.

Palliative Sedation: When and How?

Patients with advanced cancer develop a number of devastating physical and psychosocial symptoms. Although in the last 15 years there has been considerable improvement in our ability to assess and manage many of the most common symptoms, a significant proportion of patients with cancer develop refractory symptoms before death, and palliative sedation is an important therapeutic intervention, particularly for severe agitated delirium, dyspnea, and bleeding. Palliative sedation is usually defined as “the use of a sedative medication to reduce patient awareness of distressing and intractable symptoms that are insufficiently controlled by symptomspecific therapies.” Although it is practiced on a daily basis in acute care facilities and hospices, there has been limited research on the appropriateness of the different interventions and the outcomes of palliative sedation. One of the most controversial aspects of this practice is the potential for shortening life, particularly in patients who might have a potentially reversible symptom that requires palliative sedation. The article by Maltoni et al that accompanies this editorial is an important systematic literature review of studies that attempt to characterize the impact of palliative sedation on survival. Perhaps one of the most important findings of this carefully conducted review is that only 11 articles were identified, and seven of them were retrospective. There are serious ethical concerns about randomized controlled trials of palliative sedation, given that in such studies the control group would consist of patients suffering severe refractory symptoms. Therefore, this is an area where real-life studies, so to speak, can be useful. Unfortunately, the analysis of retrospective studies in patients with cancer who underwent sedation is severely limited by the absence of regular assessment of delirium and symptom severity in clinical practice. Palliative care units are very successful at adopting validated tools for the assessment of these outcomes. Although regrettably, only 25% of US comprehensive cancer centers and 20% of noncomprehensive cancer centers have designated acute palliative care beds, 10 of the 11 studies in this systematic review were conducted in palliative care units. The findings of the studies conducted in these controlled and sophisticated environments may not be applicable to the practice of palliative sedation in regular hospital wards. It is important that all clinical settings where palliative sedation is performed also measure delirium and symptom distress on a regular basis. The finding of no significant difference in survival between those patients who were sedated versus those who were not sedated by these palliative care teams is reassuring to those who regularly treat patients in palliative care settings. However, the relatively poor quality of the data points out our lack of knowledge of this very important aspect of daily patient care. Maltoni et al appropriately discuss the concerns with respect to the use of palliative sedation in patients with psychological distress. It is quite possible that many of the patients reported in these studies as having psychological distress had disinhibition related to the early stages of delirium. Because of the lack of regular screening, delirium is frequently underdiagnosed in patients with cancer. Where do we go from here? First, a more thorough definition of a refractory symptom is needed. Success in controlling a symptom not only depends on the severity of the symptom but also on the quality of the assessment and management the patient receives. Because interdisciplinary supportive and palliative care teams are highly effective in alleviating physical and psychosocial distress, until more evidence is available, it is important that physicians consult with these experts whenever possible in the case of severe symptoms. Checklists and procedures should be developed to help standardize this sensitive practice and also to help collect valuable information that will contribute to the existing body of knowledge. Palliative sedation results in considerable distress for families as well as health care professionals. It is important that the decision to begin palliative sedation be made not only in consensus with the patient and family but also with other health care professionals who are involved in the care of the patient, including the bedside nurse, counselors, pharmacists, and other colleagues. Obtaining consensus prevents conflict and potential medico-legal problems within the team. Clinical trials that compare different drugs that might be more effective at inducing and maintaining sedation, measuring outcomes such as arousal, evidence of symptom distress, and survival, are also needed. Maltoni et al have identified in their review the frequent use in palliative sedation of drugs such as haloperidol and morphine that are specific agents for the management of delirium and pain, respectively, and not for effective palliative sedation. As with many other medical interventions, the controversy that surrounds palliative sedation is not linked to the question of “yes or no?” but rather, “when and how?”

Continuous Palliative Sedation for Cancer and Noncancer Patients

Context Palliative care is often focused on cancer patients. Palliative sedation at the end of life is an intervention to address severe suffering in the last stage of life. Objectives To study the practice of continuous palliative sedation for both cancer and noncancer patients. Methods In 2008, a structured questionnaire was sent to 1580 physicians regarding their last patient receiving continuous sedation until death. Results A total of 606 physicians (38%) filled out the questionnaire, of whom 370 (61%) reported on their last case of continuous sedation (cancer patients: n = 282 [76%] and noncancer patients: n = 88 [24%]). More often, noncancer patients were older, female, and not fully competent. Dyspnea (odds ratio [OR] = 2.13; 95% confidence interval [CI]: 1.22, 3.72) and psychological exhaustion (OR = 2.64; 95% CI: 1.26, 5.55) were more often a decisive indication for continuous sedation for these patients. A palliative care team was consulted less often for noncancer patients (OR = 0.45; 95% CI: 0.21, 0.96). Also, preceding sedation, euthanasia was discussed less often with noncancer patients (OR = 0.42; 95% CI: 0.24, 0.73), whereas their relatives more often initiated discussion about euthanasia than relatives of cancer patients (OR = 3.75; 95% CI: 1.26, 11.20). Conclusion The practice of continuous palliative sedation in patients dying of cancer differs from patients dying of other diseases. These differences seem to be related to the less predictable course of noncancer diseases, which may reduce physicians’ awareness of the imminence of death. Increased attention to noncancer diseases in palliative care practice and research is, therefore, crucial as is more attention to the potential benefits of palliative care consultation.