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Statement on Palliative Sedation

Approved by the AAHPM Board of Directors on December 5, 2014

Background

Palliative care supports patients whose diseases are associated with significant burden. Distressing symptoms exist on a spectrum from the most easily treated to the most refractory. Although preservation of awareness at the end of life is viewed as a priority for many, for some, the relief of symptoms may outweigh the desire to be conscious. Palliative sedation (PS), as defined in this statement, is the intentional lowering of awareness towards, and including, unconsciousness for patients with severe and refractory symptoms.

Statement

A primary objective of palliative medicine is the easing of suffering via pharmacologic and non-pharmacologic techniques. As with any medical procedure, PS must satisfy the criteria of having a specific clinical indication, a target outcome, and a benefit/risk ratio that is acceptable to both the clinician and patient. Palliative sedation is an intervention reserved for extreme situations. The use of palliative sedation should only be considered after all available expertise to manage the target symptom has been accessed. The level of sedation should be proportionate to the patient’s level of distress. As with all treatments, patients, when able, should participate in the decision to use palliative sedation. Treatment of other symptoms should be continued alongside palliative sedation, because sedation may decrease the
patient’s ability to communicate or display discomfort.

Palliative sedation raises ethical concerns when it significantly reduces patient consciousness to the degree that the patient is unable to substantially interact with others, does not have the ability or opportunity to change his mind, and is unable to eat and drink (thus potentially shortening survival in particular circumstances). Palliative sedation is ethically defensible when used 1) after careful interdisciplinary evaluation and treatment of the patient, and 2) when palliative treatments that are not intended to affect consciousness have failed or, in the judgment of the clinician, are very likely to fail, 3) where its use is not expected to shorten the patient’s time to death, and 4) only for the actual or expected duration of symptoms. Palliative sedation should not be considered irreversible in all circumstances. It may be appropriate, in some clinical situations when symptoms are deemed temporary,
to decrease sedation after a predetermined time to assess efficacy, continued symptoms and need for ongoing sedation.

In clinical practice, palliative sedation usually does not alter the timing or mechanism of a patient’s death, as refractory symptoms are most often associated with very advanced terminal illness. Practitioners who use palliative sedation should be clear in their intent to palliate symptoms and to
not shorten survival. Because patients receiving palliative sedation are typically close to death, most patients will no longer have desire to eat or drink. Artificial nutrition and hydration are not generally expected to benefit the patient receiving palliative sedation, however questions about the use of artificial nutrition and hydration should be addressed before palliative sedation is undertaken. (See AAHPM Position Statement of Artificial Nutrition and Hydration Near the End of Life).

There is no clear consensus or scientific evidence regarding the most appropriate medication(s) to effect palliative sedation. As elsewhere in medicine, the agent should be selected based on safety, efficacy, and availability.

Although the Academy recognizes that existential distress may cause patients to experience suffering of significant magnitude, there is no consensus around the ability to define, assess, and gauge existential suffering, to measure the efficacy of treatments for existential distress, and whether it is in the realm of medicine to palliate such suffering when it occurs absent of physical symptoms. Patients with existential suffering should be thoroughly assessed and treated through vigorous multidisciplinary efforts which may include involving professionals who are not usual members of the palliative care team (e.g. experts in psychological, family therapy, or specific spiritual services). If palliative sedation is used for truly refractory existential suffering, as for its use for physical symptoms, it should not shorten survival.

Bibliography

Broeckaert, B. (2011). Palliative sedation, physician-assisted suicide, and euthanasia: “Same, same but different”? AJOB. 11, 62 – 64.

Cherny, N.I. Radbruch, L. for the Board of the European Association for Palliative Care. (2009). European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care, Journal of Clinical Oncology. 23, 581 – 593.

Claessens, P. Menten, J. Schotsmans, P. Broeckaert, B. (2008). Palliative sedation: A review of the research literature. Journal of Pain Symptom Management. 36, 310 – 333.

Claessens, P. Menten, J. Schotsmans, P. Broeckaert, B. on behalf of the Palsed Consortium. (2011). Palliative sedation, not slow euthanasia: A prospective, longitudinal study of sedation in Flemish Palliative Care Units. Journal of Pain Symptom Management. 41, 14 – 24.

Kirk, T.W. Mahon, M. M. (2010). National Hospice Palliative Care Organization (NHPCO) position statement and commentary on the use of palliative sedation in immediately dying terminally ill patients. Journal of Pain Symptom Management. 39, 914 – 923.

Kon, A.A. (2011). Palliative sedation: It’s not a panacea. AJOB. 11, 41 – 42.

Maltoni, M. Scarpi, E. Rosati, M. Derni, S. Fabbri, L. Martini, F. Amadori, D. Nanni, O. (2012). Palliative sedation in end-of-life care and survival: A systematic review. Journal of Clinical Oncology. 30, 1378 – 1383.

Morita, T. Akechi, T. Sugawara, Y. Chihara, S. Uchitomo, Y. (2002). Practices and attitudes of Japanese oncologists and palliative care physicians concerning terminal sedation: A nationwide survey. Journal of Clinical Oncology. 20, 758 – 764.

Olsen, M.L. Swetz, K.M. Mueller, P.S. (2010). Ethical decision making with end of life care: Palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clin Prac. 85, 949 – 954.

Powers, C.L. McLean, P.C. (2011). The community speaks: Continuous deep sedation as caregiving versus physician-assisted suicide as killing. AJOB. 11, 65 -66.

Quill, T.E. Lo, B. Brock, D.W. (2009). Last-resort options for palliative sedation. Annals of Internal Medicine. 141, 421 – 424

Schildmann Schildmann. (2014) Palliative sedation therapy: a systematic literature review and critical appraisal of available guidance on indication and decision making. J Palliat Med. 17(5):601-611.

Vacco vs. Quill, 117 S.Ct. 2293 (1997).

Washington v. Glucksberg, 117 S.Ct. 2258 (1997).

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