Palliative Sedation in Patients with Cancer Marco Maltoni, MD, and Elisabetta Setola, MD

Communication between patients, their relatives, and health care staff is very important when administered palliative sedation. Photo courtesy of Lisa Scholder. Organic Walk, 16" × 24". Palliative Sedation in Patients With Cancer Marco Maltoni, MD, and Elisabetta Setola, MD Background: 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 un- derstanding. Methods: The relevant medical literature pertaining to palliative sedation was analyzed and reviewed from various technical, relational, and bioethical perspectives. Results: 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. Conclusions: 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. Introduction sort in the final phase of a patient’s life. However, Within the context of palliative medicine, the prac- terminal sedation is a confusing and inappropriate tice of drug-induced sedation for symptom control term because it implies that the practice is designed — the use of all possible antisymptomatic treatments to shorten life; thus, more appropriate terminology notwithstanding — is called palliative sedation. His- was needed and, hence, the term palliative sedation. torically, palliative sedation was often known as ter- Its implementation into everyday clinical practice has minal sedation because it was considered a last re- led to the use of the term in the majority of studies focusing on this topic.1 From the Palliative Care Unit (MM), Istituto Scientifico Romagnolo By reducing the level of consciousness, palliative per lo Studio e la Cura dei Tumori, Meldola, Italy, and the Oncology sedation uses sedative medication to control refractory Unit (ES), Saint Giuseppe Hospital, Milan, Italy. symptoms in patients with cancer.2 As this approach Submitted April 15, 2015; accepted July 15, 2015. Address correspondence to Marco Maltoni, MD, Palliative Care became more widespread and was acknowledged as Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei an important part of palliative care, procedural princi- Tumori, Via P. Maroncelli 40, 47014 Meldola, Italy. E-mail: ples were needed to avoid malpractice. The guidelines [email protected] created clarified the definition and practice of pallia- No significant relationships exist between the authors and the companies/organizations whose products or services may be ref- tive sedation, also underlining its inherent and intrin- erenced in this article. sic difference from euthanasia.3-10 Various guidelines October 2015, Vol. 22, No. 4 Cancer Control 433 state that sedation in palliative care is a therapy mainly den procedure (see Table 1). Choice of sedation has a performed in the last days or hours of life, with an un- clinical basis and is oriented toward different clinical ambiguous aim, a precise procedure, and well-defined needs: rapid palliative sedation for catastrophic and results — all of which are in contrast to those of eutha- acute symptoms compared with proportional sedation nasia.9-12 In addition, use of palliative sedation does not for progressively worsening symptoms. Thus, imple- hasten death when conducted in accordance with stan- menting palliative sedation is based on the suddenness dard guidelines.13-15 of symptom appearance. Different methods of palliative sedation exist, Methods and Types namely, the proportional method of palliative seda- Some adjunctive characteristics of palliative sedation tion (also called proportionate palliative sedation), have been included in more detailed definitions of the and sustained, deep and continuous palliative se- practice.16 For example, the definition of palliative sedation from the onset, regardless of the intensity of dation as the “intentional administration of sedative symptoms.17-21 The latter suggests that relational con- drugs in dosages and in combinations required to re- tinuity between patients and relatives is not neces- duce the consciousness of a terminal patient as much sarily a value, that the concept of hastening or not as necessary to adequately relieve one or more refrac- hastening death is irrelevant (given the patient’s con- tory symptoms,” considers a number of specific param- dition), and that the process of drug titration may de- eters, including short-term prognosis, proportionality of lay the clinical effect of sedation. We consider that the intervention, effectiveness of the sedation through the supporters of this view are in favor of adminis- adequate monitoring, and refractoriness of symptoms.16 tering drugs in a “standardized” way, which leads to This definition also implies that palliative sedation is not deep sedation, and interrupting all forms of hydra- a fixed intervention; rather, it is a dynamic process that tion and nutrition. Taking this concept to an extreme, can be adapted to the needs of the patient.16 many patients in this setting would be candidates for Palliative sedation can vary in terms of depth of deep continuous sedation or continuous sedation un- sedation and correlated level of unconsciousness, til death. In our opinion, those in favor of using pal- continuity, drugs used, and rapidity of implementa- liative sedation in this way do not consider that this tion (Table 1). In that sense, palliative sedation is not view is a departure from the original practice; indeed, necessarily deep continuous sedation or continuous such an approach could be counterproductive to its sedation until death, which is the last step of a pro- large-scale implementation. gressive process. By contrast, some proportional palliative sedation supporters view proportionality as a fundamental “Proportionality” Theme characteristic of palliative sedation and maintain that When symptom-guided, dose-titrated, and result-as- relational continuity is an important issue.6,14 They also sessed, palliative sedation can be a progressive or sud- argue that the effects of palliative sedation on refrac- Table 1. — Definitions of Terms Used in Palliative Sedation Term Definition Depth Superficial Patient conserves (at least partially) the ability to communicate with family or caregivers Deep Patient enters a state of total unconsciousness Continuity Intermittent Sedation is performed for a limited period of time for a specific symptom and discontinued if a reduction (albeit slight) in the distress caused by the symptom has been obtained Continuous Drugs are administered without interruption to obtain a persistent effect, which more frequently occurs near death and in severe cases Use of Drugs Primary palliative sedation Sedatives are used to lower the level of consciousness Secondary palliative sedation Dosage of drugs primarily used for symptom control (ie, morphine for pain or dyspnea) is increased to make use of an adverse event (eg, somnolence) to reduce the level of consciousness (not recommended) Rapidity of Administration and Effect Progressive Most common method in which the dose of sedative drugs is monitored and modified according to patient needs Sudden, rapid intervention method Also called “emergency” sedation; required for a catastrophic event such as massive bleeding, severe dyspnea, agitated delirium, or acute pain 434 Cancer Control October 2015, Vol. 22, No. 4 tory symptoms must be carefully monitored to avoid been explored.5 In the event of insufficient psy- undersedation or oversedation and that the drug dos- chological support, the palliative care team may age should be individually titrated to the minimum be at risk of burn out and, thus, might perform effective dose level.6,14 Not every palliative sedation is unnecessary palliative sedation36 deep continuous sedation or continuous sedation until • Adoption of wider or narrower definition of pallia- death, and the latter approach is required in patients tive sedation may influence prevalence for whom a lower level of sedation is insufficient to However, the real frequency of palliative sedation control refractory symptoms.7,22-25 A survey carried out has also been suggested to vary: possibly between 25% by Putman et al26 on intention and practice in US physi- and 35% of all patients admitted to a hospice or pallia- cians reported that many of these physicians preferred tive care unit.14,15 In home-care hospice programs, pal- the proportional method, because they did not wish to liative sedation may be a feasible option. Mercadante pursue full unconsciousness in patients without moni- et al37 reported that 13.2% of patients with cancer were toring the effect of such sedation. sedated in their homes. Moreover, some of the first articles published on palliative

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