Transcript Palliat Med

Palliative Sedation at the
End-of-Life
Gary D. Ceneviva, MD
Penn State Hershey Children’s Hospital
Objectives
 Describe the Patterns of Childhood Death
 Define Palliative Sedation
 Describe the Indications and Conditions of
Palliative Sedation
 Discuss the Ethics of Sedation at the End of
Life
 Describe Palliative Medication Selection,
Dosing, and Titration
Epidemiology
 Approximately 500,000 children cope with
life-threatening conditions annually in the
United States1
 Over 50,000 infants and children die annually
in the United States2
1. Himelstein BP et al. N Eng J Med 2004; 350:1752
2. Hoyert DL et al. Pediatrics 2006; 117:168
Leading Causes of Infant Death
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Congenital & Chromosomal Anomalies
Disorders related to SGA & LBW
SIDS
Maternal Complications of Pregnancy
Complications of Placenta, Cord & Membranes
Respiratory Distress
Accidents
Bacterial Sepsis
Diseases of the Circulatory System
Intrauterine Hypoxia & Birth Asphyxia
Martin JA et al. Pediatrics 2005; 115:619
Leading Causes of Childhood
Death (1- 19 years old)
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Accidents (unintentional injuries)
Assault (homicide)
Malignant Neoplasms
Intentional Self Harm (suicide)
Congenital & Chromosomal Anomalies
Diseases of Heart
Chronic Lower Respiratory Diseases
Influenza and Pneumonia
Septicemia
Cerebrovascular Diseases
Martin JA et al. Pediatrics 2005; 115:619
Epidemiology
 1 in 5 Americans die using intensive care
services
 Nationally, this translates to approximately
540,000 Americans each year
Angus DC et al. Crit Care Med 2004: 32:638
Epidemiology
Feudtner C et al Pediatrics 2006; 117:e932
Angus DC et al. Crit Care Med 2004; 32:638
Epidemiology
 Commonly these children die following
a decision to either withdraw or limit life
sustaining therapies
Vernon DD et al. Crit Care Med 1993; 21:1798
Mink RB et al. Pediatrics 1992; 89:961
Sedation in Palliative Care –
Definition and Terminology
 Sedation
 Terminal sedation
 Sedation for intractable distress in the
imminently dying
 End of life sedation
 Total sedation
 Sedation in terminal or final stages of life
 Palliative sedation
 Palliative sedation therapy
Morita T et al. J Pain Symptom Manage 2002;24:447
De Graeff A et al. J Palliat Med 2007;10:67
Terminal Sedation
 Often used in the USA literature
 Does not emphasize symptom palliation
 May be interpreted as an intention to
terminate the patient’s life
Palliative Sedation
 The use of sedative medications to relieve
intolerable suffering from refractory
symptoms by a reduction in patient
consciousness
Morita T et al. J Pain Symptom Manage 2002;24:447
De Graeff A et al. J Palliat Med 2007;10:67
Criteria for Palliative Sedation Intolerable Suffering
 Subjective
 The patient can only determine the suffering
to be intolerable
 If the patient is unable to express the degree
the discomfort or suffering experienced a
proxy judgment by family and care givers
should be sought
Palliative Sedation
 The use of sedative medications to relieve
intolerable suffering from refractory
symptoms by a reduction in patient
consciousness
Morita T et al. J Pain Symptom Manage 2002;24:447
De Graeff A et al. J Palliat Med 2007;10:67
Criteria for Palliative Sedation Refractory Symptoms
 Further interventions are:
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Not capable of providing adequate relief
Associated with excessive or intolerable
morbidity
Unlikely to provide relief within a tolerable time
frame
 Implies an experienced colleague or palliative
care specialist judge the symptom refractory
Cherney NI et al. J Palliat Care 1994;10:31
Criteria for Palliative Sedation Refractory Symptoms
 Dyspnea
 Pain
 Agitation
 Delirium
 Nausea or vomiting
 Seizures
 Myoclonus
Levy MH et al. Semin Oncol 2005;32:237
Palliative Sedation
 The use of sedative medications to relieve
intolerable suffering from refractory
symptoms by a reduction in patient
consciousness
Morita T et al. J Pain Symptom Manage 2002;24:447
De Graeff A et al. J Palliat Med 2007;10:67
Criteria for Palliative Sedation Patient Selection
 Applies to patients with progressive or
terminal diseases with a life expectancy of
hours to days
 The illness is irreversible and death is
expected imminently
 An order to withhold cardiopulmonary
resuscitation must be obtained before
sedation is instituted
Levy M et al. Semin Oncol 2005;32:237
Case
 A 5 year old with stage 4 neuroblastoma has
recurrent disease despite surgery, chemotherapy,
and a bone marrow transplantation. She develops
severe bone pain refractory to opioids and adjuvant
analgesics. Palliative sedation was considered the
most viable option for symptom control. The mother
is told that the additive effects of these medications
could predispose the patient to respiratory
depression and death, even though this was not the
primary aim of the treating doctor.
Collins J. Ethics Rounds 1998;15:258
Nurses Perspectives with Palliative
Sedation
 Some nurses thought palliative sedation had
not accelerated death
 Others thought that it may have accelerated
death but that this was justified when there
was no other way of relieving discomfort.
 A third group thought that palliative sedation
was close to the practice of euthanasia and
they often found it difficult to be involved in its
use.
Rietjens J et al. Palliat Med 2007;21:643
Ethics of Palliative Sedation
 Is palliative sedation different form physician
assisted suicide and euthanasia?
 Is palliative sedation ever ethically
appropriate for patients who are not
imminently dying?
 Should willingness to forgo life sustaining
treatment be a condition for administering
palliative sedation?
 May palliative sedation be provided to
patients who lack decision making capacity?
National Ethics Committee Am J Hosp Palliat Med 2007;23:483
Is Palliative Sedation Different From
Physician Assisted Suicide and Euthanasia?
 Intention (Principle of Double Effect)
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The primary intention in physician assisted
suicide and euthanasia is to cause the
patient’s death; the patients suffering ends as
a result
The primary intention in palliative sedation is
to relieve the patient’s suffering; death occurs
as result of the underlying disease process
 Deep sedation is unlikely to hasten death
Levy M et al. Semin Oncol 2005;32:237
Partridge et al. Pedatrics 1997;99;76
Chan JD et al. Chest 2004;126:286
Is Palliative Sedation Ethically Appropriate
for Patients Who Are Not Imminently Dying
 Palliative sedation is understood to be an
intervention of last resort at the end of life for
terminally ill patients who are imminently
dying
 Allowing palliative sedation when the patient
can be expected to live for months risks
eroding the distinction between palliative
sedation and physician assisted suicide
Is Forgoing Life Sustaining Treatment
a Condition for Palliative Sedation
 Consensus in the professional community is
that candidates for palliative sedation should
have a DNR order
 There is no compelling argument to limit other
concurrent life sustaining interventions such
as artificial nutrition & hydration for patients
who receive palliative sedation
May palliative sedation be provided to
patients who lack decision making
capacity?
Decision Making Capacity &
Competency
 Refers to the ability of a person to make
decisions
 Involves 3 essential elements
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The ability to understand & communicate
information relevant to a decision
The ability to reason and deliberate
concerning a decision
The ability to apply a set of values to decision
AAP Committee on Bioethics Pediatrics 1994; 93:532
Decision Making Capacity &
Competency
 Surrogates
Usually the parents
 May include other family members or court appointed
guardians
 Emancipated minor
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Definition varies from state to state
Examples: high school graduates, married, members
of the armed forces, pregnant or parents, or those
living apart independently from their parents
 Mature Minor
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Definition also varies among courts and legislatures
> 14 years old assessed to have decision making
capacity
AAP Committee on Bioethics Pediatrics 1994; 93:532
Standards for Decision Making
 Substituted Judgment Standard
 Surrogates can make inferences about the preferences
of previously competent patients
 Can be used for children who are emancipated or
mature
 Best Interest Standard
 Serves as the basis for decisions for patients who
never achieve decision making capacity
 Usually used by surrogates of infants and young
children
May Palliative Sedation be Provided to
Patient’s Lacking Decision Making Capacity
 Confining palliative sedation to patient who
have decision making capacity risks
excluding many patients whose suffering
cannot be relieved by other means for whom
surrogates are empowered to make all other
treatment decisions
Case
 DG is a 6 week old premature infant with a past
medical history of trisomy 18, moderate sized atrial &
ventricular septal defects, pulmonary hypertension,
ventricular tachycardia, and renal insufficiency who
was admitted to the PICU following an out of hospital
cardiopulmonary arrest. The hospital course was
remarkable for severe multiple organ dysfunction.
 Following several discussions with DG’s family
regarding her grave prognosis the family requested
all life sustaining therapies be withdrawn
Respiratory Distress Versus Agonal
Breathes
 Respiratory distress manifested by:
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Increased work of breathing
A sense of shortness of breath (dyspnea)
Signs of air hunger
 Agonal Respirations (terminal breathes)
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Breaths occur sporadically with long periods of
apnea
The patient is invariably unconscious
reflexive
Choosing a Medication Regimen
 Plan needs to include
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Selection of medication(s)
Starting doses of the medication(s)
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usually administered before extubation
Titration of the medication(s)
 Needs to relieve all signs of discomfort
including grimacing, agitation, anxiety, and
physiologic signs of distress
Narcotics
 When used alone, are usually insufficient in
the management of air hunger and
respiratory distress at the end of life
Palliative Sedation Medications
 Anxiolytic Sedatives
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Midazolam, lorazepam
 Neuroleptics
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Haloperidol
 Barbituates
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Phenobarbital, thiopental, pentobarbital
 General Anesthetics
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Propofol, ketamine
Levy MH et al. Semin Oncol 2005;32:237
De Graeff A et al. J Palliat Med 2007;10:67
Chater S et al. Palliat Med 1998;12:255
Palliative Sedation Medications
Sedation During Withdraw of
Ventilation
Burns JP et al Crit Care Med 2000;28:3060
Neuromuscular Blockade (NMB)
 NMBA may be required to facilitate mechanical
ventilation
 NMBA possess no sedative or analgesic
activity
 Prevents the assessment of a patient’s pain or
level of sedation
Truog RD et al. Crit Care Med 2001; 29:2332
Neuromuscular Blockade Agents
 Approximately 1/3 of pediatric intensivists &
over 85% of other pediatric subspecialists
were either uncertain or agreed that it was
appropriate to provide NMB with analgesia
before withdrawing a ventilator in a child
whose death was imminent
Solomon MZ et al. Pediatrics 2005; 116:872
Guidelines for the Use of NMB
When Ventilation is Withdrawn
 NMB should never be introduced when
mechanical ventilation is being withdrawn
 In patients who are already receiving NMB,
neuromuscular function should be restored
before the life support is withdrawn.
Troug RD et al. New Engl J Med 2000; 342:582
Guidelines for the Use of NMB
When Ventilation is Withdrawn
 The only exception to this rule should be:
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Death is expected to be both rapid and certain
and the burden to the child & family of waiting for
the neuromuscular blockade to diminish to a
reversible level exceed the benefits of allowing
better assessment of the patient's comfort and the
possibility of interaction with loved ones.
Troug RD et al. New Engl J Med 2000; 342:508
Guidelines for the Use of NMB
When Ventilation is Withdrawn
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When death is expected to be both rapid and
certain after the removal of ventilation, and
When the burdens to the child & family of waiting
for the neuromuscular blockade to diminish to a
reversible level exceed the benefits of allowing
better assessment of the patient's comfort and the
possibility of interaction with loved ones.
Troug RD et al. New Engl J Med 2000; 342:508
Conclusion
 Most pediatric deaths occur in intensive care
settings following a decision to forgo life
sustaining therapies
 Palliative Sedation is the use of sedative
medications to relieve intolerable suffering
from refractory symptoms in patients who are
imminently dying