Transcript should not - Compassus

Issues in Palliative Sedation
Bruce A. Ferrell, MD
Professor of Clinical Medicine
UCLA David Geffen School of Medicine
Director of Palliative Care
Disclosures
• None
Background
• Healthcare professionals have an ethical obligation to
provide comfort and relieve suffering, especially near
the end of life.
• They dying process may be attended by intractable
pain and suffering despite vigorous efforts.
• In rare circumstances, it may be appropriate to
specifically sedate a patient to achieve intractable or
intolerable symptom relief.
Ordinary Sedation
• Sedation is the administration of a drug that causes
an alteration of consciousness.
• Many medications intended for distressing symptom
relief (moderate pain, anxiety, insomnia, depression,
etc.), may cause minimal, limited or temporary
sedation.
• Emphasis on “intent” and “limited”
Definitions
• Palliative sedation is the lowering of patient
consciousness for the purpose of limiting intolerable
or intractable symptom relief and suffering.
– Respite: Time Limited
– Terminal: In the last hours until death
Palliative Sedation
• U.S. Supreme Court ruled in 1997 that patients with terminal
illness who are experiencing great pain should have “no legal
barriers to obtaining medication, from qualified physicians, to
alleviate that suffering, even to the point of causing
unconsciousness and hastening death.”
• Both the American Medical Association and the National
Ethics Committee of the Veterans Health Administration have
issued ethics policies endorsing the use of palliative sedation.
Features of Sedation
Intervention
Cause of Death
Intent
Legal Status
Respite Sedation
Underlying disease
Alleviation of
symptoms for a
predetermined time
period
Legal in all states
Palliative Sedation
Underlying disease
Alleviation of
symptoms
Legal in all states
Physician Assisted
Suicide
Medication prescribed
by physician used by
patient
Termination of life
Legal in California,
Oregon, Washington,
Vermont
Euthanasia
Medication
administered by
physician
Termination of life
Illegal in all states
Principles
• Palliative sedation SHOULD NOT be used with the
intent to cause or hasten death.
• Palliative sedation SHOULD NOT be used for purely
existential suffering.
• Physicians or other healthcare professionals who
object to providing palliative sedation for reasons of
conscience may withdraw from the case but ensure
that the patient is not abandoned.
Principles
• Palliative sedation should be used only as a last
resort for comfort.
• Informed consent must be obtained prior to
palliative sedation.
• Palliative sedation should be limited to those near
the end of life.
• Patients for palliative sedation should have a DNR
order.
Compassus Policy
• The primary physician and hospice medical director
have agreed on the need and patient eligibility.
• Hospice medical director has consulted with another
medical director and documented the consultation.
• Note: It is recommended that the medical director
consults with a member of the Compassus Medical
Director Advisory Committee
Documentation is Critical
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Patient criteria
Failed treatments
Intent of sedation
Informed consent
Concurrence of consultants
Consistence with policy
Drugs for Palliative Sedation
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Midazolam (Versed)
Propofol (Diprivan)
Lorazepam (Ativan)
Phenobarbitol
Ketamine
Dexmedetomidine (Precedex)
Summary
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Palliative Sedation is a tool to be used rarely
Remains controversial in some areas
Documentation is critical
Consult Hospice Compassus Policy