Transcript Palliative Sedation

Debra Nobbe, RN, CNS, ACHPN
[email protected]
Brian Bagley-Bonner, MDiv
bbonner#@hospicewr.org
Exploring Palliative Sedation
The What, Why, When, and How?
Objectives
 Define and discuss Palliative Sedation by
reviewing current evidenced based research
 Explore legal and ethical precedents
Objectives
 Discuss Hospice of the Western Reserve’s
Practice and Procedure
 Discuss refractory pain and suffering
by building on a holistic model
One Definition
Palliative Sedation is the monitored use of
medications to relieve refractory and
unendurable physical, spiritual and psychosocial distress for patients with a terminal
diagnosis, by inducing varied degrees of
unconsciousness. The purpose of the
medication is to provide comfort and relieve
suffering and not to hasten death.
- Hospice and Palliative Care Federation of Massachusetts.
Levels of Sedation
 3 levels of sedation
– Mild (Somnolence) pt awake - level of
consciousness lowered
– Intermediate/Respite (stupor) pt asleep but can
be woken to communicate briefly
– Deep (coma) the patient is unconscious and
unresponsive
DeGraeff & Dean
Precedents to Consider
Legal
Ethical
Legal Precedent
1997 US Supreme Court ruled:
“a patient who is suffering from a terminal
illness and who is experiencing great pain has
no legal barriers to obtaining medication, from
qualified physicians, to alleviate suffering, even
to the point of causing unconsciousness and
hastening death…”
Ethical Principles
 Double Effect
 Beneficence
Why?
To alleviate a patient’s pain and
suffering.
Cycle of Pain and Suffering
Physical
Emotional
Pain
Suffering
Spiritual
Social
How Can We Stop the Cycle?
Sedation
as a Side
Effect
Sedation
as
Primary
Means of
Reducing
Suffering
Physician
Assisted
Suicide
(PAS) as
Primary
Means of
Ending
Suffering
Meds
allow
sleep
Respite
PAS
Sedation
Meds cause
drowsiness
Meds
ensure
sleep
Palliative
Sedation
Double
Effect
Sedation
as a Side
Effect
Sedation
as
Primary
Means of
Reducing
Suffering
Physician
Assisted
Suicide
(PAS) as
Primary
Means of
Ending
Suffering
Who?
Assessing Appropriateness:
 Terminal Illness
 Symptoms
 Dyspnea
 Delirium/Agitation
 Physical Pain
 N/V and Uncontrolled Bleeding
 Anxiety/psychological distress *
 * Not The American Medical Association (AMA)
When?
How to determine when a symptom is truly refractory?
– Are further interventions capable of providing relief?
– Is the anticipated acute or chronic morbidity of the
intervention tolerable to the patient?
– Are the interventions likely to provide relief within a
tolerable time frame?
*J. Hallenbeck, MD National Ethics Tele-Conference 7/26/06
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30 years old
Stage 4 lymphoma
Drug/Alcohol Abuse
Juvenile Behavior
Limited Coping Skills
Multiple Wounds
Refractory
Pain/Anxiety
w/dressing changes
 Breaking Cycle
Hospice of the Western Reserve’s
Practice and Procedure
Purpose
– To safely and effectively induce and monitor
palliative sedation (lowered conscious awareness)
as a means to manage refractory symptoms. The
determination of when palliative sedation is being
utilized is based solely on the intent for which it is
prescribed, rather than the medication used, the
dose, or the route by which it is given.
Hospice of the Western Reserve’s
Practice and Procedure
 Procedure Requirements
– Define refractory symptom (s)
– DNRCC in effect
– Patient/Family Education
– Review/complete psychosocial and spiritual
assessment
How?
Medications
“The choice of an agent is dependent , for
the most part, upon clinical institutional
policy and formulary restrictions. Also
in difficult cases a second medication
may be needed to sedate a patient
adequately. Medications may be
administered sublingually, rectally,
intravenously or subcutaneously.”
Rousseau End of Life Online Curriculum
Medications
Patient goal drives titration phase
State and Federal Laws
Benzodiazepines
Lorazepam (Ativan)
Midazolam (Versed)
Antipsychotic
Chlorpromazine (Thorazine)
Butyrophenone
Haloperidol (Haldol)
Barbiturates
Phenobarbital
Medications and Suggested Doses for Palliative Sedation
Drug
Suggested Dose (a)
Midazolam
0.5-5 mg bolus IV/SC, then CII/CSI at 0.5-1 mg/h; usual
maintenance dose, 20-120 mg/d
Lorazepam
0.5-2 mg PO, SL, or SC every 1-2 hours OR
1-5 mg bolus IV/SC, then CII/CSI at 0.5-1 mg/h; usual
maintenance dose, 4-40 mg/d
Chlorpromazine
10-25 mg PO, IV, or PR every 2-4 hours
Haloperidol
0.5-5 mg PO or SC every 2-4 hours OR
1-5 mg bolus IV/SC, then CII/CSI at 5 mg/d; usual maintenance
dose, 5-15 mg/d
Pentobarbital
60-200 mg PR every 2-4 hours OR
2-3 mg/kg bolus IV, then CII at 1 mg/h; titrate upward to
maintain sedation
Thiopental
5-7 mg/kg bolus IV, then CII at 20 mg/h; usual maintenance dose,
70-180 mg/h
Propofol
10 mg/h as CII; may titrate by 10 mg/h every 15-20 minutes;
bolus of 20-50 mg may be used for emergency sedation
a
Clinicians should consult pharmacy textbooks, pharmacists, and other
knowledgeable professionals for further dosing suggestions. PO=oral; PR = per
rectum; SL=sublingual; SC=subcutaneous; CII=continuous intravenous infusion;
CSI=continuous subcutaneous infusion. Rousseau P. 2004 used with permission
Hastening Death?
Recent studies have found no
difference in survival between
hospice patients who required
sedation for intractable symptom
control during their last days and
those who did not.
M. Maltone, C Pittureri, L Piccinini et all.
Implementation into Practice
Intent
Physical
Emotional
Individualized
Spiritual
Social
Education - early conversations
In Summary
Patients need and deserve
assurance that suffering will be
effectively addressed, as both the
fear of suffering and the suffering
itself add to the burden of the
terminal illness
- AAHPM position Statement 9/15/2006b
References
 Slide 2 – Palliative Sedation Protocol -Resources and
conferences -Best Practices – Reports – Hospice and Palliative
Care Federation of Massachusetts Web Page
http://www.hospicefed.org
 Slide 3 – DeGraef A and Dean M, Palliative Sedation Therapy
in the Last Weeks of Life; A Literature Review and
Recommendations for Standards, Journal of Palliative Medicine,
vol 10 Number 1, 2007
 Slide 7 - Compassion in Dying v Washington, 79 F3d 790 (9th Cir
1996) (en banc) and Quill v Vacco, 830 F3d 716 (2nd Cir 1996).
 Slide 14 – AMA meeting: AMA OKs palliative sedation for
terminally ill. O’Reilly, K, amednews.com July 7,2008
 Slide 15 –Hallenbeck J, MD
http://www.ethics.va.gov/pubs/netsum.asp National Ethics TeleConference 7/26/06
 Slide 19 -Rousseau P. Existential suffering and palliative
sedation: a brief commentary with a proposal for clinical
guidelines. American Journal of Hospice and Palliative Care
2001;18:226-228
References
 Slide 24 - Maltoni M, Pittureri C, Piccinini L et al. Palliative
sedation therapy does no hasten death: results from a
prospective multicenter study Annals of Oncology 2009
20:1163-1169
 Slide 25 – Rousseau P. Palliative Sedation in the management of
refractory symptoms. J Support Oncol. 2004 Mar-Apr; 2(2):181-6
 Kirk T, Mahon M, NHPCO Positions Statement and
Commentary on the Use of Palliative Sedation in
Imminently Dying Terminally Ill Patients. Journal of Pain and
Symptom Management Special Article 2010 doi
10.1016/j.jpainsymman.201.01.009
 Seale, C Continuous Deep Sedation in Medical Practice .
Journal of Pain and Symptom Management Vol. 39 No. 1 January
2010 doi 10.1016/j.jpainsymman.2009.06.007
 PEDIATRIC – Anghelescu D, Hamilton H, Faughnan et al. Pediatric
Palliative Sedation Therapy with Propofol: Recommendations
Based on Experience in Children with Terminal Cancer. Journal
of Palliative Medicine 2012 15(10): 1082-1090
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