Friday, September 18, 2009
Palliative Sedation in Annals
Annals has a review of 'last resort' palliative sedation techniques (this makes two Tim Quill papers in a month in Annals). It begins with an apparently true story of a home hospice patient who was denied 'total sedation' despite refractory symptoms and requesting it (patient had to fire the hospice, and a previous palliative care consultant physician managed deep sedation for him over the phone: crazy).
The paper attempts 3 things: first, it tries to clarify the language used to describe sedating practices at life's end; second, it discusses ethical controversies about sedation; and third, it makes some practical suggestions that palliative sedation should be practiced by organizations only with explicit policies, procedures, and quality control.
The language proposed in the paper are three phrases:
- Ordinary sedation: attempts to relieve a symptom (e.g. anxiety) without trying to alter a patient's level of consciousness. (I don't know why this then would be called 'sedation' as opposed to, e.g., anxiolysis with a medication which can have a sedating side effect, but that's not really important here.)
- Proportionate Palliative Sedation (from the article): sedating medications (usually benzodiazepines) are progressively increased alongside other symptom-relieving measures, resulting in increasing levels of sedation during both waking and sleeping hours to help relieve suffering. It is usually initiated in response to otherwise intractable physical suffering in imminently dying patients, as in the case described, for example, or for agitated terminal delirium. The end point is relief of suffering that is acceptable to the patient by using the minimum amount of sedation needed to achieve this goal.
- Palliative Sedation to Unconsciousness: This is what has variously been known as 'terminal sedation,' 'continuous deep sedation,' etc. Deliberately, pharmacologically, inducing a state of unconsciousness in order to relieve otherwise refractory symptoms, and with a plan of maintaining such a state until the patient dies (usually while withholding life-sustaining treatments otherwise such as artificial hydration/nutrition). They mention that this has been proposed, controversially, for existential suffering.
One can appreciate that, in real life, what starts as PPS 'turns into' PSU in those rare occurances when you realize relief of suffering cannot be obtained without induction of unconsciousness, and that clinicians on the ground often don't spend too much time worrying about whether they are doing PPS or PSU. I also wonder that, with these definitions, and by describing PSU as a last resort practice, which it should be and I think by and large is used this way, one should argue that PSU should only be peformed after a trial of PPS, because how else can we be sure it is a last resort option? Which is another indication that trying to distinguish between these practices on the grounds of initial therapeutic goal (adequate sedation vs. coma) can't entirely account for real clinical practice - I think it's fuzzier. That said, there are times in which PSU is attempted from the get-go; for me it's when I conclude suffering is tremendous and death is very imminent (and I don't have hours or a couple days to tinker - or if I did it would be at the expense of ensuring a peaceful death) and you just go straight for deep sedation. Of course, I'd argue this is absolutely 'proportionate' when the alternative is a scenario when an imminently dying patient spends half their remaining hours suffering just so I can be 100% sure that I'm being 'proportionate.'
Which highlights the element of all this which I think they undersell in this paper: the question of imminence. It's actually barely mentioned, at least in frank terms. While they discuss ethical objections to PSU (as potentially death hastening, such as when artificial nutrition and hydration are withheld), such objections, to me, only have merit (which is not to say one has to agree with them) if one concludes that providing PSU is materially death-hastening (by weeks, months let's say). A declining, advanced cancer patient, bedbound, not taking much PO, who is developing altered mental status - this is someone who has days to maybe a couple weeks to live (generally speaking) - PSU without artificial nutritional support is unlikely to be death hastening, and if so by hours or a day or two. And if one is worried about hours or a day or two in dying cancer patients then we should all be debating about whether we should intubate and ventilate these patients to get them those precious days.
These questions have not been rigorously researched (there have been some preliminary attempts), and certainly would be difficult to study (e.g. prognoses of patients who have PSU performed, etc.). Along these lines the authors note that it's very difficult to tell in the palliative sedation literature what exact practice is being studied, due to the lack of agreed upon definitions of these practices. It's possible the authors don't believe imminence, per se, matters - it's less important than the refractory nature of the symptoms and lack of other options. Fair enough, but not foregrounding the importance of prognosis gives fuel to the fire that PSU is PAS-lite, or otherwise ethically suspicious. We all think in terms of risk-benefits; and the risk of a loss of two days vs 2 months, to me, are different.
Leaving my agenda aside here, the paper also gives important recommendations to all hospice and palliative care groups to establish sedation policies, procedures, checks, and quality control to both ensure the best possible care but to also mitigate potential for abuse or misinterpretation of these practices. I think one could also add we, as a community, should agree upon research definitions of these terms, to improve our ability to actually study sedation practices.
(Image is from an August Annals issue.)
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3 Responses to “Palliative Sedation in Annals”
September 19, 2009
I think imminence is crucial - otherwise PSU becomes an alternative to intrathecal analgesia for difficult pain issues, or to PAS for those who can't travel to Belgium. That's fine if society so desires, but let's be honest. Survival from onset of PSU is short. By calling it PSU, we'd be fooling some of ourselves some of the time.
I do wish I was more efficient in the pharmacological approach to proportionate sedation for refractory symptoms in imminently dying patients (am reserving PPS for a certain performance measurement tool). Too often, as Drew says, 50% of those remaining few days have incomplete symptom relief while I proportionately titrate with blunt instrument neurolep/bzd/opioid cocktails. Propofol, anyone?
We had two cases just this week requiring proportionate sedation - a young woman with agitated delerium dying of cancer & a man with ALS who wished ventilator withdrawl at home.
We have an 'exception to policy' allowing us to use propofol on our palliative care unit, which I have never used. Am going to have a look at Critical Care Vol 12 Suppl 3 Analgesia and sedation in the intensive care unit & invite an intensivist to discuss with our fellows.
Always a good topic for an AAHPM meeting ...
Paul McIntyre
Halifax, NS
September 19, 2009
I wonder about how we distinguish deep palliative sedation in the home or inpatient palliative care setting, compared with the ICU. Meaning, when we intentionally withdraw life support in the ICU in order to allow death to proceed, it is rare for there to be confusion about why we induce or maintain unconsciousness in the patient. There are protocols to follow, and agreement about how and when to do this. We consider suffering in terms of patient and family. Family members are often hoping for a quick death (a "hastened" death?) although I have occasionally encountered objections to hastening death, even by a few moments, by ICU nurses. In general, though, it is not "controversial" per se, whereas it seems to be controversial in palliative care settings, where the intent is a peaceful death. Any thoughts about this?
September 20, 2009
Hi Paul. Re: efficiency - I think we all wish the same. You never know, of course, when you start out whether you're looking at one or two doses, or a single dose escalation --> acceptable comfort/symptom relief vs. hours/days of titration; home vs. hospital/hospice-palliative unit makes a difference too.
At my institution we use barbituates and that's what I'm comfortable with. I'd be curious if there were other institutions which allowed propofol outside of the ICU/operative areas as well?
Risa: if I'm reading you correctly you are saying for the most part you've seen general comfort with deeply sedating dying patients in ICUs but not in palliative settings? I can't say that I've noticed that, but it might be institution-dependent. ICUs and vent withdrawals are good examples, though, of why the language and attempts to parse out intent can be confusing. There are so many variations here and why exactly drugs are used:
1) Spontaneously comatose (e.g. due to a brain injury for instance but not meds) patient on vent who is showing signs of labored respiration: opioids/sedatives to treat 'discomfort'/labored resps even if patient appears to be comatose and not experiencing anything. This is not exactly sedation even, although it is symptom palliation.
2) Dying patient in drug-induced coma on vent (started for routine ICU vent/sedation reasons) who is expected to die shortly once vent is d/c'd: continue meds to ensure minimization of suffering once vent is off. What do we call this type of sedation?
3) Awake patient who is vent dependent and wants to come off (ie. end stage pulmonary fibrosis) who is expected to suffer tremendously from air hunger once the vent is d/c'd: what do we call pre-sedating them to ensure no suffering once vent is off? seems kinda like PSU but one should note it is actually started to prevent future suffering and not to treat current.
At times I've used identical drugs in an identical fashion in scenario #1 than I have with #3 - my intent both times was to minimize symptoms/suffering in imminently dying patients, and the approach, dosing strategies, etc. were identical. Using the intent framework proposed in this paper #3 is like preemptive PSU and #1 PPS except that the patient is already comatose and the intent is not to sedate but to ameliorate gasping/snorting/what-looks-to-families-as-choking-suffocating-to-death. I bring this up because, again, I think the boxes (definitions) we put things into fail, at times, to really describe actual practice. Useful, but.... None of which is to say that the importance of quality standards and protocols as proposed in the paper cannot be overstated.
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