Comments on Pallimed: A Hospice & Palliative Medicine Blog: Palliative Sedation in Annals

Hi Paul. Re: efficiency - I think we all wish the...

2009-09-20T19:39:29.439-05:00

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.

I wonder about how we distinguish deep palliative ...

2009-09-19T11:32:30.156-05:00

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?

I think imminence is crucial - otherwise PSU becom...

2009-09-19T05:46:28.770-05:00

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