Palliative or Terminal Sedation Overview

Alleviating suffering when all else fails

Senior man at palliative care unit
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Despite even the best palliative care, some people can't get adequate relief from their suffering and may need what's known as palliative sedation to avoid agony and distress.

Before sedation is considered, the team of people caring for you or your loved one—often known as the palliative care team—will look at many possible options to help relieve suffering, such as aggressive symptom management (using any and all medications and treatments that may help) and mental support to help with emotional concerns.

The goal is to make the suffering person as comfortable as possible. When this effort isn't enough, palliative sedation may be an option.

Pain Management

Sometimes symptoms are difficult to treat and don't seem to respond to any treatment. This outcome is sometimes seen in people who have cancer and experience severe pain. Despite high doses of pain medications, some pain just can't be relieved. Other symptoms may cause severe distress as well—frequent and severe nausea and vomiting, uncontrollable tremors or seizures, and severe breathlessness are just a few examples of distressing conditions. In these cases, sedation may be the only way to get adequate relief.

Once the decision has been made by a physician in cooperation with the patient or her decision maker to use palliative sedation, a sedative medication is given and increased until the desired comfort level is achieved. Often, people undergoing palliative sedation maintain consciousness while sedated to a comfortable degree.

But if you or your loved one still experiences intolerable symptoms, inducing unconsciousness may be an acceptable last resort.

Medication Therapies

Medications used to sedate someone may include anti-anxiety drugs such as Valium (diazepam) and phenobarbital, or pain medications. The feeling of sedation may range from a gentle calm sensation to complete unconsciousness.

Generally, the lowest amount of sedative medication that has the desired effect of relieving suffering is used to ensure that the person being treated remains conscious for as long as possible.

If inducing an unconscious state is the only way to relieve suffering, it may be tried as a temporary solution with the medical staff allowing the sedatives to wear off to reassess the patient's comfort level. It may be decided that the only way to ensure comfort is to maintain complete sedation until death occurs. If this approach is followed, death will usually occur within one week. One study indicates the average time is about 27 hours.

Clinical Criteria

There are typically three criteria that a patient's case should meet before palliative sedation is considered:

  • Alternative means of alleviating suffering have been ineffective or have produced intolerable side effects
  • The goal of sedation must be to alleviate suffering, not end the patient's life or hasten death
  • The patient must be close to death already, so sedation would not significantly shorten survival

Palliative sedation is never done without the patient's or his appointed decision maker's consent. This requirement is what is referred to as an autonomous decision—one that is made by the person being affected, or a surrogate, based on his or her personal values, beliefs, and goals.

The requirement for healthcare providers to secure this permission ensures that the decision, if chosen, is made in line with the individual's personal wishes and without the influence of a doctor's personal ethics regarding the matter.

Sources:

Bernard Lo, MD; Gordon Rubenfeld, MD, MSc. "Palliative Sedation in Dying Patients". JAMA. 2005;294:1810-1816.

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