Palliative sedation is the medical practice of using sedative medications to relieve intolerable suffering in terminally ill patients by inducing decreased or absent awareness. It is an important and ethical option in end-of-life care when symptoms cannot be adequately controlled while keeping the patient conscious.
What is palliative sedation?
Palliative sedation involves administering sedative medications to terminally ill patients to induce a state of decreased or absent awareness in order to relieve suffering from refractory symptoms. Refractory symptoms are symptoms that cannot be adequately controlled while keeping the patient conscious. Palliative sedation is only considered as a last resort when all other symptomatic treatments have failed. The goal is to relieve suffering, not to hasten death. Patients are kept comfortable with small incremental doses of sedatives until the symptoms are relieved.
When is palliative sedation used?
Palliative sedation is only utilized when terminally ill patients have severe, refractory symptoms such as:
- Dyspnea (shortness of breath)
- Delirium
- Pain
- Nausea/vomiting
- Severe terminal restlessness
These symptoms must be refractory, meaning they cannot be adequately controlled while keeping the patient conscious. Palliative sedation is only considered if all other treatment options have failed to provide relief. It is used as a last resort.
Benefits of palliative sedation
Palliative sedation has several benefits when used appropriately:
Relieves Suffering
The main goal of palliative sedation is to relieve unbearable suffering from refractory symptoms in dying patients when no other treatments are effective. It is an option to provide comfort at the end of life.
Allows a Peaceful Death
By relieving extreme suffering, palliative sedation can allow terminally ill patients to have a more peaceful death. Decreased or absent awareness relieves distress.
Sparing the Family
Witnessing the extreme suffering of a loved one can be very distressing for family members. Palliative sedation spares the patient’s family and loved ones from observing uncontrolled suffering at the end of life.
Upholds Patient Autonomy
Palliative sedation is only administered with the informed consent of the patient and/or family members. This upholds patient autonomy and the right to refuse treatments.
Does Not Hasten Death
Studies have shown that palliative sedation does not appear to hasten death when used appropriately. The doses required for sedation are not expected to cause respiratory depression or significantly impact lifespan.
Guidelines for responsible use of palliative sedation
Several guidelines should be followed to ensure palliative sedation is used responsibly:
Refractory symptoms
There must be severe, refractory symptoms present that cannot be managed by any other treatments. Mild or moderate symptoms controlled by medications and therapies do not warrant palliative sedation.
Informed consent
Informed consent must be obtained from the patient and/or appropriate family members before initiating palliative sedation. Alternatives must be discussed.
Intermittent sedation preferred
Intermittent sedation is preferred over continuous deep sedation when possible. The patient can be briefly awakened to assess symptoms.
Minimum dose required
The lowest effective dose of sedatives should be used to relieve symptoms while maintaining patient comfort.
skilled administration
Palliative sedation should be administered and monitored by clinicians experienced in end-of-life care such as palliative medicine physicians.
Artificial nutrition/hydration optional
Artificial nutrition and hydration are optional during palliative sedation and may be discontinued.
Common medications used
Some medications commonly used for palliative sedation include:
| Medication | Class |
|---|---|
| Midazolam | Benzodiazepine |
| Propofol | Anesthetic |
| Phenobarbital | Barbiturate |
| Morphine | Opioid |
The doses and medications are customized to each patient’s needs and responses. Benzodiazepines like midazolam are commonly first line.
Is palliative sedation euthanasia?
Palliative sedation is often mistaken as a form of euthanasia, but there are important differences:
Intent
The intent of palliative sedation is to relieve intolerable suffering, not to cause death. The intent of euthanasia is to deliberately end a patient’s life by administering lethal medications.
Medication doses
Palliative sedation utilizes doses of medications targeted to relieve symptoms. Euthanasia utilizes deliberate lethal overdoses to cause death.
Artificial hydration/nutrition
Artificial hydration/nutrition may be continued during palliative sedation but are always stopped in euthanasia.
Loss of consciousness
Permanent loss of consciousness is intended with euthanasia. Palliative sedation may utilize intermittent sedation when appropriate.
Hastening death
Euthanasia deliberately ends life prematurely. Studies show palliative sedation does not appear to hasten death with proper use.
Conclusion
In summary, palliative sedation provides an ethical and necessary option for relieving severe, refractory symptoms at the end of life when all other treatments have failed. When utilized responsibly under proper guidelines, palliative sedation controls suffering without hastening death. It is an important tool in upholding patient autonomy and allowing a peaceful death. Palliative sedation should be available as a last resort to terminally ill patients with severe refractory symptoms, but must be distinguished from euthanasia. Healthcare professionals specializing in hospice and palliative medicine are best qualified to employ and monitor this treatment.