National Hospice and Palliative Care
Organization
Palliative Sedation in
Hospice and Palliative Care
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National Hospice and Palliative Care
Organization
Palliative Sedation in
Hospice and Palliative Care
National Hospice and Palliative Care Organization
Ethics Committee
July 2012
National Hospice and Palliative Care
Organization
Goals




Define palliative sedation
Discuss ethical justification
Discuss implementation issues
Review relevant organizational policies and
procedures
 Explore process using case studies
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Define PST
 Palliative sedation is
 lowering of patient consciousness using sedative
medications; with the
 intent of limiting patient awareness of suffering;
 when suffering is otherwise intractable and
intolerable (Morita et al., 2002; Kirk & Mahon,
2010).
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Process and Conditions of Sedation
 Use of sedatives via evidence-based protocol
(Cherny et al.)
 Appropriateness considering patient’s
trajectory toward death
 Proportionate sedation: only to the degree
necessary to make suffering tolerable as
defined by patient
 Reversible
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Ethical Justification
 Nonmaleficence
 Do no harm
 Preventing/reducing harm
 Beneficence
 Benefitting patient/family
 Conceive of “benefit” in a way informed by
patient/family values/goals
 Autonomy
 Honoring wishes/preferences of patient/family
 Removing barriers/threats to patient’s sense of self
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Confusion about Ethical Justification
 Assisted suicide debate
 Doctrine of double effect
 Sedation & the proximate cause of death
 Distinct from high-dose opioid use
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Ethical Implementation
 Thoughtfully and thoroughly developed policy and
procedures
 Rigorous interdisciplinary assessment
 Excellent but unsuccessful interdisciplinary
interventions prior to initiation
 Clear communication with patient and family
 Careful, expert implementation
 Accurate and complete documentation
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Clinical Use
 Far end of palliative care continuum
 Part of interdisciplinary plan of care
 Revocable
 Only for unrelieved symptoms
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Pediatric Considerations
 Appropriate for children
 Unrelieved distress
 Inadequately alleviated by other measures
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Artificial Nutrition and Hydration
 Separate the decision for sedation from ANH and
other concomitant therapies
 Consider clinical appropriateness for each
intervention
 Patients have right to refuse invasive procedures
 Hospice and palliative care organizations have
responsibility to offer only therapies consistent with
their mission, scope of practice, expertise, and
policies and procedures
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Who Decides?
 Patient: autonomy and related rights
 Family: involved in care planning
 Interdisciplinary team: develops care plan
with patient and family
 Advice from external ethics consultation may
be helpful
 Advice from external clinicians may be helpful
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
When Death is not Imminent
 Relationship of sedation and voluntary intake of food
& hydration
 Does sedation preventing intake of food & hydration
for >10 days become contributing cause of death?
 Questions to consider:
 Voluntary intake?
 Benefit/burden?
 Temporary sedation appropriate?
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Organizational Policy and Procedure
POLICY
 Definition of PST
 Indications for PST
 Clinical & ethical rationale for PST
 Guidelines for patient, family, & team assessment
& support during and after PST
 Guidelines for annual case review & quality
improvement process
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Organizational Policy and Procedure
PROCEDURES
 Checklist for intractable & intolerable symptoms
& trialed/failed interventions
 Checklist for patient/family education/consent
 Plan/rationale for continuing/not continuing ANH
 Evidence-based protocol for selection & dosage of
sedative medication
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Organizational Policy and Procedure
PROCEDURES
 Checklist for ongoing support of family and
team during sedation
 Evidence-based protocol for symptom
assessment during induction, & regular
assessment during sedation to ensure level of
suffering is tolerable
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Case Studies
 Case 1: Mr. Martin, 73-years old, has prostate ca.
 Case 2: Ms. North is 68 and has lung ca.
 Case 3: Ms. Smith is 22 years old and has a
peripheral neuroectodermal tumor that responded
poorly to treatment.
 Case 4: Mr. George is in his late 50s and has ALS.
 Case 5: Ms. Lopez is in her mid-30s and has cervical
ca that has become metastatic to multiple organs
and to bone.
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Bibliography
 Cherny, N & Radbruch, L. “European Association for Palliative
Care (EAPC) Recommended Framework for the Use of
Sedation in Palliative Care.” Palliative Medicine 23, no. 7
(2009): 581-593.
 Kirk, T. & Mahon, M. “National Hospice and Palliative Care
Organization (NHPCO) Position Statement and Commentary
on the Use of Palliative Sedation in Imminently Dying
Terminally Ill Patients.” Journal of Pain & Symptom
Management 39, no. 5 (2010): 914-923.
National Hospice and Palliative Care Organization
National Hospice and Palliative Care
Organization
Bibliography
 Maltoni, M., Scarpi, E., Rosati, M. et al. “Palliative Sedation in End-of-Life
Care and Survival: A Systematic Review.” Journal of Clinical Oncology 30,
no. 12 (2012): 1378-1383.
 Morita, T., Tsuneto, S. & Shima, Y. “Definition of Sedation for Symptom
Relief: A Systematic Literature Review and a Proposal of Operational
Criteria.” Journal of Pain & Symptom Management 24, no. (2002): 447453.
National Hospice and Palliative Care Organization