Palliative Sedation in Hospice and Palliative Care

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2. Palliative Sedation in Hospice and Palliative Care National Hospice and Palliative Care Organization Ethics Committee July 2012

3. Goals • Define palliative sedation • Discuss ethical justification • Discuss implementation issues • Review relevant organizational policies and procedures • Explore process using case studies

4. 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).

5. 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

6. 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

7. Confusion about Ethical Justification • Assisted suicide debate • Doctrine of double effect • Sedation & the proximate cause of death • Distinct from high-dose opioid use

8. 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

9. Clinical Use • Far end of palliative care continuum • Part of interdisciplinary plan of care • Revocable • Only for unrelieved symptoms

10. Pediatric Considerations • Appropriate for children • Unrelieved distress • Inadequately alleviated by other measures

11. 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

12. 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

13. 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?

14. 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

15. 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

16. 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

17. 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.

18. 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.

19. 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): 447-453.