What is the current practice regarding palliative sedation in palliative care? This is the main question that answers this systematic review of prospective studies. It is part of a Horizon2020 project, Palliative Sedation, in which different countries and centres across Europe are participating. Consortium members, Dr Maria Arantzamendi, Dr Alazne Belar, RN PhD and Dr Carlos Centeno, MD PhD (researchers at the Instituto Cultura y Sociedad, Universidad de Navarra, Spain), explain more about the conducted study, which is now published in the ‘Journal of Pain and Symptom Management’ and available in open access.
Alazne Belar Beitia, Carlos Centeno and María Arantzamendi.
There are symptoms that are common at the end of life as disease progresses. Usually, there are different treatment options available to manage these. Sometimes, however, standard treatments are no longer effective; the benefits are not reached in sufficient time or treatments provoke more negative effects than benefits.1 In these cases, palliative sedation may be considered as a therapeutic option.
The European Association for Palliative Care (EAPC) defines palliative sedation as the monitored use of medications intended to induce a state of decreased or absent awareness to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family and healthcare providers. 2 (p.593)
But what are the most common refractory symptoms and how are they assessed? Who participates in the decision-making process for palliative sedation? Which are the treatment strategies applied, and how is the effectiveness of palliative sedation measured?
These are some of the questions that we have tried to answer. We undertook a search of prospective studies published in the last five years in: Pubmed, Medline Wos, Embase, Cinahl and Cochrane Library. We identified 43 articles and included ten that were conducted in palliative care services in six countries: Belgium, Italy, Japan, The Netherlands, Colombia and Mexico. The majority related to patients with cancer.
Which are the most common refractory symptoms and how are they assessed?
The most frequently reported refractory symptoms were delirium, pain and dyspnoea. Some studies also considered psychological and/or existential distress as exceptional refractory symptoms for the administration of palliative sedation. Four studies mentioned the presence of more than one refractory symptom leading to the administration of palliative sedation.
Most of the papers did not specify how the assessment of refractory symptoms was conducted. This highlights the importance of implementing the use of standardised tools. In the case of psychological and existential distress, a more comprehensive evaluation is important. We concluded that when identifying a symptom as refractory, an interdisciplinary evaluation by clinicians with sufficient experience and expertise is essential.
Who participates in the decision-making process for the initiation of palliative sedation?
The reviewed articles reported that the decision-making process was usually led by the palliative care team. In addition, some of the studies support the idea that clinical assessment would benefit from a multidisciplinary team approach by experienced and expert professionals.
What treatment strategies are applied and how is the effectiveness of palliative sedation measured?
The general use of palliative sedation among different countries is similar, with midazolam reported as being utilised as the first line medication in all of the papers included. Additionally, some studies reported the use of adjuvant medications for symptom control such as opioids. Of interest, half of the included studies reported about the administration of hydration and nutrition during palliative sedation. They reported a tendency to maintain or reduce hydration.
Despite the information provided in these important papers, there are still some unanswered questions: How many countries have guidelines on the use of palliative sedation? What is the effect of palliative sedation on patient comfort? Which are the side effects of this therapeutic option? What are the families’ experiences regarding palliative sedation?
Answering these and other relevant questions is the aim of this H2020-funded project about palliative sedation. Follow the progress of this project on the EAPC blog where we have our own category for Palliative Sedation Horizon 2020.
References
1. de Graeff A, Dean M. Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. J Palliat Med. 2007 Feb; 10(1):67–85.
2. Cherny NI, Radbruch L. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med. 2009 Oct; 23(7): 581–93.
Download the complete article from the Journal of Pain and Symptom Management– Open Access
This post relates to the article, ‘Clinical aspects of palliative sedation in prospective studies. A systematic review’ by Maria Arantzamendi, Alazne Belar, Sheila Payne, Maaike Rijpstra, Nancy Preston, Johan Menten, Michael Van der Elst, Lukas Radbruch, Jeroen Hasselaar, Journal of Pain and Symptom Management, Sept 19, 2020; S0885-3924(20) 30754-5 doi: 10.1016/j.jpainsymman.2020.09.022. Online ahead of print.
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- Palliative Sedation website.
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- Read more posts about Palliative Sedation Horizon 2020.
- Read more posts about Palliative Sedation generally here.
EAPC Blog 
No mention of how consent was obtained. Nor what patients wanted in the circumstances that led to palliative sedation been used. These are important issues. Thank you.