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A Blurred Line

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Fiona Byrne

on 4 December 2013

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Transcript of A Blurred Line

Palliative Sedation:
Nursing Implications
Patel B., Gorawara-Bhat, R., Levine, S., & Shega, J.W. (2012) interviewed nurses and identified five key concepts for consideration and implementation of Palliative Sedation (PS)
Ability to define palliative sedation
Factors that determine eligibility for PS
Skills needed for administering PS
Policy and procedural guidelines
Education on palliative sedation and end of life (EOL) care
Case Study
RH is a 58yo male with a history of 3 packs per day since he was 20, and COPD. About two years ago, he noticed a patch on his tongue but he did not seek medical attention and continued to smoke and use chewing tobacco. He came to our care six months ago c/o difficulty chewing and swallowing, difficulty moving his tongue, and some numbness of his tongue. A work up revealed oral squamous carcinoma of the anterior two thirds of the tongue and the floor of the mouth, which has metastasized to the cervical lymph nodes. He was treated with surgical resection of the tongue and bone and soft tissue of the mouth.
A Blurred Line
By: Fiona Byrne, Ky Duong, Courtney Gagne, Ying Lin, Christina Litavec, and Masiel Mendoza
What is it?
Palliative Sedation is the use of medication to induce unconsciousness in a patient suffering from refractory symptoms.
But, without a clear definition it is hard to determine if symptoms are truly refractory, especially those symptoms in the realm of existential suffering
Eligibility for palliative sedation includes;
imminent death,
an active DNR/DNI,
the presence of refractory symptoms,
and that all other treatment options have been exhausted.
Dr. William Shaver, who practices in Texas has published many articles concerning ethical issues surrounding palliative sedation. In this address, he focuses on these points:
Palliative Sedation
Palliative sedation is the administration of sedative medications within monitored settings, which is aimed to induce unconsciousness, in order to relieve refractory symptoms. It is a last resort used in the end of life.
Refractory symptoms are those that aren't adequately managed by other means of treatment (dyspnea, agitated delirium, convulsions, pain, etc.).
The intent of PS is to preserve the sensibilities of the patient, loved ones and of the health care professionals involved in their care, while relieving the patient of intolerable suffering due to refractory symptoms.
Indications: adult and children with terminal illnesses experiencing refractory symptoms.
Medications used:
Midazolam: a short-acting benzodiazepine, with rapid onset of action is often prescribed for palliative sedation.
Levomepromazine and chlorpromazine (first generation anti-psychotics), phenobarbital (barbiturate), and propofol (short-acting anesthetic) are used as alternatives.
Education is important for the patient’s loved ones. Letting them know that other methods and/or treatments have not worked is crucial for their understanding of palliative sedation use, and how the goal is to provide comfort to the patient and relieve their refractory suffering.
Medication administration to induce unconsciousness. Used to treat refractory symptoms when all other treatments have failed.
Also known as terminal sedation, controlled sedation, deep sedation, sedation for the imminently dying.
Without a clear definition it is hard to determine if symptoms are truly refractory, especially those symptoms in the realm of existential suffering
What Are Refractory Symptoms?
-Unresolved guilt
-Uncertainty of afterlife
-Worry about the people being left behind
*Can not be relieved by other aggressive measures that do not induce unconsciousness
(Cherny, 2013)
Assures patient comfort, without hastening death
Does not hasten death; with dose titration and monitoring, adequate relief is reached by using the lowest level of sedation
(Cherny, 2013).
Rousseau's study (2005) found no significant difference in hospital stay among patients who received PS and those who didn't, suggesting that death isn't hastened by PS.
Provides comfort/relief to the patient when other treatments haven’t worked
The patient does not experience pain, dyspnea, etc., which can complicate the patient’s already compromising state
(Cherny, 2013)
Berger, J.T. (2010). Rethinking guidelines for the use of palliative sedation, Hastings Center Report, 40(3), 32-38. Retrieved from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=386ca578-6d4e-49f8-bffc-89ecbdb1bbbf%40sessionmgr113&vid=2&hid=118
Cherny, N. (2013). Palliative sedation. UpToDate. Retrieved from http://www-uptodate-com.ezproxy.uvm.edu/contents/palliative-sedation?topicKey=PALC%2F83710&elapsedTimeMs=0&source=search_result&searchTerm=palliative+sedation&selectedTitle=1~15&view=print&displayedView=full#
Crenshaw, J. (2009). Palliative sedation for existential pain: an ethical analysis. Journal of Hospice and Palliative Nursing, 11(2).
Ferrell, B., Coyle, N.,. (2010). Palliative nursing (3rd ed.). Oxford: Oxford Univeristy Press.
Hasselaar, J.G.J., Verhagen, S.C.A.H.H.V.M., Wolff, A.P., Engels, Y., Crul, B.J.P, & Vissers, K.C.P. (2009). Changed patterns in Dutch palliative sedation practices after the introduction of a national guideline. Archives of Internal Medicine, 196(5), 430-437. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19273772
Morita, T. (2004). Emotional burden of nurses in palliative sedation therapy. Palliative Medicine, 18(6), 550-57. Retrieved from http://pmj.sagepub.com/content/18/6/550.short
Patel, B., Gorawara-Bhat, R., Levine, S., & Shega, J.W. (2012). Nurses’ attitudes and experiences surrounding palliative sedation: components for developing policy for nursing professionals. Journal of Palliative Medicine, 15(4), 432-437. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22500480
Periyakoil, VJ. (2007) Palliative Sedation case study. End of Life curriculum Stanford University Medical School. Retrieved from http://endoflife.stanford.edu/M16_pall_sed/case.html
Rousseau P. Palliative sedation in the control of refractory symptoms. J Palliat Med. 2005;8:10-12. Abstract
Shaver, W. A challenge to the ethical validity of palliative sedation. Program and abstracts of the American Academy of Hospice and Palliative Medicine/Hospice and Palliative Nurses Association Annual Assembly; January 19-23, 2005; New Orleans, Louisiana. Abstract 318.
Verkerk, M., van Wijlick, E., Legemaate, J., & de Graeff, A. (2007). A national guideline for palliative sedation in the Netherlands. Journal of Pain and Symptom Management, 34(6), 666-670. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17618078
Wolf, M. T. (2013). Palliative sedation in nursing anesthesia. AANA Journal, 81(2), 113-117.
Morphine 0.2-15 mg q 2-4 hours
Haldol 0.5-1 mg q 2-4 hours
Ativan 0.5-1 mg q 2-4 hours

Oxycodone, Valium, Clonopin, Xanax

Routes: IV, IM, SQ
Imminent death
All other treatment options have been exhausted
All non-comfort-inducing interventions have been discontinued
Communication between patient, family, and provider are clear and understood
Maintain hygiene and non-pharmacological measures of comfort
No routine vital signs (if patient is imminently dying)
Look out for signs of distress (tachypnea, dyspnea, discomfort, etc.)
When respirations slow, don't titrate down; it's an expected response
Monitor patient for comfort, maintaining it
(Cherny, 2013)
(Ferrell, 2010) & (Cherny, 2013)
Palliative sedation may remove the patient's ability to change his or her decision after treatment has begun.
Distinction between euthanasia, patient assisted suicide, and palliative sedation may be unclear.
Unclear if best practice should continue artificial nutrition and hydration
Difficult to evaluate if the positive outcome outweighs the negative outcome.
Is existential suffering an indication for palliative sedation? The American Medical Association doesn't recommend palliative sedation as a response to primarily existential suffering (AMA, 2008).
Existential suffering is an ill-defined concept.
No universal protocol for palliative sedation.
Arguably hastens death.
Emotional burden on nurses
(Wolf, 2013)
The Netherlands set up national guideline for palliative sedation in 2005.
Palliative sedation can be used in two ways:
1) continuous sedation until death
2) short term or intermittent sedation

presence of 1 or more refractory symptoms, which leads to unbearable suffering for the patient
refractory symptom is if none of the conventional treatments are effective, or have unacceptable side effects
*deep and continuous sedation until death - death must be expected within 1-2 weeks
International Guidelines
(Verkerk, M., van Wijlick, E., Legemaate, J. & de Graeff A., 2007)
(Ferrel, 2010)
(Crenshaw, 2009)
(Ferrel, 2010)
Annual Assembly of the American Academy of Hospice and Palliative Medicine (AAHPM) - January 2005
"suffering is a dynamic and transforming process in which the incomplete, fractured nature of the self begins to reemerge into consciousness"
Suggests that patients redirect their locus of control, from 'How can I control my disease?' to 'How can I see the meaning of my disease in my life?'
"When a patient is sedated until death, the clinician removes any opportunity for personal or spiritual reconciliation, as well as any opportunity for the sufferer to change their mind about the program of care"
Believes there is no way of knowing whether unconsciousness truly relieves suffering, which makes it difficult to know if the action is 'good'.
The Hastings Center (2010). [Table illustration of current vs proposed guidelines for when PSU is acceptable May 1 2010]. Rethinking guidelines for the use of palliative sedation
Recommendations of the guideline were applied in practice after introduction:
most physicians distinguished continuous sedation from euthanasia
number of patient requests for euthanasia before sedation decreased
patient involvement in decision making increased

Systemic use of a guideline was reported significantly more often after introduction of the national guideline
(Hasselaar, G.J., Verhagen, S.C.A.H.H.V.M., Wolff, A.P., Engels, Y., Crul, B.J.P., & Vissers, K.C.P., 2009)
p. 433-436
(Shaver, 2005)
'Emotional Burden of Nurses In Palliative Sedation Therapy'
Questionnaire survey of nurses who have had experience with palliative sedation
reported they wanted to leave their position due to "sedation- related burden"
stated that being involved in the sedation was a burden
stated they felt "helpless" when patients received sedation
stated they would avoid a situation in which they had to perform sedation
stated they felt it was "of no value" when they performed sedation
(Morita 2004)
RH's symptoms progressed to loss of tongue and hypernasality (making speech unintelligible), loss of teeth (coupled with loss of tongue making it difficult to swallow), severe facial disfigurement (D/T surgical resections), oral ulcers causing severe mal-odor and facial pain.
Pharmaceutical treatment of continuous subcutaneous infusion of morphine (6mg/h), morphine sulfate PCA of 2mg q15 mins, lorazepam (0.5mg q4hrs), metronidazole gel for ulcerated tissue, oxygen via nasal cannula and non-pharmacological comfort measures
This treatment is not alleviating the severe pain that RH is experiencing...
over the past few months...
Family and Patient wishes
RH refuses further surgery, chemotherapy, and radiation therapy. RH and his family have elected to continue symptomatic treatment and invoke RH's DNR. RH and his family refuse a feeding tube. They would like to progress with comfort care for the end of his life. RH's children and wife are very adamant that they do not want to see him in pain. RH's pain continue to worsen despite aggressive pain management. He is clearly suffering causing severe distress to his wife and children. His pain is unendurable and refractory to all palliative measures.
Palliative sedation was been proposed to RH and his family as a humane and compassionate approach to alleviate his suffering.
After explaining the procedure, RH and his family readily agreed to deep and continuous sedation, Informed consent was documented and the plans recorded in the patient's chart. Titration of sedation continued over the next few hours until he was deeply sedated. He died 4 days later, sedated, peaceful and with his family at his bedside.
(Periyakoil, 2007)
Benefits of PS include that it provides comfort/relief to the patient and preserves the sensibilities of the patient, loved ones and healthcare professionals involved in care.
But, arguments against it include once started there is no opportunity for the patient to change their decision, the concept is ill-defined with vague protocols, and arguably elicits an emotional burden on nurses. There is still much controversy in the health care field if PS hastens or does not hasten death.
Moving forward there is much consideration that would go into the implementation of palliative sedation as an accepted practice. Specifically the field needs to consider the;
Ability to define palliative sedation
Skills needed for administering PS
Policy and procedural guidelines
Factors that determine eligibility for PS
Education on palliative sedation and end of life (EOL) care
Patel B., Gorawara-Bhat, R., Levine, S., & Shega, J.W. (2012)
Cherny, 2013., Wolf, 2013., Morita, 2004.
Ferrel, 2010
Ferrel, 2010
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