Skip to main content
SpringerLink
Log in

Clinical Guidelines for the Use of Palliative Sedation: Moving from Contention to Consensus

  • Chapter
  • First Online:
Sedation at the End-of-life: An Interdisciplinary Approach

Part of the book series: Philosophy and Medicine ((CSBE,volume 116))

  • 690 Accesses

Abstract

At its core, medicine strives for a compassionate and skilled response to all patients experiencing pain and suffering. Through the concurrent growth of palliative care as a medical specialty and an enhanced pharmaceutical armamentarium available to clinicians working with patients at the end of life, this core aim can be realized. Evidence-based data demonstrates that the range of refractory or intolerable symptomatology is constantly being reduced. Nonetheless, the clinical presentation of disease, particularly at the end of life, can be such a distressing experience that induced sedation may be the most appropriate and clinically beneficial treatment. This chapter will attempt to present a case for the utility of establishing clinical guidelines to support the practice of palliative sedation by exploring the contextual history of end-of-life care, particularly as it relates to the contentious advent of sedation as a therapy of choice for the palliation of refractory and intolerable symptoms in a subset of terminally ill patients.

Our patients come to us complaining not of disease, but of their subjective experience of illness. (Mount 2003)

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 54.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  • Agency for Healthcare Research and Quality. 2006. National Guideline Clearinghouse. Available at: http://www.guideline.gov/

  • Alberta Health Services. 2011. Clinical practice guidelines for palliative sedation. Calgary Zone, Alberta, Canada. Available from http://www.docstoc.com/docs/72057199/Palliative-Sedation-Guidelines---CLINICAL-PRACTICE-GUIDELINE-FOR

  • Alonso-Babarro, A., M. Varela-Cerdeira, I. Torres-Vigil, R. Rodriguez-Barrientos, and E. Bruera. 2010. At-home palliative sedation for end-of-life cancer patients. Palliative Medicine 24(5): 486–492.

    Article  Google Scholar 

  • American Academy of Hospice and Palliative Medicine. 2006. Position statement: Statement on palliative sedation. Available at: http://www.aahpm.org/positions/default/sedation.html. Accessed 10 July 2010.

  • American Academy of Hospice and Palliative Medicine. 2007. Position statement on physician-assisted death. Journal of Pain & Palliative Care Pharmacotherapy 21(4): 55–57.

    Article  Google Scholar 

  • Ashby, M. 2010. Ethical issues at the end of life. In-special issue: Abstracts for the world congress of internal medicine, world congress of internal medicine in conjunction with physicians week, 20–25 March 2010, Melbourne convention & exhibition centre, Melbourne, Australia. Internal Medicine Journal 40(s1): 2.

    Google Scholar 

  • Behuniak, S.M. 2003. Physician-assisted suicide: The anatomy of a constitutional law issue. Lanham: Rowman & Littlefield Publishers.

    Google Scholar 

  • Billings, J.A., and S.D. Block. 1997. Opportunity to present our observations and opinions on slow euthanasia. Journal of Palliative Care 13(2): 55–56.

    Google Scholar 

  • Bloche, M.G. 2006. The Supreme Court and the purposes of medicine. The New England Journal of Medicine 354(10): 993–995.

    Article  Google Scholar 

  • Broeckaert, B., P. Claessens, P. Schotsmans, and J. Menten. 2011. What’s in a name? Palliative sedation in Belgium. Reply to Chambaere et al. Journal of Pain and Symptom Management 41(6): e2–e4.

    Article  Google Scholar 

  • Bulli, F., G. Miccinesi, E. Biancalani, M. Fallai, M. Mannocci, E. Paci, et al. 2007. Continuous deep sedation in home palliative care units: Case studies in the Florence area in 2000 and in 2003–2004. Minerva Anestesiologica 73(5): 291–298.

    Google Scholar 

  • Cassell, E.J. 1999. Diagnosing suffering: A perspective. Annals of Internal Medicine 131(7): 531–534.

    Article  Google Scholar 

  • Cassell, E.J., and B.A. Rich. 2010. Intractable end-of-life suffering and the ethics of palliative sedation. Pain Medicine 11(3): 435–438.

    Article  Google Scholar 

  • Cellarius, V. 2008. Terminal sedation and the “imminence condition”. Journal of Medical Ethics 34(2): 69–72.

    Article  Google Scholar 

  • Chater, S., R. Viola, J. Paterson, and V. Jarvis. 1998. Sedation for intractable distress in the dying–a survey of experts. Palliative Medicine 12(4): 255–269.

    Article  Google Scholar 

  • Cherny, N.I. 2006. Sedation for the care of patients with advanced cancer. Nature Clinical Practice Oncology 3(9): 492–500.

    Article  Google Scholar 

  • Cherny, N.I., and R.K. Portenoy. 1994. Sedation in the management of refractory symptoms: Guidelines for evaluation and treatment. Journal of Palliative Care 10(2): 31–38.

    Google Scholar 

  • Cherny, N.I., L. Radbruch, and Board of the European Association for Palliative, Care. 2009. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliative Medicine 23(7): 581–593.

    Article  Google Scholar 

  • Claessens, P., E. Genbrugge, R. Vannuffelen, B. Broeckaert, P. Schotsmans, and J. Menten. 2007. Palliative sedation and nursing: The place of palliative sedation within palliative nursing care. Journal of Hospice and Palliative Nursing 9(2): 100–106.

    Article  Google Scholar 

  • Claessens, P., J. Menten, P. Schotsmans, and B. Broeckaert. 2008. Palliative sedation: A review of the research literature. Journal of Pain and Symptom Management 36(3): 310–333.

    Article  Google Scholar 

  • Cowan, J.D., and D. Walsh. 2001. Terminal sedation in palliative medicine–definition and review of the literature. Supportive Care in Cancer 9(6): 403–407.

    Article  Google Scholar 

  • Cowan, J.D., L. Clemens, and T. Palmer. 2006. Palliative sedation in a southern Appalachian community. The American Journal of Hospice & Palliative Care 23(5): 360–368.

    Article  Google Scholar 

  • Cunningham, J. 2008. A review of sedation for intractable distress in the dying. Irish Medical Journal 101(3): 87–90.

    Google Scholar 

  • de Graeff, A., and M. Dean. 2007. Palliative sedation therapy in the last weeks of life: A literature review and recommendations for standards. Journal of Palliative Medicine 10(1): 67–85.

    Article  Google Scholar 

  • Dean, M., V. Cellarius, B. Henry, D. Oneschuck, and L. Libracth. 2012. Framework for continuous palliative sedation therapy in Canada. Journal of Palliative Medicine 15(8): 870–879.

    Article  Google Scholar 

  • Devulder, J., E. Crombez, L. Ghijs, and E. Mortier. 2004. Considering palliative termination sedation. Tijdschrift voor Geneeskunde 60(3): 159–163.

    Article  Google Scholar 

  • Elsayem, A., E. Curry Iii, J. Boohene, M.F. Munsell, B. Calderon, F. Hung, et al. 2009. Use of palliative sedation for intractable symptoms in the palliative care unit of a comprehensive cancer center. Supportive Care Cancer 17(1): 53–59.

    Article  Google Scholar 

  • Enck, R.E. 1991. Drug-induced terminal sedation for symptom control. The American Journal of Hospice & Palliative Care 8(5): 3–5.

    Article  Google Scholar 

  • Engstrom, J., E. Bruno, B. Holm, and O. Hellzen. 2007. Palliative sedation at end of life – A systematic literature review. European Journal of Oncology Nursing 11(1): 26–35.

    Article  Google Scholar 

  • Fainsinger, R.L. 1998. Use of sedation by a hospital palliative care support team. Journal of Palliative Care 14(1): 51–54.

    Google Scholar 

  • Fainsinger, R., M.J. Miller, E. Bruera, J. Hanson, and T. Maceachern. 1991. Symptom control during the last week of life on a palliative care unit. Journal of Palliative Care 7(1): 5–11.

    Google Scholar 

  • Fainsinger, R.L., W. Landman, M. Hoskings, and E. Bruera. 1998. Sedation for uncontrolled symptoms in a South African hospice. Journal of Pain and Symptom Management 16(3): 145–152.

    Article  Google Scholar 

  • Fainsinger, R.L., D. De Moissac, I. Mancini, and D. Oneschuk. 2000a. Sedation for delirium and other symptoms in terminally ill patients in Edmonton. Journal of Palliative Care 16(2): 5–10.

    Google Scholar 

  • Fainsinger, R.L., A. Waller, M. Bercovici, K. Bengtson, W. Landman, M. Hosking, et al. 2000b. A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients. Palliative Medicine 14(4): 257–265.

    Article  Google Scholar 

  • Field, M.J., and K.N. Lohr (eds.). 1990. Clinical practice guidelines: Directions for a new program. Washington, DC: National Academy Press.

    Google Scholar 

  • Forde, R., O.G. Aasland, E. Falkum, H. Breivik, and S. Kaasa. 2001. Palliative sedation to dying patients in Norway. Tidsskrift for den Norske Lægeforening 121(9): 1085–1088.

    Google Scholar 

  • Gevers, S. 2003. Terminal sedation: A legal approach. European Journal of Health Law 10(4): 359–367.

    Article  Google Scholar 

  • Gilbert, A., F. Gomez, and E. Bruera. 2004. Global assessment of symptom control at the end of life. Medicina Paliativa 11(2): 79–82.

    Google Scholar 

  • Guell, E., O. Farinas, A. Ramos, R. Solis, and A. Pascual. 2009. Cancer pain in a palliative care unit. DOLOR 24(1): 21–27.

    Google Scholar 

  • Hauser, K., and D. Walsh. 2009. Palliative sedation: Welcome guidance on a controversial issue. Palliative Medicine 23(7): 577–579.

    Article  Google Scholar 

  • Jansen, L.A., and D.P. Sulmasy. 2002. Sedation, alimentation, hydration, and equivocation: Careful conversation about care at the end of life. Annals of Internal Medicine 136(11): 845–849.

    Article  Google Scholar 

  • Kawamura, A. 1998. Washington v Glucksberg and Vacco v. Quill prohibitions on assisted suicide do not violate the Fourteenth Amendment of the United States Constitution. Journal of Contemporary Law 24(1): 167–177.

    Google Scholar 

  • King, P. 2000–2001. Washington v. Glucksberg: Influence of the court in care of the terminally ill and physician assisted suicide. Journal of Law and Health 15(2): 271–301.

    Google Scholar 

  • Kirk, T.W., and M.M. Mahon. 2010. 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 and Symptom Management 39(5): 914–923.

    Article  Google Scholar 

  • Latimer, E.J. 1991. Ethical decision-making in the care of the dying and its applications to clinical practice. Journal of Pain and Symptom Management 6(5): 329–336.

    Article  Google Scholar 

  • Legemaate, J., M. Verkerk, E. van Wijlick, and A. de Graeff. 2007. Palliative Sedation in the Netherlands: Starting-Points and Contents of a National Guidelines. European Journal of Health Law 17: 61–73.

    Article  Google Scholar 

  • Levisman, J.A., A.S. Abbasi, and M.L. Pearce. 1975. Posterior mitral leaflet motion in mitral stenosis. Circulation 51(3): 511–514.

    Article  Google Scholar 

  • Maltoni, M., C. Pittureri, E. Scarpi, et al. 2009. Palliative sedation therapy does not hasten death: Results from a prospective multicenter study. Annals of Oncology 20(7): 1163–1169.

    Article  Google Scholar 

  • McIver, B., D. Walsh, and K. Nelson. 1994. The use of chlorpromazine for symptom control in dying cancer patients. Journal of Pain and Symptom Management 9(5): 341–345.

    Article  Google Scholar 

  • McStay, R. 2003. Terminal sedation: Palliative care for intractable pain, post Glucksberg and Quill. American Journal of Law and Medicine 29(1): 45–76.

    Google Scholar 

  • Morita, T. 2004. Palliative sedation to relieve psycho-existential suffering of terminally ill cancer patients. Journal of Pain and Symptom Management 28(5): 445–450.

    Article  Google Scholar 

  • Morita, T., S. Inoue, and S. Chihara. 1996. Sedation for symptom control in Japan: The importance of intermittent use and communication with family members. Journal of Pain and Symptom Management 12(1): 32–38.

    Article  Google Scholar 

  • Morita, T., J. Tsunoda, S. Inoue, and S. Chihara. 1999. Do hospice clinicians sedate patients intending to hasten death? Journal of Palliative Care 15(3): 20–23.

    Google Scholar 

  • Morita, T., J. Tsunoda, S. Inoue, and S. Chihara. 2000. Pain and symptom management. Terminal sedation for existential distress. American Journal of Hospice & Palliative Care 17(3): 189–195.

    Article  Google Scholar 

  • Morita, T., S. Bito, Y. Kurihara, and Y. Uchitomi. 2005. Development of a clinical guideline for palliative sedation therapy using the Delphi method. Journal of Palliative Medicine 8(4): 716–729.

    Article  Google Scholar 

  • Mount, B.M. 2003. Existential suffering and the determinants of healing. European Journal of Palliative Care 10(2): 40–42.

    Google Scholar 

  • Muller-Busch, H.C., I. Andres, and T. Jehser. 2003. Sedation in palliative care – A critical analysis of 7 years experience. BMC Palliative Care 2(1): 2.

    Article  Google Scholar 

  • Olsen, M.L., K.M. Swetz, and P.S. Mueller. 2010. Ethical decision making with end-of-life care: Palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clinic Proceedings 85(10): 949–954.

    Article  Google Scholar 

  • Peruselli, C., P. Di Giulio, F. Toscani, M. Gallucci, C. Brunelli, M. Costantini, et al. 1999. Home palliative care for terminal cancer patients: A survey on the final week of life. Palliative Medicine 13(3): 233–241.

    Article  Google Scholar 

  • Porzio, G., F. Aielli, L. Verna, G. Micolucci, P. Aloisi, and C. Ficorella. 2010. Efficacy and safety of deep, continuous palliative sedation at home: A retrospective, single-institution study. Supportive Care in Cancer 18(1): 77–81.

    Article  Google Scholar 

  • Quill, T.E., and I.R. Byock. 2000. Responding to intractable terminal suffering: The role of terminal sedation and voluntary refusal of food and fluids. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine. Annals of Internal Medicine 132(5): 408–414.

    Article  Google Scholar 

  • Quill, T.E., B. Lo, D.W. Brock, and A. Meisel. 2009. Last-resort options for palliative sedation. Annals of Internal Medicine 151(6): 421–424.

    Article  Google Scholar 

  • Rietjens, J.A., A. van der Heide, A.M. Vrakking, B.D. Onwuteaka-Philipsen, P.J. Van der Maas, and G. Van der Wal. 2005. The practice of terminal sedation in the Netherlands. Nederlands Tijdschrift voor Geneeskunde 149(9): 467–471.

    Google Scholar 

  • Rietjens, J.A., et al. 2008. Continuous deep sedation for patients nearing death in the Netherlands: A descriptive study. British Medical Journal 336: 810–813.

    Article  Google Scholar 

  • Rosalki, J.R., and S.J. Karp. 1999. Guidance on the creation of evidence-linked guidelines for COIN. Clinical Oncology (Royal College of Radiologists) 11(1): 28–32.

    Article  Google Scholar 

  • Rotter, T., L. Kinsman, E. James, A. Machotta, H. Gothe, J. Willis, et al. 2010. Clinical pathways: Effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of Systematic Review (3): CD006632.

    Google Scholar 

  • Rousseau, P.C. 2002. Palliative sedation. The American Journal of Hospice & Palliative Care 19(5): 295–297.

    Article  Google Scholar 

  • Rousseau, P. 2003. Palliative sedation and sleeping before death: A need for clinical guidelines? Journal of Palliative Medicine 6(3): 425–427.

    Article  Google Scholar 

  • Rousseau, P.C. 2004. Palliative sedation in terminally ill patients. Advances in Experimental Medicine and Biology 550: 263–267.

    Article  Google Scholar 

  • Roy, D.J. 1990. Need they sleep before they die? Journal of Palliative Care 6(3): 3–4.

    Google Scholar 

  • Roy, D.J., J.R. Williams, and B.M. Dickens (eds.). 1994. Bioethics in Canada. Scarborough: Prentice Hall Canada Inc.

    Google Scholar 

  • Schuman-Olivier, Z., D.H. Brendel, M. Forstein, and B.H. Price. 2008. The use of palliative sedation for existential distress: A psychiatric perspective. Harvard Review of Psychiatry 16(6): 339–351.

    Article  Google Scholar 

  • Simon, A., M. Kar, J. Hinz, and D. Beck. 2007. Attitudes towards terminal sedation: An empirical survey among experts in the field of medical ethics. BMC Palliative Care 6: 4.

    Article  Google Scholar 

  • Sparato, R., M. Lo Re, F. Piccoli, and V. La Bella. 2010. Causes and place of death in Italian patients with amyotrophic lateral sclerosis. Acta Neurologica Scandinavica 122(3): 217–223.

    Article  Google Scholar 

  • Stiel, S., N. Krumm, O. Schroers, L. Radbruch, and F. Elsner. 2008. Indications and use of benzodiazepines in a palliative care unit. Schmerz 22(6): 665–671.

    Article  Google Scholar 

  • Stone, P., C. Phillips, O. Spruyt, and C. Waight. 1997. A comparison of the use of sedatives in a hospital support team and in a hospice. Palliative Medicine 11(2): 140–144.

    Article  Google Scholar 

  • Sykes, N., and A. Thorns. 2003a. Sedative use in the last week of life and the implications for end-of-life decision making. Archives of Internal Medicine 163(3): 341–344.

    Article  Google Scholar 

  • Sykes, N., and A. Thorns. 2003b. The use of opioids and sedatives at the end of life. The Lancet Oncology 4(5): 312–318.

    Article  Google Scholar 

  • Turner, K., R. Chye, G. Aggarwal, J. Philip, A. Skeels, and J.N. Lickiss. 1996. Dignity in dying: A preliminary study of patients in the last three days of life. Journal of Palliative Care 12(2): 7–13.

    Google Scholar 

  • van der Heide, A., B.D. Onwuteaka-Philipsen, M.L. Rurup, et al. 2007. Medical decisions around the end of life in the Netherlands after the Euthanasia Act came into effect; the fourth national study. Nederlands tijdschrift voor geneeskunde 15129(1635): 1642.

    Google Scholar 

  • Ventafridda, V., C. Ripamonti, F. de Conno, and M. Tamburini. 1990. Symptom prevalence and control during cancer patient's last days of life. Journal of Palliative Care 6(3): 7–11.

    Google Scholar 

  • Verkerk, M., E. van Wijlick, J. Legemaate, and A. de Graeff. 2007. A national guideline for palliative sedation in the Netherlands. Journal of Pain and Symptom Management 34(6): 666–670.

    Article  Google Scholar 

  • Veterans Health Administration National Ethics Committee. 2006. The ethics of palliative sedation as a therapy of last resort. The American Journal of Hospice & Palliative Care 23: 483–491.

    Article  Google Scholar 

  • Vila Santasuana, A., N. Celorrio Jimenez, X. Sanz Salvador, J. Martinez Montauti, E. Diez-Cascon Menendez, and C. Puig Rossell. 2008. The final week of life in an acute care hospital: Review of 401 consecutive patients. Revista Española de Geriatría y Gerontología 43(5): 284–290.

    Article  Google Scholar 

  • Woolf, S. 1992. Practice guidelines, a new reality in medicine. II: Methods of developing guidelines. Archives of Internal Medicine 152: 946–952.

    Article  Google Scholar 

  • Worthington, R. (ed.). 2005. Ethics and palliative care: A case based manual. Abingdon: Radcliffe.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Ethics Centre, Sunnybrook Health Sciences Centre, Room H 2 39, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada

    Blair Henry

  2. Joint Center for Bioethics, University of Toronto, Toronto, ON, Canada

    Blair Henry

Authors
  1. Blair Henry
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Blair Henry .

Editor information

Editors and Affiliations

  1. Faculty of Medicine, Centre for Bioethics and Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile

    Paulina Taboada

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer Science+Business Media Dordrecht

About this chapter

Cite this chapter

Henry, B. (2015). Clinical Guidelines for the Use of Palliative Sedation: Moving from Contention to Consensus. In: Taboada, P. (eds) Sedation at the End-of-life: An Interdisciplinary Approach. Philosophy and Medicine(), vol 116. Springer, Dordrecht. https://doi.org/10.1007/978-94-017-9106-9_9

Download citation

Publish with us

Policies and ethics

Search

Navigation