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RC Study > Palliative Sedation - CBM > Flashcards

Palliative Sedation - CBM Flashcards

1
Q

What is palliative sedation?

A
  • Monitored use of medications
  • Intended to induce state of decreased or absent awareness to relieve intractable suffering
  • Ethically acceptable to patient, family and health care providers
  • Goal is lightest level and lowest dose of sedative medication possible -titration to clinical effect
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2
Q

What are the PRE-REQUISITES for initiating Palliative Sedation?

A
  1. Intolerable suffering from refractory symptoms
  2. Imminent death (days to 1-2 weeks)
  3. Presence of incurable disease
  4. Informed consent from patient or SDM
  5. Comfort goals of care/do not resuscitate goals
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3
Q

What constitutes a refractory symptom?

A

If further interventions:

  • are incapable of providing relief
  • will have excessive/intolerable toxicity
  • are unlikely to help in an acceptable time frame
  • are not available in preferred setting of care.
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4
Q

How often is Palliative Sedation required?

A
  • difficult because of different definitions and use
  • 5-15% using more recent definitions of PS
  • higher rates in PCU, lower rates in community.
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5
Q

What are the common INDICATIONS (symptoms) for Palliative Sedation?

A
  • dyspnea
  • agitated delirium most common
  • pain
  • vomiting
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6
Q

What are the concerns with using PS to treat refractory existential or psychological suffering?

A

controversial, lack of consensus

  1. difficult to establish if truly refractory
  2. Severity of distress can be dynamic, and common part of dying process
  3. Standard treatment options have low morbidity
  4. Presence of psychological distress does not always equal advanced disease.

European Association of Palliative Care = consider light or intermittent (respite) sedation first.

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7
Q

How can Palliative Sedation be misused?

A
  • It is unethical to sedate a patient with primary goal of hastening death.
  • Inappropriate clinical situation/ insufficient symptom evaluation.
  • Inappropriate attention to good and safe practices.
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8
Q

Why are clinical practice guidelines essential for palliative sedation?

A
  • patient safety
  • maintain credibility of palliative medicine and professionals
  • meticulous adherence to guidelines and monitoring of good practice is essential.
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9
Q

Checklist for Palliative Sedation

A
  1. Terminal illness
  2. Refractory symptom(s)
  3. Failure of all other palliative interventions
  4. Prognosis hours to days (<1-2 weeks)
  5. DNR / Comfort goals of care
  6. Discussion with interprofessional team
    1. conscientious objectors given a chance to excuse themselves
  7. Guidance from palliative care specialist team
  8. Assessment and documentation of patient capacity
  9. Discussion with pt and family : effects/adverse effects/difference between PS and MAID.
  10. Informed consent documented
  11. All care providers informed
  12. DOCUMENT EVERYTHING.
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10
Q

What are the differences between Palliative Sedation and MAID?

A
  1. Intent of PS is to provide symptom relief, NOT hasten death
  2. Sedation is proportionate to symptom, severity and goals of care (lowest possible dose)
  3. Death of patient is not a criteria of success of the treatment.
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11
Q

List some ethical considerations in palliative sedation

A
  • broad consensus that pall sedation is acceptable therapeutic option (moral imperative)
  • adequate symptom control is overriding goal at end of life
  • narrow therapeutic index of palliative sedation (decreased consciousness, and possibility of shortening life)
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12
Q

What is the principle of Double Effect?

A
  • ethical justification for using pall sedation even if life may be shortened.
  • Pall sedation has both a good effect and a bad effect.
  • It is permissible if:
  1. Action is morally good or neutral.
  2. Undesired result is not directly intended
  3. Good effect is not direct result of foreseen bad effect.
  4. Good effect is proportionate to bad effect.
  5. No other way to achieve goal without the bad effect. The actio is undertaken for a proportionately grave reason
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13
Q

Does Palliative Sedation shorten life?

A
  • no difference in survival between sedation and non-sedated patients (*ref)
  • however risk of shortening life cannot be ignored:
    • respiratory depression
    • aspiration
    • hemodynamic instability
    • airway compromise
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14
Q

How does artificial nutrition and hydration affect palliative sedation?

A
  • controversial
  • when death is imminent, withholding/ withdrawing does not affect natural dying process.
  • no evidence nutrition/hydration in final hours/days improves quality or quantity of life.
  • some may decide to continue hydration as a non burdensome intervention (cultural, familial, individual beliefs).
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15
Q

What medication is considered first line for Palliative Sedation?

A
  • Midazolam ( GABAa agonist, sedative, amnestic, no active metabolites, short half life, short onset)
  • bolus dose, then sc/iv infusion at the same time
  • 1 to 10-20 mg/hour, titrate q 10 minutes to RASS score
  • bolus rescue doses 2-5 mg q 15 minutes.
  • If bolus dose required, can increase infusion by 1 mg / hour.

ADVANTAGES:

  • rapid onset
  • water soluble
  • compatible with most sc meds
  • useful for seizure control, muscle spasms, nausea, vx, cetral pruritis
  • reversal agent available (flumazenil)

DISADVANTAGES:

  • risk of paradoxical agitation
  • risk of impaired metablolism with liver disease
  • risk of psychotic reactions
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16
Q

What other medications can be used for palliative sedation (Methotrimeprazine):

A

METHOTRIMEPRAZINE:

  • D2, 5HT2, H1, alpha1, alpha 2 and muscarinic antagonist
  • analgesic and amnestic
  • onset 20-40 min
  • 12.5-25 mg sc/iv/im q 8-12h with 6.25-25 mg q1h prn
  • continuous infusion 2-3mg/hour sc
  • typically used when high doses benzos not effective

ADVANTAGES:

  • sedative, analgesic, anxiolytic
  • quick onset
  • useful for n/vx, delirium, agitation
  • can use with other meds -sc, iv, im

DISADVANTGES:

  • anticholinergic effects
  • orthostatic hypotension
  • akasthisia
  • acute dystonic reactions
  • seizures
  • cardiotoxicity with Qt prolongation
17
Q

What other medications can be used for palliative sedation (Phenobarbital)?

A

PHENOBARBITAL:

  • enhances GABA, inhibits glutamate
  • long active sedative, hypnotic, anticonvulsant
  • Loading dose 100-200 mg IV/IM
  • 0.5 mg/kg/hour IV/Sc continuous infusion (800-2400 mg/day)
  • 60-90 mg sc tid for intemittent dosing
  • second line option (first line in OXFORD)

ADVANTAGES:

  • effective in tolerance to benzos and antipsychotics
  • controls seizures
  • continuous infusion available.

DISADVANTAGES:

  • paradoxical agitation
  • hypotension, bradycardia, nausea, vomiting, cutaneous allergic reactions
  • can decrease serum concentration of other medications
18
Q

What other medications can be used for palliative sedation (propofol)?

A

PROPOFOL: -ultra rapid acting general anesthetic -GABAa agonist, glutamate inhibitor -continuous infusion 5 ug/kg/min IV -titrate every 5-10 min by 5-10 ug/kg/min -effective dose = 5-50 ug/kg/min -second (third?) line option for refractory agitation in palliative sedation ADVANTAGES: -reliable and rapid unconsciousness. -useful in extreme tolerance to benzos/antipsychotics -controls nausea/vx/seizures DISADVANTAGES: -infusion site pain, phlebitis -no SUBQ option -higher risk of line infection -requires pump -apnea, hypotension, allergic reactions (soy and egg) -bradycardia -propofol infusion syndrome** (higher doses > 48 hours) - bradycardia –> arrest - metabolic acidosis -rhabdo -hyperlipidemia -enlarged liver

19
Q

What other medications can be used for palliative sedation (Clorpromazine)?

A

CHLORPROMAZINE:

  • same as methotrimeprazine MOA
  • 12.5-25 mg IV/IM q4-12 hours
  • Infusion 3-5 mg/hour IV
  • Rectal 100 mg q6-12 hours
  • ]use if methtrimeprazine not available

ADVANTAGES:

  • quick onset
  • same as methotrimeprazine

DISADVANTAGES:

  • no SC option (tissue damage and pain)
  • same as methotrimeprazine
20
Q

Can OPIOIDS be used for palliative sedation?

A

NO

No sedative effect

21
Q

What should you do with patient’s other medications if palliative sedation is started?

A
  • continue meds for symptom control
  • opioids continued, may require reduction
  • do not abruptly discontinue
  • irrelevant medications to goals of care should be discontinued or weaned.
22
Q

What other care issues are considered in palliative sedation?

A
  • mouth care
  • eye care
  • bed positioning for pressure sores
  • urinary catheterization
  • regular monitoring
  • ongoing support to family and care team
23
Q

How is monitoring provided in palliative sedation?

A
  • Titration phase
    • q15-30 min
  • Maintenance phase q4 hours (less possibly in the home)
    • LEVEL OF SEDATION (all scales validated for crit care only but used in pall care)
      • RASS (Richmond Agitation and Sedation Scale)
      • Ramsay Sedation Scale
      • Riker Sedation - Agitation Scale (SAS)
    • LEVEL OF COMFORT
      • use pt facial expressions, etc.
    • AIRWAY PATENCY
      • obstruction, apnea - repositioning, jaw thrust
      • difficult to differentiate from dying
      • RR, 02 sats not generally recommended.
      • Normal part of dying. Case by case.
24
Q

What are medications can be used for palliative sedation (PROPOFOL)?

A

PROPOFOL

  • GABA recetor agonist
  • fast onset (15-30 seconds)
  • Duration of action 5-10 minutes
  • Half life 1-30 hours
  • Infusion 2.5-5 ug/kg/min (10-20 mg / hour)
  • Titrate q10 min by 10-20 mg/hour
  • Boluses of 10-20 mg q10 min prn

ADVANTAGES

  • rapidly titrateable
  • anxiolytic, antiemetic, anticonvulsant, antimyoclonic properties

DISADVANTAGES:

  • hypotension
  • respiratory depression
  • burning at injection site
  • seizure threshold?
  • propofol infusion syndrome with long term use
  • No anesthetic properties
  • Use outside of OR, ER, ICU may be difficult
25
Q

Respite Sedation

A
  • Time limited unconsciousness for terminally ill patients considered if:
    • Incident pain (movement for clinical care, procedures, etc)
    • Severe existential or social/emotional suffering (break the cycle of anxiety)
    • Patient requests trial of temporary sedation (may releive fatigue)
  • from a few minutes to a few days
  • Hydration if sedation expected to be > few days
  • Monitoring based on patient goals and values
26
Q

Ventilator weaning/ discontinuation at end of life:

A
  • terminal extubation will likely result in dyspnea
  • How is palliative sedation different in this situation?
    • Sedation may not be intended to relieve existing dyspnea but to prevent it prior to death.
  • Same prerequesites for palliative sedation when discontinuing mechanical ventilation
    • terminal illness, goals of care comfort, order to withdraw care, informed consent, prepared staff.
27
Q

Terminal discontinuation of mechanical ventilation : principles

A
  • continue current sedation and titrate
  • opioid therapy continue or add
  • Initiate opioids and sedation prior to removal of ventilator
  • Weaning :
    • change to pressure support mode
    • Peep 5
    • Observe
    • if agitated, resume prior settings and increase sedation
    • if apneic and now pain, dose reduce medications to lowest effective dose
    • if minimum doses and unconscious and apneic, remove ventilator
  • Stop paralytics prior to palliative sedation (to assess effect of sedation)
28
Q

Oxford protocol for Palliative Sedation Table

A

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