Overview of Palliative Sedation in Patients With Terminal Illness
Palliative sedation is a medical approach used to reduce distress in patients who are severely ill and nearing the end of life. By applying this treatment, doctors attempt to ease severe symptoms which can often not be controlled otherwise, such as intense pain, confusion (delirium), and difficulty in breathing. Most healthcare professionals generally accept the use of palliative sedation as a way of managing these symptoms in very sick patients.
However, there are ongoing discussions about the ethics of using palliative sedation to address psychological or emotional distress in terminally ill patients. Part of the controversy is the lack of clear agreement on what counts as unmanageable or uncontrollable (refractory) symptoms. There is also a need for better understanding among patients, their families, and healthcare workers about what palliative sedation really involves.
Palliative sedation can sometimes be mistaken for euthanasia or doctor-assisted suicide, which leads to legal and ethical debate and can make doctors hesitant to discuss or plan for palliative sedation. However, it’s essential to point out that the aim of palliative sedation is to minimize suffering, not intentionally end life. Research has found that palliative sedation does not shorten a patient’s life. It is often used when a patient’s estimated remaining life is measured in days or hours.
Studies have shown that there can be communication problems between doctors, patients, and their families that can make it difficult to plan for end-of-life care. This can lead to increased anxiety and frustration. There are also misunderstandings among patients and their families about palliative care – which includes things like hospice care, pain management, and palliative sedation. It is important that there is clear communication about when palliative sedation might be appropriate, what legal and ethical issues are associated with its use, what common misunderstandings are, and what drugs might be used.
Why do People Need Palliative Sedation in Patients With Terminal Illness
When a person is extremely sick and nothing seems to help their symptoms, doctors might consider something called palliative sedation. This isn’t a simple decision and it depends on the specific situation and the opinion of the healthcare team. Typically, there are some common conditions for considering palliative sedation:
First, the person should be very seriously ill and approaching the end of their life. Second, no other treatments are working to ease their symptoms, even at very high doses, and helping them would mean making them unconscious.
There could also be cases where the usual treatments might cause harmful side effects. For instance, a medicine to alleviate nausea in high or frequent doses could lead to heart problems. Instead, sedative medicines like midazolam might work well without the risks. Or, if a patient is severely agitated and confused, doctors might opt for palliative sedation for quick results to ensure the safety of the patient or caregivers.
It’s important, though, to keep the patient and their loved ones in the loop. They need to understand exactly what’s happening and be okay with the risks of using palliative sedation.
Palliative sedation does bring up some legal and ethical questions. It’s controversial because of the concern that it could speed up the person’s death. Because of this, some people associate it with assisted dying or euthanasia – but they’re not the same.
Euthanasia is when a healthcare worker intentionally ends a patient’s life to stop their suffering, either with the patient’s agreement (voluntary euthanasia) – or without it (involuntary euthanasia), the latter of which is unlawful all over.
In a physician-assisted suicide, the doctor provides lethal medicine doses, but it’s up to the patient to take them. Some US states allow this under specific circumstances, like if the patient is mentally sound, lives in the state, is extremely sick, predicted to pass away within 6 months or less, and voluntarily wants the lethal medication.
Doctors use palliative sedation to relieve severe symptoms for people nearing the end of life, which differentiates it from euthanasia and physician-assisted suicide, both aimed at ending a patient’s life. The desired outcome of palliative sedation is symptom relief, not death. Therefore, while it certainly raises ethical questions, it is legal in most countries, including the United States.
Preparing for Palliative Sedation in Patients With Terminal Illness
Choosing when to start palliative sedation, a treatment to alleviate suffering among people who are at the end of their life, can be difficult. There’s often debate among doctors about how to define “refractory symptoms,” which are symptoms that have not improved despite multiple treatments. Because of this, it can be hard to decide when these severe symptom warrants palliative sedation. One of the most challenging parts is predicting how much time a patient may have left, as it is important but often difficult to accurately predict.
Palliative sedation’s primary aim is to relieve unbearable symptoms, not to cause unconsciousness or unresponsiveness. This concept of “proportional treatment” means that medicines like benzodiazepines, opiates, and antipsychotics, are used to comfort patients, yet, their dose should always match up with the desired outcome – relief from distressing symptoms. However, there are certain severe cases where high doses of sedative medication might be the only way to calm the patient.
There’s an ethical principle associated with palliative sedation called the “double effect”. The principle says that an action – even if it could possibly result in a harmful outcome – can be generally acceptable if the ultimate goal is to do good. While palliative sedation does not generally increase the risk of death, it is important to understand potential risks such as respiratory issues, worsening unrest, or risk of aspiration. As long as everybody involved understands these potential risks, palliative sedation can be considered an acceptable course of therapy.
Talking about goals of care with patients and their families in these situations can be challenging. Doctors and other healthcare workers often need special training to navigate these difficult conversations. Misunderstandings are common – many people confuse palliative sedation with euthanasia (doctor-assisted suicide), for example. That’s why it’s important to have thorough and clear discussions about what to expect, the pros and cons and potential side effects of the treatment. These conversations typically include a team of professionals, the patient, and their loved ones.
After these in-depth conversations, the patient or their family must agree to the decision to start palliative sedation. For patients who are unable to communicate, doctors will follow any existing advance directives or ask the patient’s legal representative for permission. Patients and families should be reassured that other beneficial medical or nursing care will not be stopped just because palliative sedation is being used. Other decisions, such as whether to continue feeding tubes or nutrition in terminally ill patients, should also be discussed in detail.
How is Palliative Sedation in Patients With Terminal Illness performed
These are some of the common medications that can be used for palliative sedation, which is a type of care for people who are near the end of their lives. This care is meant to ease symptoms and make the person as comfortable as possible.
– Benzodiazepines such as lorazepam and midazolam. These drugs work on a chemical in the brain called GABA to reduce activity in the brain. This can help with symptoms like confusion and anxiety. Yet, they can sometimes make confusion and restlessness worse and slow down breathing if they’re taken with other medicines like opioids.
– First-generation antipsychotics like haloperidol and chlorpromazine. These medications work by blocking some of the chemicals in the brain, such as dopamine and serotonin, that can contribute to confusion. They’re often used for severe agitation, but can also cause side effects like dry mouth, low blood pressure, restlessness, muscle stiffness, seizures, and heart problems.
– Propofol is a drug that works similarly to benzodiazepines by affecting GABA in the brain, but also may decrease the action of another brain chemical called glutamate. It’s usually used when other drugs for confusion aren’t helping, but it can also cause side effects like low blood pressure, inflammation of the vein where it’s given, and a rare but serious reaction called propofol infusion syndrome.
– Barbiturates also work on GABA and glutamate in the brain. They’re also used when other treatments for severe agitation aren’t working. They can lead to unstable blood pressure and heart rate, nausea, vomiting, and decreased effectiveness of other drugs.
– Opioids like morphine, fentanyl, and oxycodone bind to special receptors in the brain to slow down brain activity and help with pain and difficulty breathing. But, they can also slow down breathing too much.
Two main types of palliative sedation exist:
– Respite sedation. This is when sedating drugs are used for a short, planned amount of time, like 1 to 48 hours. After this time, the dose is reduced until the person wakes up fully.
– Continuous sedation. This is when sedating drugs are used all the time, without any plans to stop them, until the person passes away. This is usually for people with terminal illness who have severe pain that’s not getting better with normal treatments.
Possible Complications of Palliative Sedation in Patients With Terminal Illness
Palliative sedation, a method used to relieve severe and unmanageable symptoms in serious illnesses, can sometimes speed up death, making it a widely debated issue. Therefore, the advantages and disadvantages should be thoroughly discussed with the patient and their family to properly set their expectations.
There’s a common belief that heavily sedating a patient can increase their risk of catching pneumonia from accidentally inhaling food, drink, or saliva into the lungs (aspiration pneumonia) or cause problems in their breathing. However, recent research work suggests that palliative sedation can be used safely without significantly increasing the chance of either respiratory complications or aspiration pneumonia.
In addition to this, other studies have indicated that palliative sedation does not notably reduce the lifespan of a patient when compared to those receiving standard or alternative treatments.
What Else Should I Know About Palliative Sedation in Patients With Terminal Illness?
It’s very important to recognize when patients with serious illnesses have symptoms that can’t be controlled by treatment, and to start conversations about their care goals as soon as possible. This helps ensure their individual preferences are respected and unhelpful treatments or procedures aren’t carried out. These procedures aren’t likely to relieve the patient’s symptoms or slow down their disease. Earlier research has shown that palliative care, which focuses on improving the quality of life for patients with serious illnesses, does much more than just manage pain.
Past studies emphasize how involving a healthcare team and organizing family meetings improves the connection between patients, their families, and their carers. This has shown to reduce feelings of stress, worry, and irritation.
