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Palliative sedation: when and how?

Patients with advanced cancer develop a number of devastating physical and psychosocial symptoms. Although in the last 15 years there has been considerable improvement in our ability to assess and manage many of the most common symptoms, a significant proportion of patients with cancer develop refractory symptoms before death, and palliative sedation is an important therapeutic intervention, particularly for severe agitated delirium, dyspnea, and bleeding. Palliative sedation is usually defined as “the use of a sedative medication to reduce patient awareness of distressing and intractable symptoms that are insufficiently controlled by symptomspecific therapies.” Although it is practiced on a daily basis in acute care facilities and hospices, there has been limited research on the appropriateness of the different interventions and the outcomes of palliative sedation. One of the most controversial aspects of this practice is the potential for shortening life, particularly in patients who might have a potentially reversible symptom that requires palliative sedation. The article by Maltoni et al that accompanies this editorial is an important systematic literature review of studies that attempt to characterize the impact of palliative sedation on survival. Perhaps one of the most important findings of this carefully conducted review is that only 11 articles were identified, and seven of them were retrospective. There are serious ethical concerns about randomized controlled trials of palliative sedation, given that in such studies the control group would consist of patients suffering severe refractory symptoms. Therefore, this is an area where real-life studies, so to speak, can be useful. Unfortunately, the analysis of retrospective studies in patients with cancer who underwent sedation is severely limited by the absence of regular assessment of delirium and symptom severity in clinical practice. Palliative care units are very successful at adopting validated tools for the assessment of these outcomes. Although regrettably, only 25% of US comprehensive cancer centers and 20% of noncomprehensive cancer centers have designated acute palliative care beds, 10 of the 11 studies in this systematic review were conducted in palliative care units. The findings of the studies conducted in these controlled and sophisticated environments may not be applicable to the practice of palliative sedation in regular hospital wards. It is important that all clinical settings where palliative sedation is performed also measure delirium and symptom distress on a regular basis. The finding of no significant difference in survival between those patients who were sedated versus those who were not sedated by these palliative care teams is reassuring to those who regularly treat patients in palliative care settings. However, the relatively poor quality of the data points out our lack of knowledge of this very important aspect of daily patient care. Maltoni et al appropriately discuss the concerns with respect to the use of palliative sedation in patients with psychological distress. It is quite possible that many of the patients reported in these studies as having psychological distress had disinhibition related to the early stages of delirium. Because of the lack of regular screening, delirium is frequently underdiagnosed in patients with cancer. Where do we go from here? First, a more thorough definition of a refractory symptom is needed. Success in controlling a symptom not only depends on the severity of the symptom but also on the quality of the assessment and management the patient receives. Because interdisciplinary supportive and palliative care teams are highly effective in alleviating physical and psychosocial distress, until more evidence is available, it is important that physicians consult with these experts whenever possible in the case of severe symptoms. Checklists and procedures should be developed to help standardize this sensitive practice and also to help collect valuable information that will contribute to the existing body of knowledge. Palliative sedation results in considerable distress for families as well as health care professionals. It is important that the decision to begin palliative sedation be made not only in consensus with the patient and family but also with other health care professionals who are involved in the care of the patient, including the bedside nurse, counselors, pharmacists, and other colleagues. Obtaining consensus prevents conflict and potential medico-legal problems within the team. Clinical trials that compare different drugs that might be more effective at inducing and maintaining sedation, measuring outcomes such as arousal, evidence of symptom distress, and survival, are also needed. Maltoni et al have identified in their review the frequent use in palliative sedation of drugs such as haloperidol and morphine that are specific agents for the management of delirium and pain, respectively, and not for effective palliative sedation. As with many other medical interventions, the controversy that surrounds palliative sedation is not linked to the question of “yes or no?” but rather, “when and how?”