Article
of the Month
by Carla Ripamonti, MD (Italy)
Palliative
sedation therapy does not hasten death: results from
a prospective multicenter study
Maltoni M, et al
Annals of Oncology 2009; 20: 1163-1169
Palliative sedation is a “hot” and frequently discussed
topic in the palliative care setting.
Palliative sedation has been defined as “the use of
sedative medications to relieve intolerable suffering
from refractory symptoms by a reduction in patient consciousness”;
however this definition is not universally accepted.
According to Cherny and Portenoy “refractory symptoms
are those for which all possible treatment has failed
or it is estimated that no methods are available for
palliation within the time frame and the risk-benefit
ratio that the patient can tolerate”.
The aim of this multi-center, observational, prospective,
nonrandomized study was to evaluate whether palliative
sedation therapy (PST) has a negative impact on survival
in two cohorts of hospice patients admitted to 4 Hospices
in the Emilia Romagna Region (middle of Italy).
The study prospectively matched sedated patients (Cohort
A) with non sedated patients (Cohort B) undergoing the
hospices’ routine approach. A total of 518 patients
were enrolled (267 in Cohort A).
The prevalence of palliative sedation therapy was 25.1%
with low variability among the centers (± 5%). The ratio
of mild to deep sedation was 2:1. Intermittent duration
of sedation was used in 56.2% of the patients while
43.8% received continuous sedation. Deep sedation was
used in 23.6% of the patients. The refractory symptoms
treated were dyspnea (19.5%); physical and psychological
distress (24.7%), pain (11.2%), delirium and/or agitation
(8.7%). The mean and median durations of sedation were
4 days (SD= 6) and 2 days respectively ( range 0 to
43 days). The drugs used for PST were neuroleptics (84.2%);
benzodiazepines (54.3%) and opioids (25.5%).
Median survival of Cohort A (sedated patients) was
12 days (90% CI 10-14) while that of Cohort B (not sedated)
was 9 days (90% CI 8-10) (log rank = 0.95, P = 0.330).
This study confirms the results of previous studies,
i.e., “PST does not shorten life when used to relieve
refractory symptoms in terminal cancer patients.”
Why I chose this article
What are the main ethical, medical and social issues
surrounding the length of survival of sedated patients
and what is the definition of managing “refractory symptoms”?
I believe that a definition of refractory symptoms
must take into consideration the following:
There must be
1. continuous monitoring of the intensity and type of
distress caused by a symptom(s) as well, as the patients’
perception of the distress
2. specific and appropriate therapies are used for each
symptom before one considers it a “refractory symptom”.
Appropriate therapy is not only the application of the
best pharmacological therapy but it must also include
the treatment of psychological, social and spiritual
symptoms
3. informed consent prior to starting sedation and the
wishes of the patient concerning the use of sedation
must be respected
4. continuous presence of well trained and psychologically
supportive member(s) of a palliative care team is mandatory
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