2009; Volume 10, No 10, October

 
 

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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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