March 2005

Dear Readers: Here's the Article for this Month:

Name of article:

Sedation for Terminally Ill Patients with Cancer
with Uncontrollable Physical Distress

Author(s): Kohara H, Ueoka H, Takeyama H, Murakami T, Morita T.
Abstract:  Journal of Palliative Medicine 8/1: 20-25; 2005

Kohara et al. report the results of a retrospective study carried out in the terminally ill patients who received sedation during admission to a hospital-based palliative care unit (PCU) in National Sanyo Hospital in Japan.

The Authors defined “sedation” as “a medical procedure to palliate patient symptoms refractory to standard treatment by intentionally dimming their consciousness”.

The following data were collected: patients’ characteristics, symptoms requiring sedation, number of patients who underwent sedation, mean duration of admission, use of opioids and sedatives in the last week of life, the parenteral midazolam equivalent, the Palliative Performance Status (PPS), the level of consciousness during sedation (by means of Communication Capacity Scale). In the analysis, patients treated with increased doses of morphine or other analgesics resulting in drowsiness were excluded and nocturnal sedation was considered separately.

In the year 1999, 124 patients were admitted to the PCU and 63 of them (50.3%) presented refractory symptoms and underwent sedation. The PPS scores before sedation were poor (10-20) in 83% of the patients.

Symptoms requiring sedation were dyspnea (63% of patients) general malaise/restlessness in 40% , pain in 25%, agitation in 21%, nausea/vomiting in 6%. In 54% of the sedated patients more than one refractory symptom was reported by the patients. The patients died on an average of 3.4 days from the beginning of sedation.

No differences were reported in the duration of hospitalization between sedated and non sedated patients.

The comparison of the level of consciousness between sedated patients and non sedated patients reached a statistically significant difference at day - 2 (before death) (p < 0.05), at day - 1 (p<0.05) and on day of death (p < 0.01).

The drugs administered for sedation were midazolam (first choice in 98% of the patients with a median daily dose during the last 4 days ranging from 26 to 32.5 mg; in 94% of the sedated patients it was used in combination with morphine), haloperidol (84% of the patients), scopolamine hydrobromide in 10%, chlorpromazine in 5%, flunitrazepam in 2% and ketamine hydrochloride in 2%.

The drugs were administered via continuous intravenous infusion in 65% of the patients and via continuous subcutaneous infusion in 35% of patients.

During the last week of life sedated patients received more opioids than non sedated patients.

Why I chose this article

In the palliative care setting, patient sedation is still an open issue and sometimes a controversial intervention which is being increasingly used for the management of refractory symptoms at the end of life. In this volume of the Journal of Palliative Medicine, this topic has been much considered.

Some of the adjectives that different authors give in this regard are : total, palliative, controlled, terminal sedation. Moreover it may be used for refractory symptoms, refractory suffering, symptoms difficult to control, intractable existential suffering/distress.

This study, with all the limitations of a retrospective study, confirm that in the last days of life it is not always possible to keep the patient aware and at the same time free of symptoms. Dyspnea, agitation and pain are the main symptoms that most frequently require terminal sedation. Unlike other authors who suggest the use of barbiturates, midazolam is considered the most used and efficient sedative drug even at low doses.

Regards,

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC