Transcript Palliative Care – An Overview Mike Harlos MD, CCFP, FCFP Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director, Winnipeg Regional Health.

Palliative Care –
An Overview
Mike Harlos MD, CCFP, FCFP
Professor and Section Head, Palliative Medicine, University of Manitoba
Medical Director, Winnipeg Regional Health Authority Palliative Care Program
What Is Palliative Care?
 Surprisingly difficult to define
 Not defined by:
– Body system (compare with dermatology,
cardiology)
– What is done (compare with anesthesiology,
surgery)
– Age (compare with pediatrics, geriatrics)
– Sex of patient (such as with gynecology)
– Location of Care (compare with ER, critical care)
Any illness, any age, any location…
Myth 1:
Palliative Care is what happens
when there’s nothing more that
can be done
Myth 2:
Palliative Care is a place
What Is Palliative Care?
(a personal definition)
Palliative Care is an approach to care which focuses on comfort and
quality of life for those affected by life-limiting/life-threatening illness. Its
goal is much more than comfort in dying; palliative care is about
living, through meticulous attention to control of pain and other
symptoms, supporting emotional, spiritual, and cultural needs, and
maximizing functional status.
The spectrum of investigations and interventions consistent with a
palliative approach is guided by goals and expectations of patient and
family and by accepted standards of health care, rather than being
boundaried by preconceptions of what is or is not "palliative".
“Thank you for giving
me aliveness”
Jonathan – 6 yr old boy terminally ill boy
Ref: “Armfuls of Time”; Barbara Sourkes
Palliative Care… The “What If…?” Tour Guides
Can Help Inform The Choice Of Not Intervening
• What would things look like?
• Time frame?
“What if…?
• Where care might take place
• What should the patient/family
expect (perhaps demand?)
regarding care?
• How might the palliative care team
help patient, family, health care
team?
Disease-focused Care
(“Aggressive Care”)
PHYSICAL
SUFFERING
PSYCHOSOCIAL
EMOTIONAL
SPIRITUAL
CHALLENGEAlleviate Suffering for a Condition Which:
• Ultimately will affect every one of us:
•
•
•
•
•
•
- Large numbers
- We have our own “death issues” as care providers
Only approximately 10% of Canadians have access to specialty
care
Few physicians or nurses have even basic training
Clinicians don’t intuitively know when they need advice…
They don’t know what they don’t know
The process & outcome are expected to be terrible… after all, it is
death
 How can you tell when something inherently horrible goes
badly?
Has a tremendous impact on those close to the individual…
“collateral suffering”
No chance of feedback from patient “after the fact”
• Don’t confuse “Palliative Care” – the philosophy
of approach to care in the context of life-limiting
illness with “Palliative Care service delivery”….
• the latter is the application of the broad
philosophy within the constraints of existing
(limited) resources
• Services are focused on the most needy, which
tends to be in the final months of life
Increase capacity
through education,
advocacy,
partnerships
Palliative Care as a
philosophy of care
Formal
Program
Potential Palliative Conditions
 “The Usual Suspects” – progressive life-limiting illness
– Incurable cancer
– Progressive, advanced organ failure (heart, lung, kidney,
liver)
– Advanced neurodegenerative illness (ALS, Alzheimer’s
Disease)
 Sudden fatal medical condition
– Acute stroke
– Withholding or withdrawing life-sustaining interventions
(ventilation, dialysis, pressors, food/fluids…)
– Trauma – eg. head injury
– Ischemic limbs, gut
– Post-cardiac arrest ischemic encephalopathy
– etc…
Potential Palliative Care
Interventions
Generally
Not Palliative
Palliative
Support
• Emotional
• Spiritual
• Psychosocial
Variable
CPR
Ventilation
Transfusions
Infections
Control of
•
•
•
•
Pain
Dyspnea
Nausea
Vomiting
Hypercalcemia
Tube Feeding
Dialysis
Highly
burdensome
Interventions
Potential Palliative Care Settings
Anywhere
Key Considerations In Remote Areas
 Anticipate
– Potential concerns around functional decline, food & fluids,
decreased LOC, “treatable” complications, sudden change,
– Loss of oral route of administration
– End-of-life development of pneumonia, delirium with potential for
dyspnea, congestion, agitation
 Plan
– Medication supplies
– Rehearse (ie. think through the steps with patient, family, health
care team) the “what to do when…” scenarios
 Communicate
– Ongoing dialogue, availability for questions/concerns
– Preemptive discussions
COMMUNICATION
ISSUES
IN
PALLIATIVE CARE
• Don’t assume that the absence of question
reflects an absence of concerns
• Upon becoming aware of a life-limiting Dx, it
would be very unusual not to wonder:
– “How long do I have?”
– “How will I die”
• Waiting for such questions to be posed may
result in missed opportunities to address
concerns; consider exploring preemptively
When Families Wish To Filter Or Block
Information
• Don’t simply respond with “It’s their right to know” and dive in.
• Rarely an emergent need to share information
• Explore reasons / concerns – the “micro-culture” of the family
• Perhaps negotiate an “in their time, in their manner”
resolution
• Ultimately, may need to check with patient:
“Some people want to know everything they can about
their illness, such as results, prognosis, what to expect.
Others don’t want to know very much at all, perhaps
having their family more involved. How involved would you
like to be regarding information and decisions about your
illness?”
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“Set the Stage”
• In person
• Sitting down
• Minimize distractions
• Family / friend possibly present
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Seek Permission
• “Many people in this situation wonder
about / are concerned about …[fill in
blank].
Would you like to talk about that?”
• “Are you comfortable discussing these
issues?”
21
Be Clear
Make sure you’re both talking about the
same thing
There’s a tendency to use euphemisms
and vague terms in dealing with difficult
matters… this can lead to confusion
“Euphemasia”
22
Being Clear
When you think people are asking about prognosis…
• “How long do you think I have?”
• “What kind of time frame am I looking at?”
… they might well be asking about discharge
“Do you mean how long do you have stay
in hospital, or are you wondering about
how long you might have to live”?
23
Being Clear
ctd
“Am I going to get better?”
• Seems like a straightforward question,
but…
• Might be referring to specific
symptoms, or to overall illness (“big
picture”)
24
Acknowledge / Validate / Normalize
• This is a biggie!
• People can spend an entire lifetime
without hearing others talk about
dying… their worries, fears
• End up feeling as if they are cowards
for their concern – alone in being
worried about dying
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Explore “The Who”
What is the context / frame of reference into
which this information in being received ?
• Understanding of illness
• Expectations / hopes / goals
• Concerns / worries / fears
• Cultural / Spiritual factors that may influence
individual’s approach to illness / dying /
communication
 “Micro” (family) vs. “Macro” cultures
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Preemptive Discussions
“You might be wondering…”
Or
“At some point soon you will likely wonder
about…”
• Food / fluid intake
• Meds or illness to blame for being
weaker / tired / sleepy /dying?
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Titrate information
with “measured
honesty”
“Feedback Loop”
Check Response:
Observed &
Expressed
The response of the patient determines the
nature & pace of the sharing of information
Debriefing
• Clarifications, further questions
• Are other supports wanted/needed (SW,
Pastoral Care)
• Do they want help in discussing with
relatives/friends?
• Plans for follow-up
• Do they want you to call someone to pick them
up?
29
Specific Communication Issues
1.
2.
3.
4.
5.
6.
7.
8.
9.
Prognosis
Unrealistic hopes
Desire for early/hastened death
Close calls
Talking about dying
Substituted judgment
Just one more day
Sudden Change
Can they hear us? Bedside dynamics
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DISCUSSING PROGNOSIS
“How long have I got?”
1. Confirm what is being asked
2. Acknowledge / validate / normalize
3. Explore “frame of reference” (the “Who”… understanding
of illness, what they are aware of being told.
4. Check if there’s a reason that this is has come up at this
time
5. Tell them that it would be helpful to you in answering the
question if they could describe how the last month or so
has been for them
6. How would they answer that question themselves?
7. Answer the question
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Close Calls
• After a resolved pain / dyspnea crisis
• People experiencing such bad symptoms often
believe that they are dying
• While they may be glad that you’ve made them
feel better…
… if that wasn’t dying… and it was the worst
experience that I could possibly imagine… what
will dying be like?
32
TALKING ABOUT DYING
“Many people think about what they might
experience as things change, and they become
closer to dying.
Have you thought about this regarding yourself?
Do you want me to talk about what changes are
likely to happen?”
33
First, let’s talk about what you should not
expect.
You should not expect:
–
pain that can’t be controlled.
–
breathing troubles that can’t be
controlled.
–
“going crazy” or “losing your mind”
If any of those problems come up, I will
make sure that you’re comfortable and
calm, even if it means that with the
medications that we use you’ll be sleeping
most of the time, or possibly all of the
time.
Do you understand that?
Is that approach OK with you?
You’ll find that your energy will be less,
as you’ve likely noticed in the last while.
You’ll want to spend more of the day
resting, and there will be a point where
you’ll be resting (sleeping) most or all of
the day.
Gradually your body systems will shut down,
and at the end your heart will stop while you
are sleeping.
No dramatic crisis of pain, breathing,
agitation, or confusion will occur we won’t let that happen.
OBTAINING SUBSTITUTED JUDGMENT
• Avoid making families feel as though they are
making a choice, when the illness has dictated
that no choice exists
• Ideally, phrase the discussion in terms of their
thoughts on what the patient would want
• Avoid presenting the “letting die” vs.
“prolonging suffering” choice to families.
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PHRASING REQUEST:
SUBSTITUTED JUDGMENT
“If he could come to the bedside as
healthy as he was a year ago, and look
at the situation for himself now, what
would he tell us to do?”
Or
“If you had in your pocket a note from
him telling you that to do under these
circumstances, what would it say?”
39
Sudden Change
Steady decline
Accelerated deterioration begins,
medications changed
Rapid decline due to
illness progression with
diminished reserves.
Medications questioned
or blamed
40
The Perception of the “Sudden Change”
When reserves are depleted, the change seems sudden
and unforeseen.
However, the changes had been happening.
That
was
fast!
Melting ice = diminishing reserves
Day 1
Day 2
Day 3
Final
Pain Management In
Palliative Care
Clinical Terms For The Sensory
Disturbances Associated With Pain
 Dysesthesia – An unpleasant abnormal sensation,
whether spontaneous or evoked.
 Allodynia – Pain due to a stimulus which does not
normally provoke pain, such as pain caused by light
touch to the skin
 Hyperalgesia – An increased response to a stimulus
which is normally painful
 Hyperesthesia - Increased sensitivity to stimulation,
excluding the special senses. Hyperesthesia includes
both allodynia and hyperalgesia, but the more specific
terms should be used wherever they are applicable.
Approach To Pain Control in Palliative Care
1. Thorough assessment by skilled and knowledgeable
clinician
– History
– Physical Examination
2. Pause here - discuss with patient/family the goals of care,
hopes, expectations, anticipated course of illness. This will
influence consideration of investigations and interventions
3. Investigations – X-Ray, CT, MRI, etc - if they will affect
approach to care
4. Treatments – pharmacological and non-pharmacological;
interventional analgesia (e.g.. Spinal)
5. Ongoing reassessment and review of options, goals,
expectations, etc.
TYPES OF PAIN
NOCICEPTIVE
NEUROPATHIC
Visceral
Somatic
• bones, joints
• connective tissues
• muscles
• Organs –
heart, liver,
pancreas, gut,
etc.
Deafferentation Sympathetic
Maintained
Peripheral
Somatic Pain
•
•
•
•
Aching, often constant
May be dull or sharp
Often worse with movement
Well localized
Eg/
– Bone & soft tissue
– chest wall
Visceral Pain
•
•
•
•
Constant or crampy
Aching
Poorly localized
Referred
Eg/
– CA pancreas
– Liver capsule distension
– Bowel obstruction
FEATURES OF NEUROPATHIC PAIN
COMPONENT
Steady,
Dysesthetic
DESCRIPTORS
• Burning, Tingling
• Constant, Aching
• Squeezing, Itching
• Allodynia
EXAMPLES
• Diabetic neuropathy
• Post-herpetic
neuropathy
• Hypersthesia
Paroxysmal,
Neuralgic
• Stabbing
• trigeminal neuralgia
• Shock-like, electric
• may be a component
of any neuropathic
pain
• Shooting
• Lancinating
Pain
Assessment
“Describing pain only in terms of its
intensity is like describing music
only in terms of its loudness”
von Baeyer CL; Pain Research and Management 11(3) 2006; p.157-162
PAIN HISTORY
 Description: severity, quality, location,
temporal features, frequency, aggravating
& alleviating factors
 Previous history
 Context: social, cultural, emotional,
spiritual factors
 Meaning
 Interventions: what has been tried?
Example Of A Numbered Scale
Medication(s) Taken
•
•
•
•
•
•
Dose
Route
Frequency
Duration
Efficacy
Adverse effects
Physical Exam In Pain Assessment
Inspection / Observation
“You can observe a lot just by watching”
Yogi Berra

Overall impression… the “gestalt”?

Facial expression: Grimacing; furrowed brow; appears anxious; flat
affect

Body position and spontaneous movement: there may be
positioning to protect painful areas, limited movement due to pain

Diaphoresis – can be caused by pain

Areas of redness, swelling

Atrophied muscles

Gait

Myoclonus – possibly indicating opioid-induced neurotoxicity
Physical Exam In Pain Assessment
Palpation
 Localized tenderness to pressure or
percussion
 Fullness / mass
 Induration / warmth
Physical Exam In Pain Assessment
Neurological Examination

Important in evaluating pain, due to the possibility of spinal cord
compression, and nerve root or peripheral nerve lesions

Sensory examination
– Areas of numbness / decreased sensation
– Areas of increased sensitivity, such as allodynia or hyperalgesia

Motor (strength) exam - caution if bony metastases (may fracture)

Deep tendon reflexes – intensity, symmetry
– Hyperreflexia and clonus: possible upper motor neuron lesion,
such as spinal cord compression or cerebral metastases.
– Hyoporeflexia - possible lower motor neuron impairment,
including lesions of the cauda equina of the spinal cord or
leptomeningeal metastases.

Sacral reflexes – diminished rectal tone and absent anal reflexes
may indicate cauda equina involvement of by tumour
Physical Exam In Pain Assessment
Other Exam Considerations
Further areas of focus of the physical
examination are determined by the clinical
presentation.
Eg: evaluation of pleuritic chest pain would
involve a detailed respiratory and chest wall
examination.
Pain
Treatment
Non-Pharmacological Pain Management
 Acupuncture
 Cognitive/behavioral therapy
 Meditation/relaxation
 Guided imagery
 TENS
 Therapeutic massage
 Others…
W.H.O. ANALGESIC LADDER
3
By the
Strong opioid
+/- adjuvant
2
Clock
1
Non-opioid
+/- adjuvant
Weak opioid
+/- adjuvant
STRONG OPIOIDS
• most commonly use:
– morphine
– Hydromorphone (Dilaudid ®)
– transdermal fentanyl (Duragesic®)
– oxycodone
– Methadone
• DO NOT use meperidine (Demerol) long-term
– active metabolite normeperidine  seizures
OPIOIDS and
INCOMPLETE CROSS-TOLERANCE
• conversion tables assume that tolerance to a
specific opioid is fully “crossed over” to other
opioids.
• cross-tolerance unpredictable, especially in:
– high doses
– long-term use
• divide calculated dose in ½ and titrate
Drug
Hydromorphone
Oxycodone
Codeine
Daily Morphine
Dose
Methadone
30 – 90 mg
90 – 300 mg
> 300 mg
Fentanyl
Approximate Equipotency
with Morphine
(Morphine:Drug)
5:1
1.5:1 to 2:1
1:12
3.7:1
7.75:1
12.75:1
80:1 to 100:1 (for subcutaneous
dosing of each)
NB: Does not consider incomplete cross-tolerance
TITRATING OPIOIDS
• dose increase depends on the situation
• dose by 25 - 100%
EXAMPLE: (doses in mg q4h)
Morphine
Hydromorphone
5 10 15 20 25 30 40 50 60
1
2
3
4
5
6
8 10 12
http://palliative.info
http://palliative.info
TOLERANCE
PSYCHOLOGICAL
DEPENDENCE /
ADDICTION
PHYSICAL
DEPENDENCE
TOLERANCE
A normal physiological
phenomenon in which increasing
doses are required to produce
the same effect
Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
PHYSICAL DEPENDENCE
A normal physiological
phenomenon in which a withdrawal
syndrome occurs when an opioid
is abruptly discontinued or an
opioid antagonist is administered
Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
PSYCHOLOGICAL DEPENDENCE
and ADDICTION
A pattern of drug use characterized
by a continued craving for an opioid
which is manifest as compulsive
drug-seeking behaviour leading to
an overwhelming involvement in the
use and procurement of the drug
Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
Changing Route Of Administration
In Chronic Opioid Dosing
po / sublingual / rectal routes
reduce by ½
SQ / IV / IM routes
Using Opioids for Breakthrough Pain
•Empirically titrated…
 The correct dose is “the one that works”
 The dose range is somewhere between “not enough”
and “too much”
•Patient must feel in control, empowered
•Use aggressive dose and interval
Patient Taking Short-Acting Opioids:
• 50 - 100% of the q4h dose, given q1h prn
Patient Taking Long-Acting Opioids:
• 10 - 20% of total daily dose given, q1h prn
with short-acting opioid preparation
Opioid Side Effects
 Constipation – need proactive laxative use
 Nausea/vomiting – consider treating with dopamine
antagonists and/or prokinetics (metoclopramide, domperidone,
prochlorperazine [Stemetil], haloperidol)
 Urinary retention
 Itch/rash – worse in children; may need low-dose naloxone
infusion. May try antihistamines, however not great success
 Dry mouth
 Respiratory depression – uncommon when titrated in
response to symptom
 Drug interactions
 Neurotoxicity (OIN): delirium, myoclonus  seizures
Spectrum of Opioid-Induced Neurotoxicity
Opioid
tolerance
Mild myoclonus
(eg. with sleeping)
Delirium
Opioids
Increased
Severe myoclonus
Seizures,
Death
Hyperalgesia
Agitation
Misinterpreted
as Pain
Opioids
Increased
Misinterpreted
as Disease-Related Pain
OIN: Treatment
 Switch opioid (rotation) or reduce opioid
dose; usually much lower than expected
doses of alternate opioid required… often
use prn initially
 Hydration
 Benzodiazepines for neuromuscular
excitation
Adjuvant Analgesics
 first developed for non-analgesic indications
 subsequently found to have analgesic activity in
specific pain scenarios
 Common uses:
– pain poorly-responsive to opioids (eg. neuropathic
pain), or
– with intentions of lowering the total opioid dose
and thereby mitigate opioid side effects.
Adjuvants Used In Palliative Care
 General / Non-specific
– corticosteroids
– cannabinoids (not yet commonly used for pain)
 Neuropathic Pain
– gabapentin
– antidepressants
– ketamine
– topiramate
– clonidine
 Bone Pain
– bisphosphonates
– (calcitonin)
CORTICOSTEROIDS AS ADJUVANTS
 inflammation
 edema
}
tumor mass
effects
 spontaneous nerve depolarization
CORTICOSTEROIDS: ADVERSE EFFECTS
IMMEDIATE
 Psychiatric
 Hyperglycemia
 risk of GI bleed
gastritis
aggravation of
existing lesion
(ulcer, tumor)
 Immunosuppression
LONG-TERM
 Proximal myopathy
often < 15 days
 Cushing’s syndrome
 Osteoporosis
 Aseptic / avascular
necrosis of bone
DEXAMETHASONE
• minimal mineralcorticoid effects
• po/iv/sq/?sublingual routes
• perhaps can be given once/day;
often given more frequently
• If an acute course is discontinued
within 2 wks, adrenal suppression
not likely
Treatment of Neuropathic Pain
Pharmacologic treatment
• Opioids
• Steroids
• Anticonvulsants – eg. gabapentin
• TCAs (for dysesthetic pain, esp. if depression)
• NMDA receptor antagonists: ketamine,
methadone
• Anesthetics
Radiation therapy
Interventional treatment
• Spinal analgesia
• Nerve blocks
Gabapentin
 Common Starting Regimen
– 300 mg hs Day 1, 300 mg bid Day2, 300
mg tid Day 3, then gradually titrate to effect
up to 1200 mg tid
 Frail patients
– 100 mg hs Day 1, 100 mg bid Day 2, 100
mg tid Day 3, then gradually titrate to effect
Incident Pain
Pain occurring as a direct and
immediate consequence of a
movement or activity
Circumstances In Which
Incident Pain Often Occurs
• Bone metastases
• Neuropathic pain
• Intra-abd. disease aggravated by respiration
» “incident” = breathing
» ruptured viscus, peritonitis, liver hemorrhage
• Skin ulcer: dressing change, debridement
• Disimpaction
• Catheterization
Having a steady level of enough opioid to treat
the peaks of incident pain...
Pain
...would result in
excessive dosing
for the periods
between
incidents
Incident
Incident
Time
Incident
Fentanyl and Sufentanil
 synthetic µ agonist opioids
 highly lipid soluble
• transmucosal absorption; effect in approx 10 min
• rapid redistribution, including in / out of CSF; lasts
approx 1 hr.
 fentanyl » 100x stronger than morphine
 sufentanil » 1000x stronger than morphine
10 mg morphine
10 µg sufentanil
100 µg fentanyl
INCIDENT PAIN PROTOCOL ctd...
• fentanyl or sufentanil is administered SL 10
min. prior to anticipated activity
• Eg/ 25 mcg – 50 mcg fentanyl SL prior to
activity
• See: http://palliative.info/IncidentPain.htm
The Management Of
Irreversible Delirium In
The Imminently Dying
Mike Harlos MD, CCFP, FCFP
Professor and Section Head, Palliative Medicine, University of Manitoba
Medical Director, Winnipeg Regional Health Authority Palliative Care Program
Objectives
1. Be aware of the prevalence of delirium at the end of life
2. Recognize the factors that make a delirium “irreversible”
3. Consider options for the aggressive management of
delirium in the imminently dying patient
4. Develop an approach to communication issues with
families regarding delirium and its impact on their
experience with a dying loved one
What Is “Imminently Dying”?
“What exactly constitutes ‘‘imminence’’ is somewhat vague
in the literature but nonetheless roughly coherent…. it is
stipulated as hours or days or, at most, weeks.”
Cellarius V.; Terminal sedation and the “imminence condition”
J Med Ethics. 2008 Feb;34(2):69-72.
What Makes A Delirium Irreversible
At End Of Life?
1. Clinical factors:


Refractory to available interventions, eg. recurrent
hypercalcemia after multiple bisphosphonate treatments
No therapeutic options available – eg. end-stage liver
failure
2. Directive from patient/proxy that no further investigations be
done and that interventions focus strictly on comfort.
3. Limitations of care setting chosen by patient/family – eg. a
steadfast commitment to remain at home to die
Obtaining Substituted Judgment –
Exploring Choices

Our approach should be guided by how the patient
would direct care if he/she could do so

Families should not be put in positions of making
impossible choices, such as…
– “We can give sedation so he’ll be calm – but he
might never wake up again. Or, we can let him stay
alert and agitated, but at least you can still connect
with him… what would you like us to do?”
Phrasing Request For Substituted Judgment
“If he could come to the bedside as healthy as he was a year
ago, and look at the situation for himself now, what would he
tell us to do?”
Or
“If you had in your pocket a note from him telling you that
to do under these circumstances, what would it say?”
Families will usually indicate that he would say “Just keep me
comfortable… don’t let me be like that”
94
Agitated EOL Delirium Is A
Medical Emergency

Imagine in the last few hours of life being:
– agitated, combative, striking out at caregivers
– paranoid, saying hurtful things to family
– children / grandchildren afraid to visit

Loss of self / personhood / dignity

Lifelong difficult memories for family

No chance for a “do-over” if poorly managed
95
Implications Of Irreversibility

Won’t get better… ever

Interventions to sedate and calm the patient must be aggressive and
ongoing until the patient’s expected death from their underlying
condition
• a “little bit” of sedatives will only further compromise the function
of a failing brain and aggravate agitated state.
• factors causing / contributing to the delirium are becoming worse
with time – there is no expectation of spontaneous improvement
that would allow decreasing the sedatives

An overarching goal of care becomes the effective, consistent
sedation of the patient until the condition's natural course unfolds,
and the patient dies as expected from the underlying condition
• i.e. the goal is to ensure that the patient does not waken again
before dying
96
Implications Of Irreversibility ctd…

The family must be informed of these implications, so they are
not expecting that after pt is settled he will awaken and be clear
and communicative

Need to help family and care providers with concerns that the
sedation is speeding up or contributing to the dying… perhaps
more so when continuous infusions are used
• This concern may not be overtly expressed, however it is
important enough to strongly consider preemptive
discussions
“Sometimes people may wonder if the medications are
speeding things up… is that something that you had
wondered about? Would it be helpful to talk about that?”
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Implications Of Irreversibility ctd…
The literature evidence does not support that palliative sedation
hastens the dying process when death is proximate due to the
underlying condition1,2,3
1.
Claessens P, Menten J, Schotsmans P, Broeckaert B.; Palliative sedation: a
review of the research literature.; J Pain Symptom Manage. 2008 Sep;
36(3):310-33
2.
Morita T, Tsunoda J, Inoue S, et al. Effects of high dose opioids on survival
in terminally ill cancer patients. J Pain Symptom Manage 2001;21:282–9
3.
Sykes N, Thorns A. The use of opioids and sedatives at the end of life. Lancet
Oncol 2003;4:312–8.
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Considerations Regarding Medications Used In
Aggressive Sedation (Adult Patients)
 Sedatives (as with opioids) are titrated to empirical effect after an initial
dose is selected… the correct dose is “the one that works” and the dose
range is somewhere between “not enough” and “too much”
 Tend to use a neuroleptic +/- benzodiazepine; subcutaneous route is
most common
 Methotrimeprazine (Nozinan®) commonly used due to its sedating
effects, though be aware of anticholinergic effects potentially aggravating
the delirium
 Can add a benzodiazepine such as lorazepam sublingually or
midazolam subcutaneously
 Commonly need regular intermittently scheduled doses (eg. q4h or q6h)
plus a prn dose of q1h prn
 prn Medication orders must allow nursing or family to “stack” doses…
i.e. repeat a dose once its empirical effect should have been realized,
yet before it has begun to lose effect
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Supporting Families
 At minimum, effective sedation changes the beside
dynamics from one in which people are afraid to visit and
there is no meaningful interaction to one in which people
can talk, read, sing, play favourite music, pray, tell stories,
touch.
 Health care team has a role in facilitating meaningful
visits… family/friends may not know “the right things to
do”
 Individuals may want time alone but be reluctant to ask
others (friends/family) to leave the room. The health care
team can suggest that this might be something that the
family can explore with each other
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Supporting Families
The question of “can they still hear us?” arises frequently…
of course it’s not possible to know this, however:
 Hearing is a resilient sense, as evidenced by its potential
to endure into the early phase of general anesthesia
 If not true “hearing”, the comforting/settling effect of the
awareness of the presence of family can be remarkable
 The operative approach is that some nature of
hearing/awareness/spiritual connection is maintained…
this therefore must be considered when speaking about
the patient in his/her presence.
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