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National Hospice and Palliative Care Organization Palliative Sedation in Hospice and Palliative Care Instructions for using this presentation: 1.Download and save the file to your computer. 2.Review the speaker notes at the bottom of each slide. 3.If needed, copy the speaker notes into another document for reformatting and ease of use during presentation
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Palliative Sedation in Hospice and Palliative Care

Jan 24, 2016

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Page 1: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

Palliative Sedation in Hospice and Palliative Care

Instructions for using this presentation:

1.Download and save the file to your computer.2.Review the speaker notes at the bottom of each slide.3.If needed, copy the speaker notes into another document for reformatting and ease of use during presentation

Page 2: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

Palliative Sedation in Hospice and Palliative Care

National Hospice and Palliative Care Organization Ethics Committee

July 2012

Page 3: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Goals

Define palliative sedation Discuss ethical justification Discuss implementation issues Review relevant organizational policies and

procedures Explore process using case studies

Page 4: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Define PST

Palliative sedation is lowering of patient consciousness using sedative

medications; with the intent of limiting patient awareness of suffering; when suffering is otherwise intractable and

intolerable (Morita et al., 2002; Kirk & Mahon, 2010).

Page 5: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Process and Conditions of Sedation Use of sedatives via evidence-based protocol

(Cherny et al.) Appropriateness considering patient’s trajectory

toward death Proportionate sedation: only to the degree

necessary to make suffering tolerable as defined by patient

Reversible

Page 6: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Ethical Justification Nonmaleficence

Do no harm Preventing/reducing harm

Beneficence Benefitting patient/family Conceive of “benefit” in a way informed by

patient/family values/goals Autonomy

Honoring wishes/preferences of patient/family Removing barriers/threats to patient’s sense of self

Page 7: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Confusion about Ethical Justification Assisted suicide debate

Doctrine of double effect

Sedation & the proximate cause of death

Distinct from high-dose opioid use

Page 8: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Ethical Implementation Thoughtfully and thoroughly developed policy and

procedures Rigorous interdisciplinary assessment Excellent but unsuccessful interdisciplinary

interventions prior to initiation Clear communication with patient and family Careful, expert implementation Accurate and complete documentation

Page 9: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Clinical Use

Far end of palliative care continuum Part of interdisciplinary plan of care Revocable Only for unrelieved symptoms

Page 10: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Pediatric Considerations Appropriate for children

Unrelieved distress Inadequately alleviated by other measures

Page 11: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Artificial Nutrition and Hydration

Separate the decision for sedation from ANH and other concomitant therapies

Consider clinical appropriateness for each intervention Patients have right to refuse invasive procedures Hospice and palliative care organizations have

responsibility to offer only therapies consistent with their mission, scope of practice, expertise, and policies and procedures

Page 12: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Who Decides?

Patient: autonomy and related rights Family: involved in care planning Interdisciplinary team: develops care plan

with patient and family Advice from external ethics consultation may

be helpful Advice from external clinicians may be helpful

Page 13: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

When Death is not Imminent Relationship of sedation and voluntary intake of food

& hydration Does sedation preventing intake of food & hydration

for >10 days become contributing cause of death? Questions to consider:

Voluntary intake? Benefit/burden? Temporary sedation appropriate?

Page 14: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Organizational Policy and ProcedurePOLICY

Definition of PSTIndications for PSTClinical & ethical rationale for PSTGuidelines for patient, family, & team assessment & support during and after PSTGuidelines for annual case review & quality improvement process

Page 15: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Organizational Policy and ProcedurePROCEDURES

Checklist for intractable & intolerable symptoms & trialed/failed interventionsChecklist for patient/family education/consentPlan/rationale for continuing/not continuing ANHEvidence-based protocol for selection & dosage of sedative medication

Page 16: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Organizational Policy and ProcedurePROCEDURES

Checklist for ongoing support of family and team during sedationEvidence-based protocol for symptom assessment during induction, & regular assessment during sedation to ensure level of suffering is tolerable

Page 17: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Case Studies

Case 1: Mr. Martin, 73-years old, has prostate ca. Case 2: Ms. North is 68 and has lung ca. Case 3: Ms. Smith is 22 years old and has a peripheral

neuroectodermal tumor that responded poorly to treatment.

Case 4: Mr. George is in his late 50s and has ALS. Case 5: Ms. Lopez is in her mid-30s and has cervical ca

that has become metastatic to multiple organs and to bone.

Page 18: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Bibliography Cherny, N & Radbruch, L. “European Association for Palliative

Care (EAPC) Recommended Framework for the Use of Sedation in Palliative Care.” Palliative Medicine 23, no. 7 (2009): 581-593.

Kirk, T. & Mahon, M. “National Hospice and Palliative Care Organization (NHPCO) Position Statement and Commentary on the Use of Palliative Sedation in Imminently Dying Terminally Ill Patients.” Journal of Pain & Symptom Management 39, no. 5 (2010): 914-923.

Page 19: Palliative Sedation in  Hospice and Palliative Care

National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Bibliography Maltoni, M., Scarpi, E., Rosati, M. et al. “Palliative Sedation in End-of-Life

Care and Survival: A Systematic Review.” Journal of Clinical Oncology 30, no. 12 (2012): 1378-1383.

Morita, T., Tsuneto, S. & Shima, Y. “Definition of Sedation for Symptom Relief: A Systematic Literature Review and a Proposal of Operational Criteria.” Journal of Pain & Symptom Management 24, no. (2002): 447-453.