2. Issues in Palliative Sedation Bruce A. Ferrell, MD Professor of Clinical Medicine UCLA David Geffen School of Medicine Director of Palliative Care

3. None Disclosures

4. Healthcare professionals have an ethical obligation to provide comfort and relieve suffering, especially near the end of life. They dying process may be attended by intractable pain and suffering despite vigorous efforts. In rare circumstances, it may be appropriate to specifically sedate a patient to achieve intractable or intolerable symptom relief. Background

5. Sedation is the administration of a drug that causes an alteration of consciousness. Many medications intended for distressing symptom relief (moderate pain, anxiety, insomnia, depression, etc.), may cause minimal, limited or temporary sedation. Emphasis on “intent” and “limited” Ordinary Sedation

6. Palliative sedation is the lowering of patient consciousness for the purpose of limiting intolerable or intractable symptom relief and suffering. – Respite: Time Limited – Terminal: In the last hours until death Definitions

7. U.S. Supreme Court ruled in 1997 that patients with terminal illness who are experiencing great pain should have “no legal barriers to obtaining medication, from qualified physicians, to alleviate that suffering, even to the point of causing unconsciousness and hastening death.” Both the American Medical Association and the National Ethics Committee of the Veterans Health Administration have issued ethics policies endorsing the use of palliative sedation. Palliative Sedation

8. Features of Sedation InterventionCause of DeathIntentLegal Status Respite SedationUnderlying diseaseAlleviation of symptoms for a predetermined time period Legal in all states Palliative SedationUnderlying diseaseAlleviation of symptoms Legal in all states Physician Assisted Suicide Medication prescribed by physician used by patient Termination of lifeLegal in California, Oregon, Washington, Vermont EuthanasiaMedication administered by physician Termination of lifeIllegal in all states

9. Principles Palliative sedation SHOULD NOT be used with the intent to cause or hasten death. Palliative sedation SHOULD NOT be used for purely existential suffering. Physicians or other healthcare professionals who object to providing palliative sedation for reasons of conscience may withdraw from the case but ensure that the patient is not abandoned.

10. Principles Palliative sedation should be used only as a last resort for comfort. Informed consent must be obtained prior to palliative sedation. Palliative sedation should be limited to those near the end of life. Patients for palliative sedation should have a DNR order.

11. Compassus Policy The primary physician and hospice medical director have agreed on the need and patient eligibility. Hospice medical director has consulted with another medical director and documented the consultation. Note: It is recommended that the medical director consults with a member of the Compassus Medical Director Advisory Committee

12. Patient criteria Failed treatments Intent of sedation Informed consent Concurrence of consultants Consistence with policy Documentation is Critical

13. Drugs for Palliative Sedation Midazolam (Versed) Propofol (Diprivan) Lorazepam (Ativan) Phenobarbitol Ketamine Dexmedetomidine (Precedex)

14. Palliative Sedation is a tool to be used rarely Remains controversial in some areas Documentation is critical Consult Hospice Compassus Policy Summary