Palliative Care Tips - Edited by Doreen Oneschuk MD. Tertiary Palliative Care Unit, Grey Nuns Community Hospital. Original Contributor: Peter Lawlor, MD - Issue #21 (Collect them all) (issued June 2002). Downloadable PDF file

Terminal Sedation:
•This process involves pharmacological interventions aimed to induce/maintain sedation, in order to palliate refractory symptoms in the terminally ill.
•The purpose of sedation is to reduce patient awareness of distressing symptom(s).
•Inducing sedation could conceivably shorten life by reducing airway protective mechanisms.
•For the physician therefore, the ethical principle of "double-effect" operates in this situation. Here the primary intent (relief of distress from refractory symptoms) outweighs a foreseen potentially negative outcome (potential shortening of life).
• Despite the emotive debate concerning the underlying ethical principles, most situations where the need arises in clinical practice present relatively straightforward indications.

Types of pharmacological sedation and clinical indications:

Maintenance	• Agitated delirium uncontrolled on less sedating neuroleptics, eg, haloperidol • Dyspnea uncontrolled on maximal standard therapy •Any refractory symptom that is uncontrolled using best standard care.
Specific Emergencies	• Seizure/acute stridor/massive bleeding. Sedation order written as prn Use a rapid onset, short-acting benzodiazepine, eg, midazolam or lorazepam

Questions that need to be answered prior to initiating sedation

•has a thorough assessment been conducted to identify and treat reversible problems?
•have appropriate consultations been made with palliative care and other specialists?
•have non-pharmacological approaches been maximized, eg, distraction or relaxation techniques in the case of anxiety/dyspnea?
•have other pharmacological treatments been maximized, eg, appropriate titration of opioids in the case of dyspnea or appropriate dosing of neuroleptics for delirium?
• have the goals of sedation been explained to and discussed with the patient and/or family?
• has a consensus been reached as a result of the these discussions? (Conference)
• has temporary sedation been considered? Consider, if necessary, in the event of potentially reversible delirium, and while awaiting the outcome of interventions aimed at reversal.

Suggested agents for inducing/maintaining pharmacological sedation

Methotrimeprazine (can be tried prior to midazolam)	•6.25mg sc q8 hourly (h) and q 1h prn for breakthrough (BT) agitation. • If necessary, increase dose to 12.5 or 25mg sc q8h and q1h prn for BT • If ineffective, or deeper sedation needed, proceed to midazolam
Midazolam (short-acting, hence given as infusion except for seizures, stridor or bleeding)	• In some situations (severe agitation) a loading dose of 2.5mg sc is given • Start infusion at 1mg/hour sc, titrate to keep patient sleepy/sedated • The infusion can be titrated up/down every 5-10 minutes as needed. •For seizure activity, a massive bleed, or acute stridor give 5mg im stat (im route - faster absorption) Preloaded syringes last 30 days approx.

•Less commonly used agents include chlorpromazine (iv or pr) and propofol (iv).
• Midazolam has rapid onset of effect, ease of titration, and reversal (short half-life), if indicated.
•Please consult palliative care physicians as needed, especially if indications are not straightforward.

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