The decision to sedate a patient should never be undertaken lightly.46 A sedated patient will be less able to interact with his or her environment. If the patient is still eating and drinking, sedation strong enough to interfere with these functions becomes ethically problematic.47 Fortunately, in most cases that require strong sedation, the patient has already stopped eating and drinking, which minimizes concern that the sedating process might hasten death. The decision to employ sedation should follow discussion with the patient, when clear (if possible), and/or the patient's proxy. Documentation of patient and/or proxy involvement in the decision to sedate should be included in the medical record. Having said this, it is important to recognize that sedation occurs along a wide spectrum, from very low doses of lorazepam, for example, at one end to rare cases using general anesthesia at the other. Most patients require only small to modest doses of sedating agents titrated not to coma, but to peaceful drowsiness. Deep sedation (variously called terminal, total, or palliative sedation) should be reserved for patients with otherwise intractable distress who are very close to death. In all cases the physician must weigh the potential benefits and burdens of sedation. To avoid any possible misunderstandings as to the intent of such sedation, orders and medical record documentation should be as explicit as possible regarding the endpoint(s) against which the sedating dose is to be titrated. For example, the order may read, "drug X given PRN qY hours for distress as evidenced by grimacing, moaning, or statements of pain or suffering." When the agreed-upon endpoint has been reached, further upward titration ceases, and the drug dose is stabilized.
A variety of sedatives may be used.9,38,48 Benzodiazepines, such as lorazepam, can be sedating, although some care must be used, particularly in the elderly, because they may cause further disorientation and disinhibit the patient.44,49 Rather like one drink of alcohol, 0.5 mg of lorazepam may make some people sleepy while disinhibiting others, resulting in wild behavior. Higher doses of lorazepam may be needed for sedation. Anticholinergic agents such as scopolamine, commonly given for respiratory secretions in those who are actively dying, may also produce adequate sedation.
Sedating neuroleptics, such as chlorpromazine and thioridazine, are commonly employed in hospice. I have had the most experience with chlorpromazine. Chlorpromazine has the advantage of coming in a very concentrated oral solution, 100 mg/cc. Often 10-20 mg (0.1-.2 cc) will adequately sedate, and it can be administered orally even to patients unable to swallow. Chlorpromazine can also be given via rectal suppositories, IM, but not SC and only rarely in a diluted IV solution. Chlorpromazine blocks dopamine, cholinergic, and histaminic receptors as well as alpha receptors. It should be avoided in patients with Parkinson's disease and in patients prone to orthostatic hypotension. Chlorpromazine (and other neuroleptics) can lower the seizure threshold. It should not be used in patients with active seizure disorders and only with caution in those prone to seizures. It is virtually impossible to predict a therapeutic dose. Some patients respond to very low doses, and some require considerably higher doses. In severely agitated patients doses should be given every hour, gradually increasing the dosage until the desired clinical end-point (lack of evidence of distress) is obtained. Based on the amount of drug given, the patient can be maintained on q6-q8-hour dosing.
When chlorpromazine is contraindicated or ineffective, barbiturates may be given. They have an additional advantage of being anticonvulsants in patients with seizures. Again, proper dosing must be individualized. I have found phenobarbital elixir useful. Phenobarbital has a slow onset and prolonged action. Pentobarbital (Nembutal) is faster in onset and can be given via rectal suppositories. Pentobarbital can also be given IM. Dosing intervals for the patient should be individualized because of a highly variable plasma half-life. Rarely, short-acting sedatives such as midazolam or propofol may be required for sedation of severely agitated patients when quick titration is desired. Consultation from either palliative care experts or anesthesiologists should first be obtained.
In most cases nonpharmacologic interventions should be used in conjunction with pharmacologic interventions. Patients in distressed altered states at the end of life can be remarkably sensitive to their environments. Maintaining a peaceful, quiet environment is essential. Family members and staff should be coached, if necessary, to speak lovingly to the patient and to encourage pleasant aspects of the experience while carefully steering patients away from unpleasant content. This is what I attempted to do with Fred, the librarian. Working with patients in distressed altered states is difficult and requires experience to do so well. Although specific guidelines are beyond the scope of this book, a few principles can be shared.
Some mildly disoriented patients can be reoriented through simple interventions - open windows (revealing day and night), clocks, and straightforward reminders of what is happening. Some patients cannot be so oriented and may become distressed by attempts to do so. In such cases recall that for the person experiencing an altered state, it is real. Going along and guiding the patient through such a state is not the same as humoring the patient. The altered experience must be approached respectfully. Suggestions to encourage positive aspects of the experience may be given, and the patient may be distracted or diverted from negative aspects. The presence of loving family members and their peaceful words and soothing touches can go far toward encouraging a positive experience. Sometimes, the best thing to do is back off for a while and use time as your ally. For example, rather than force an agitated patient to take a bath, wait until the agitation (bad dream) passes. Returning later, you may find the patient much more amenable to what you suggest. (This principle may also work well with patients suffering from dementia, who may resist some care, such as a bath, but then forget why they resisted and agree a short time later.)
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.