National Hospice and Palliative Care Organization Palliative Sedation in Hospice and Palliative Care...
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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
National Hospice and Palliative Care Organization Palliative Sedation in Hospice and Palliative Care Instructions for using this presentation: 1.Download
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
Slide 2
National Hospice and Palliative Care Organization Palliative
Sedation in Hospice and Palliative Care National Hospice and
Palliative Care Organization Ethics Committee July 2012
Slide 3
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
Slide 4
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).
Slide 5
National Hospice and Palliative Care Organization Process and
Conditions of Sedation Use of sedatives via evidence-based protocol
(Cherny et al.) Appropriateness considering patients trajectory
toward death Proportionate sedation: only to the degree necessary
to make suffering tolerable as defined by patient Reversible
Slide 6
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
patients sense of self
Slide 7
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
Slide 8
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
Slide 9
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
Slide 10
National Hospice and Palliative Care Organization Pediatric
Considerations Appropriate for children Unrelieved distress
Inadequately alleviated by other measures
Slide 11
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
Slide 12
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
Slide 13
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?
Slide 14
National Hospice and Palliative Care Organization
Organizational Policy and Procedure POLICY Definition of PST
Indications for PST Clinical & ethical rationale for PST
Guidelines for patient, family, & team assessment & support
during and after PST Guidelines for annual case review &
quality improvement process
Slide 15
National Hospice and Palliative Care Organization
Organizational Policy and Procedure PROCEDURES Checklist for
intractable & intolerable symptoms & trialed/failed
interventions Checklist for patient/family education/consent
Plan/rationale for continuing/not continuing ANH Evidence-based
protocol for selection & dosage of sedative medication
Slide 16
National Hospice and Palliative Care Organization
Organizational Policy and Procedure PROCEDURES Checklist for
ongoing support of family and team during sedation Evidence-based
protocol for symptom assessment during induction, & regular
assessment during sedation to ensure level of suffering is
tolerable
Slide 17
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.
Slide 18
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.
Slide 19
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.