Abstract

Background: Canada does not have a standardized ethical and practice framework for continuous palliative sedation therapy (CPST). Although a number of institutional and regional guidelines exist, Canadian practice varies. Given the lack of international and national consensus on CPST, the Canadian Society for Palliative Care Physicians (CSPCP) formed a special task force to develop a consensus-based framework for CPST.
Objective: Through a preliminary review of sedation practices nationally and internationally, it was determined that although considerable consensus was emerging on this topic, there remained both areas of contention and a lack of credible scientific evidence to support a definitive clinical practice guideline. This led to the creation of a framework to help guide policy, practice, and research.
Methods: This framework was developed through the following steps: 1) literature review; 2) identification of issues; 3) preparation of a draft framework; 4) expert consultation and revision; 5) presentation at conferences and further revision; and 6) further revision and national consensus building.
Results: A thorough literature review, including gray literature, of sedation therapy at the end of life was conducted from which an initial framework was drafted. This document was reviewed by 30 multidisciplinary experts in Canada and internationally, revised several times, and then submitted to CSPCP members for review. Consensus was high on most parts of the framework.
Conclusion: The framework for CPST will provide a basis for the development of safe, effective, and ethical use of CPST for patients in palliative care and at the end of life.

Get full access to this article

View all available purchase options and get full access to this article.

References

1.
Schüklenk Uvan Deiden JJDownie JMclean SAUpshir RWeinstock D. End-of-life decision making in Canada: The report by The Royal Society of Canada, Expert Panel Report on: End-of-life Decision MakingBioethics201125Suppl11-73. 1. Schüklenk U, van Deiden JJ, Downie J, Mclean SA, Upshir R, Weinstock D: End-of-life decision making in Canada: The report by The Royal Society of Canada, Expert Panel Report on: End-of-life Decision Making. Bioethics 2011;25Suppl1:1–73.
2.
Ventafridda VRipamonti Cde Conno FTamburini M. Symptom prevalence and control during cancer patients' last days of lifeJ Palliat Care199067-11. 2. Ventafridda V, Ripamonti C, de Conno F, Tamburini M: Symptom prevalence and control during cancer patients' last days of life. J Palliat Care 1990;6:7–11.
3.
Enck RE. Drug-induced terminal sedation for symptom controlAm J Hosp Palliat Care199183-5. 3. Enck RE: Drug-induced terminal sedation for symptom control. Am J Hosp Palliat Care 1991;8:3–5.
4.
Billings JABlock SD. Slow euthanasiaJ Palliat Care19961221-304. Billings JA, Block SD: Slow euthanasia. J Palliat Care 1996;12:21–30
5.
Mount BM. Morphine drips, terminal sedation, and slow euthanasia: Definitions and facts, not anecdotesJ Palliat Care19961231-37. 5. Mount BM: Morphine drips, terminal sedation, and slow euthanasia: Definitions and facts, not anecdotes. J Palliat Care 1996;12:31–37.
6.
Rietjens JAvan der Heide AVrakking AMOnwuteaka-Philipsen BDvan der Maas PJvan der Wal G. Physician reports of terminal sedation without hydration or nutrition for patients nearing death in the NetherlandsAnn Intern Med2004141178-185. 6. Rietjens JA, van der Heide A, Vrakking AM, Onwuteaka-Philipsen BD, van der Maas PJ, van der Wal G: Physician reports of terminal sedation without hydration or nutrition for patients nearing death in the Netherlands. Ann Intern Med 2004;141:178–185.
7.
Chambaere KBilsen JCohen JRietjens JAOnwuteaka-Philipsen BDMortier FDeliens L. Continuous deep sedation until death in Belgium: A nationwide surveyArch Intern Med2010170490-493. 7. Chambaere K, Bilsen J, Cohen J, Rietjens JA, Onwuteaka-Philipsen BD, Mortier F, Deliens L: Continuous deep sedation until death in Belgium: A nationwide survey. Arch Intern Med 2010;170:490–493.
8.
Lewis C. Euthanasia “favorable” to Quebec MDs: SurveyNational PostOctober132009. 8. Lewis C.:Euthanasia “favorable” to Quebec MDs: Survey. National Post, October 13, 2009.
9.
Berger JT. rethinking guidelines for the use of palliative sedationHastings Centre Report20104032-38. 9. Berger JT: rethinking guidelines for the use of palliative sedation. Hastings Centre Report 2010;40:32–38.
10.
Royal Dutch Medical AssociationNational guideline for palliative sedationUtrecht, The NetherlandsRoyal Dutch Medical Association2005. 10. Royal Dutch Medical Association: National guideline for palliative sedation. Utrecht, The Netherlands: Royal Dutch Medical Association, 2005.
11.
Morita TBito SKurihara YUchitomi Y. Development of a clinical guideline for palliative sedation therapy using the Delphi methodJ Palliat Med20058716-729. 11. Morita T, Bito S, Kurihara Y, Uchitomi Y: Development of a clinical guideline for palliative sedation therapy using the Delphi method. J Palliat Med 2005;8:716–729.
12.
Kirk TWMahon MMfor the Palliative Sedation Task Force of the National Hospice and Palliative Care Organization Ethics Committee. National Hospice and Palliative Care Organization (NHPCO) position statement and commentary on the use of palliative sedation in imminently dying terminally ill patientsJ Pain Symptom Manage201039914-923. 12. Kirk TW, Mahon MM for the Palliative Sedation Task Force of the National Hospice and Palliative Care Organization Ethics Committee: National Hospice and Palliative Care Organization (NHPCO) position statement and commentary on the use of palliative sedation in imminently dying terminally ill patients. J Pain Symptom Manage 2010;39:914–923.
13.
Cherny NIRadbruch L. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative carePalliat Med200923581-593. 13. Cherny NI, Radbruch L: European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009;23:581–593.
14.
Braun TCHagen NAClark T. Development of a clinical practice guideline for palliative sedationJ Palliat Med20036345-350. 14. Braun TC, Hagen NA, Clark T: Development of a clinical practice guideline for palliative sedation. J Palliat Med 2003;6:345–350.
15.
Downing GMBlack F. Palliative sedation framework and guidelineDowning GMWainwright WMedical Care of the Dying4thVictoriaVictoria Hospice Society2006605-615. 15. Downing GM, Black F: Palliative sedation framework and guideline. In: Downing GM, Wainwright W, (eds): Medical Care of the Dying, 4th ed. Victoria: Victoria Hospice Society, 2006, pp. 605–615.
16.
Fainsinger RLWaller ABercovici M et al. A multicenter international study for uncontrolled symptoms in terminally ill patientsPalliat Med200014257-265. 16. Fainsinger RL, Waller A, Bercovici M, et al.: A multicenter international study for uncontrolled symptoms in terminally ill patients. Palliat Med 2000;14:257–265.
17.
Krakauer ELPenson RTTruog RDKing LAChabner BALynch TJ Jr. Sedation for intractable distress of a dying patient: Acute palliative care and the principle of double effectOncologist2000553-62. 17. Krakauer EL, Penson RT, Truog RD, King LA, Chabner BA, Lynch TJ Jr: Sedation for intractable distress of a dying patient: Acute palliative care and the principle of double effect. Oncologist 2000;5:53–62.
18.
Levy MHCohen SD. Sedation for the relief of refractory symptoms in the imminently dying: A fine international lineSemin Oncol200532237-246. 18. Levy MH, Cohen SD: Sedation for the relief of refractory symptoms in the imminently dying: A fine international line. Semin Oncol 2005;32:237–246.
19.
Cherny NI. Sedation in response to refractory existential distress: Walking the fine lineJ Pain Symptom Manage.199816404-406. 19. Cherny NI: Sedation in response to refractory existential distress: Walking the fine line. J Pain Symptom Manage. 1998;16:404–406.
20.
Taylor BRMcCann RM. Controlled sedation for physical and existential suffering?J Palliat Med20058144-147. 20. Taylor BR, McCann RM: Controlled sedation for physical and existential suffering? J Palliat Med 2005;8:144–147.
21.
Morita TTsunoda JInoue SChihara S. Terminal sedation for existential distressAm J Hosp Palliat Care200017189-195. 21. Morita T, Tsunoda J, Inoue S, Chihara S: Terminal sedation for existential distress. Am J Hosp Palliat Care 2000;17:189–195.
22.
Morita T. Palliative sedation to relieve psycho-existential suffering of terminally ill cancer patientsJ Pain Symptom Manage200428445-450.26Rousseau P: Existential suffering and palliative sedation in terminal illness Prog Palliat Care 2002;10:222–224. 22. Morita T: Palliative sedation to relieve psycho-existential suffering of terminally ill cancer patients. J Pain Symptom Manage 2004;28:445–450.26. Rousseau P: Existential suffering and palliative sedation in terminal illness Prog Palliat Care 2002;10:222–224.
23.
Roussean P. Existential suffering and palliative sedation in terminal illnessProg Palliat Care200210222-224. 23. Roussean P: Existential suffering and palliative sedation in terminal illness. Prog Palliat Care 2002;10:222–224.
24.
Shaiova L. Case presentation: Terminal sedation and existential distressJ Pain Symptom Manage199816403-404. 24. Shaiova L: Case presentation: Terminal sedation and existential distress. J Pain Symptom Manage 1998;16:403–404.
25.
Blondeau DRoy LDumont SGodin GMartineau I. Physicians' and pharmacists' attitudes toward the use of sedation at the end of life: Influence of prognosis and type of sufferingJ Palliat Care200521238-245. 25. Blondeau D, Roy L, Dumont S, Godin G, Martineau I: Physicians' and pharmacists' attitudes toward the use of sedation at the end of life: Influence of prognosis and type of suffering. J Palliat Care 2005;21:238–245.
26.
Schuman-Oliver ZBrendel DHFerstein MPrice BH. The use of palliative sedation for existential distress: A psychiatric perspectiveHarvard Rev Psychiatry2008339-351. 26. Schuman-Oliver Z, Brendel DH, Ferstein M, Price BH: The use of palliative sedation for existential distress: A psychiatric perspective. Harvard Rev Psychiatry 2008;: 339–351.
27.
Rousseau P. Palliative sedation in terminally ill patientsC. MachadaShewman DDBrain Death and Disorders of ConsciousnessNew YorkKluwer Academic/Plenum2004263-267. 27. Rousseau P: Palliative sedation in terminally ill patients. In: C. Machada, Shewman DD (eds): Brain Death and Disorders of Consciousness. New York: Kluwer Academic/Plenum, 2004, pp. 263–267.
28.
Cherny NIPortenoy RK. Sedation in the management of refractory symptoms: Guidelines for evaluation and treatmentJ Palliat Med19941031-38. 28. Cherny NI, Portenoy RK: Sedation in the management of refractory symptoms: Guidelines for evaluation and treatment. J Palliat Med 1994;10:31–38.
29.
De Graeff ADean M. Palliative sedation therapy in the last weeks of life: A literature review and recommendations for standardsJ Palliat Med20071067-85. 29. De Graeff A, Dean M: Palliative sedation therapy in the last weeks of life: A literature review and recommendations for standards. J Palliat Med 2007;10:67–85.
30.
Rousseau P. The ethical validity and clinical experience of palliative sedationMayo Clin Proc2000751064-1069. 30. Rousseau P: The ethical validity and clinical experience of palliative sedation. Mayo Clin Proc 2000;75:1064–1069.
31.
Chater SViola RPaterson JJarvis V. Sedation for intractable distress in the dying: A survey of expertsPalliat Med199812255-269. 31. Chater S, Viola R, Paterson J, Jarvis V: Sedation for intractable distress in the dying: A survey of experts. Palliat Med 1998;12:255–269.
32.
Beel AMcClement SEHarlos M. Palliative sedation therapy: A review of definitions and usageInt J Palliat Nurs20028190-199. 32. Beel A, McClement SE, Harlos M: Palliative sedation therapy: A review of definitions and usage. Int J Palliat Nurs 2002;8:190–199.
33.
Boyle J. Medical ethics and double effect: the case of terminal sedationTheor Med Bioeth20042551-60. 33. Boyle J: Medical ethics and double effect: the case of terminal sedation. Theor Med Bioeth 2004;25:51–60.
34.
McIntyre A. The double life of double effectTheor Med Bioeth20042561-74. 34. McIntyre A: The double life of double effect. Theor Med Bioeth 2004;25:61–74.
35.
Quill TEDresser RBrock DW. The rule of double effect—a critique of its role in end-of-life decision makingN Engl J Med19973371768-1771. 35. Quill TE, Dresser R, Brock DW: The rule of double effect—a critique of its role in end-of-life decision making. N Engl J Med 1997;337:1768–1771.
36.
Quill TELo BBrock DW. Palliative options of last resort: A comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasiaJAMA19972782099-2104. 36. Quill TE, Lo B, Brock DW: Palliative options of last resort: A comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. JAMA 1997;278:2099–2104.
37.
Gillon R. Foreseeing is not necessarily the same thing as intendingBMJ19993181431-1432. 37. Gillon R: Foreseeing is not necessarily the same thing as intending. BMJ 1999;318:1431–1432.
38.
Sulmasy DPPellegrino ED. The rule of double effect: Clearing up the double talkArch Intern Med1999159545-550. 38. Sulmasy DP, Pellegrino ED: The rule of double effect: Clearing up the double talk. Arch Intern Med 1999;159:545–550.
39.
Maltoni MPittureri CScarpi EPiccinini LMartini FTurci PMontanari LNanni OAmadori D. Palliative sedation therapy does not hasten death: Results from a prospective multicenter studyAnn Oncol2009201163-1169. 39. Maltoni M, Pittureri C, Scarpi E, Piccinini L, Martini F, Turci P, Montanari L, Nanni O, Amadori D: Palliative sedation therapy does not hasten death: Results from a prospective multicenter study. Ann Oncol 2009; 20:1163–1169.
40.
Sykes NThorns A. The use of opiods and sedatives at the end of lifeLancet Oncol20034312-318. 40. Sykes N, Thorns A: The use of opiods and sedatives at the end of life. Lancet Oncol 2003;4:312–318.
41.
Muller-Busch HCAndres IJehser T. Sedation in palliative care: A critical analysis of 7 years experienceBMC Palliat Care200321-9. 41. Muller-Busch HC, Andres I, Jehser T: Sedation in palliative care: A critical analysis of 7 years experience. BMC Palliat Care 2003;2: 1–9.
42.
Sneiderman B. Decision-making at the end of lifeDownie JCaulfield TFlood CCanadian Health Law and PolicyMarkham and Vancouver, CanadaButterworths2002501-531. 42. Sneiderman B: Decision-making at the end of life. In: Downie J, Caulfield T, Flood C (eds): Canadian Health Law and Policy. Markham and Vancouver, Canada: Butterworths, 2002, pp. 501–531.
43.
Joint Centre for Bioethics: Aid To Capacity Evaluation (ACE)www.utoronto.ca/jcb/disclaimers/ace.htm(Last accessed). 43. Joint Centre for Bioethics: Aid To Capacity Evaluation (ACE). www.utoronto.ca/jcb/disclaimers/ace.htm (Last accessed).
44.
Jansen LASulmasy DP. Sedation, alimentation, hydration and equivocation: Careful conversation about care at the end of lifeAnn Intern Med2002136845-849. 44. Jansen LA, Sulmasy DP: Sedation, alimentation, hydration and equivocation: Careful conversation about care at the end of life. Ann Intern Med 2002;136: 845–849.
45.
Viola RAWells GAPetersen J. The effects of fluid status and fluid therapy on the dying: A systematic reviewJ Palliat Care19971341-52. 45. Viola RA, Wells GA, Petersen J: The effects of fluid status and fluid therapy on the dying: A systematic review. J Palliat Care 1997;13:41–52.
46.
Broeckaert BNunez Olarte JM. Sedation in palliative care: Facts and conceptsTen Have HClark DThe Ethics of Palliative Care: European PerspectivesBuckinghamOpen University Press2002166-180. 46. Broeckaert B, Nunez Olarte JM: Sedation in palliative care: Facts and concepts. In: Ten Have H, Clark D (eds.): The Ethics of Palliative Care: European Perspectives. Buckingham: Open University Press, 2002, pp. 166–180.
47.
Rietjens JAvan Delden JJvan der Heide AVrakking AMOnwuteaka-Philipsen BDvan der Maas PJvan der Wal G. Terminal sedation and euthanasia: A comparison of clinical practicesArch Intern Med2006166749-753. 47. Rietjens JA, van Delden JJ, van der Heide A, Vrakking AM, Onwuteaka-Philipsen BD, van der Maas PJ, van der Wal G: Terminal sedation and euthanasia: A comparison of clinical practices. Arch Intern Med 2006; 166:749–753.
48.
Gillon R. Palliative care ethics: Non-provision of artificial nutrition and hydration to terminally ill sedated patientsJ Med Ethics199420131-132. 48. Gillon R: Palliative care ethics: Non-provision of artificial nutrition and hydration to terminally ill sedated patients J Med Ethics 1994;20:131–132.
49.
Purnell L. The Purnell Model for Cultural Competence. J Multicult Nursi Health (Summer 2005)http://findarticles.com/p/articles/mi_qa3919/is_200507/ai_n14825638/(Last accessed). 49. Purnell L: The Purnell Model for Cultural Competence. J Multicult Nursi Health (Summer 2005). http://findarticles.com/p/articles/mi_qa3919/is_200507/ai_n14825638/ (Last accessed).
50.
Polacek GNLJMartinez R. Assessing cultural competence at a local hospital system in the United StatesHealth Care Manager20092898-110. 50. Polacek GNLJ, Martinez R: Assessing cultural competence at a local hospital system in the United States. Health Care Manager 2009;28:98–110.
51.
McWilliams KKeeley PWWaterhouse ET. Propofol for terminal sedation in palliative care: A systematic reviewJ Palliat Med20101373-76. 51. McWilliams K, Keeley PW, Waterhouse ET: Propofol for terminal sedation in palliative care: A systematic review. J Palliat Med 2010;13:73–76.
52.
Twycross RWilcock ADean MKennedy BPalliative Care Formulary [Canadian edition]Nottingham, UKPalliativedrugs.com2010226-230. 52. Twycross R, Wilcock A, Dean M, Kennedy B: Palliative Care Formulary [Canadian edition]. Nottingham, UK: Palliativedrugs.com, 2010, pp. 226–230.
53.
Morita TTsunoda JInoue SChihara SOka K. Communication Capacity Scale and the Agitation Distress Scale to measure the severity of delirium in terminally ill cancer patients: A validation studyJ Pain Symptom Manage200115197-206. 53. Morita T, Tsunoda J, Inoue S, Chihara S, Oka K: Communication Capacity Scale and the Agitation Distress Scale to measure the severity of delirium in terminally ill cancer patients: A validation study. J Pain Symptom Manage 2001;15;197–206.
54.
Ramsay MAESavage TMSimpson BRJGoodwin R. Controlled sedation with alpaxalone-alphadoloneBr Med J19742656-659. 54. Ramsay MAE, Savage TM, Simpson BRJ, Goodwin R: Controlled sedation with alpaxalone-alphadolone.Br Med J 1974;2:656–659.
55.
Ely EWTruman BShintani AThomason JWWheeler APGordon S et al. Monitoring sedation status over time in ICU patients: Reliability and validity of the Richmond Agitation-Sedation Scale (RASS)JAMA20032892983-2991. 55. Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, et al.: Monitoring sedation status over time in ICU patients: Reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 2003;289: 2983–2991.
56.
Devlin JWBoleski GMlynarek MNerenz DRPeterson EJankowski MHorst HMZarowitz BJ. Motor Activity Assessment Scale: A valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unitCrit Care Med1999271271-1275. 56. Devlin JW, Boleski G, Mlynarek M, Nerenz DR, Peterson E, Jankowski M, Horst HM, Zarowitz BJ: Motor Activity Assessment Scale: A valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit. Crit Care Med 1999;27:1271–1275.
57.
Teasdale GJennett B. Assessment of coma and impaired consciousnessLancet1974281-84. 57. Teasdale G, Jennett B: Assessment of coma and impaired consciousness. Lancet 1974;2:81–84.
58.
Gonçalves FBento MJAlvarenga MCosta ICosta L. Validation of a Consciousness Level Scale for palliative carePalliat Med200822724-729. 58. Gonçalves F, Bento MJ, Alvarenga M, Costa I, Costa L: Validation of a Consciousness Level Scale for palliative care. Palliat Med 2008;22:724–729.
59.
Rousseau P. Existential suffering and palliative sedation: A brief commentary with a proposal for clinical guidelinesAm J Hospice Palliat Care200118151-153. 59. Rousseau P: Existential suffering and palliative sedation: A brief commentary with a proposal for clinical guidelines. Am J Hospice Palliat Care 2001;18:151–153.
60.
Morita TInoue SChihara SSedation for symptom control in Japan. the importance of intermittent use and communication with family membersJ Pain Symptom Manage19961232-38. 60. Morita T, Inoue S, Chihara S Sedation for symptom control in Japan: the importance of intermittent use and communication with family members. J Pain Symptom Manage 1996;12:32–38.
61.
Chiu T-YHu W-YLue B-HCheng S-YChen C-Y. Sedation for refractory symptoms of terminal cancer patients in TaiwanJ Pain Symptom Manage200121467-472. 61. Chiu T-Y, Hu W-Y, Lue B-H, Cheng S-Y, Chen C-Y: Sedation for refractory symptoms of terminal cancer patients in Taiwan. J Pain Symptom Manage 2001;21:467–472.

Information & Authors

Information

Published In

cover image Journal of Palliative Medicine
Journal of Palliative Medicine
Volume 15Issue Number 8August 2012
Pages: 870 - 879
PubMed: 22747192

History

Published in print: August 2012
Published online: 31 July 2012
Published ahead of print: 2 July 2012
Accepted: 13 March 2012

Permissions

Request permissions for this article.

Topics

Authors

Affiliations

Mervyn M. Dean
Palliative Care, Western Memorial Regional Hospital, Corner Brook, Newfoundland and Labrador, Canada.
Victor Cellarius
Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
Blair Henry
Ethics Centre, Sunnybrook Health Sciences Centre, Department of Family and Community Medicine, University of Toronto, University of Toronto, Toronto, Ontario, Canada.
Joint Centre for Bioethics, University of Toronto, Ontario, Canada.
Doreen Oneschuk
Edmonton Regional Palliative Care Program, Grey Nuns Hospital, Edmonton, Alberta, Canada.
S. Lawrence Librach (Canadian Society of Palliative Care Physicians Taskforce)
Joint Centre for Bioethics, University of Toronto, Ontario, Canada.

Notes

Address correspondence to:Mervyn M. Dean, M.B., Ch.B.95 Brookfield AvenueCorner Brook, NLCanada, AZH ZRS
E-mail: [email protected]

Author Disclosure Statement

No competing financial interests exist.

Metrics & Citations

Metrics

Citations

Export citation

Select the format you want to export the citations of this publication.

View Options

Get Access

Access content

To read the fulltext, please use one of the options below to sign in or purchase access.

Society Access

If you are a member of a society that has access to this content please log in via your society website and then return to this publication.

Restore your content access

Enter your email address to restore your content access:

Note: This functionality works only for purchases done as a guest. If you already have an account, log in to access the content to which you are entitled.

View options

PDF/EPUB

View PDF/ePub

Full Text

View Full Text

Media

Figures

Other

Tables

Share

Share

Copy the content Link

Share on social media

Back to Top