Background:

A 42 year old male with know stage IV rhabdomyosarcoma of the neck presented to the ED from subacute rehab with severe dyspnea.  He had already undergone chemotherapy and radiation therapy, and had planned for home hospice after discharge from subacute rehab.  He had previously signed a DNR/DNI, but rescinded, and was intubated.  CT confirmed that tumor was compressing his airway, and he was admitted to the ICU.  Palliative care was familiar with the patient from previous encounters, and was consulted on admission.  At one point, he had self-extubated, requiring nasal intubation within hours.

It was apparent that his trachea would collapse without a rigid endo- or naso-tracheal tube.  Patient was alert, oriented, and along with his family decided that a tracheostomy was not in his best interests, and consented to a palliative extubation.  He was now in a situation, that even with narcotics, his last minutes would be filled with intractable suffering.

Purpose:

Debate arouse over the use of Palliative Sedation Therapy (PST), as no guidelines or protocols exist at our institution.  Intractable suffering with no significant chance of meaningful recovery and a prognosis of hours to days is an indication for a narcotic drip; rarely has there been a need for true PST.  All literature agrees that the intent of PST is the relief of suffering, and not the shortening of life.  However, there is no single consensus guideline or protocol regarding PST, or randomized controlled trials to validate the recommendations. 

Description:

After reviewing available literature on the subject, our facility is attempting to adopt the following guideline:

Patient Selection Criteria

  1. Patient must have an incurable condition, with a limited prognosis (hours to days)
  2. Patient must have, or anticipated to have intractable suffering, and all corrective measures have failed.
  3. Patient is DNR/DNI, and patient/family have agreed to comfort measures only
  4. The patient is not delirious, or use of antipsychotics has been exhausted.
  5. Informed consent of patient/family has been documented
  6. An interdisciplinary team, consisting of Bioethics, Palliative Care, Nursing and Social Work, agrees with Criteria 1-5

**Criteria 5-6 may be obtained in anticipation of the need for PST

Once patient selection criteria are met, PST may proceed with the following recommendations:

           – Narcotic drips are not used for sedation

           – Benzodiazepines should be the drug of choice, in addition to the narcotic drip

           – Medications are titrated to the lowest dose required, and no large boluses are provided

           – If signs/symptoms of toxicity arise, brief medication holidays should be used rather then reversal agents

           – Existential suffering is difficult to quantify and treat.  Pastoral Care should offered to all patients/families prior to initiation

Conclusions:

The above guideline has been endorsed by the Chief of Geriatrics and Palliative Medicine.  The next steps are to have approval from the Hospice & Palliative Care Committee, Bioethics Committee, and Medical Board.  After input and approval from these committees, it will become an official hospital guideline.  With this guideline in place, we will be able to treat intractable end of life symptoms more efficiently and effectively, making this trying experience more comfortable for patients, families, and providers alike.