ANAHEIM, CALIFORNIA—A multidisciplinary approach that also heavily incorporates input from patients and their families helped alleviate concerns about inappropriate use of palliative sedation and improved patient-centered care, a speaker said at the Oncology Nursing Society (ONS) 39th Annual Congress.
During a podium session, Mali Wold, MS, MSN, ANP-BC, of Massachusetts General Hospital in Boston, discussed a project in which she and her colleagues reflected on cases of palliative sedation through open discussion by the health care team. These collaborations included oncology nurse practitioners, nurses, oncologists, and the palliative care team comprised of nurse practitioners and physicians. These teams worked to facilitate shared decisions with the patients and their families regarding palliative sedation.
Wold opened by describing the circumstances under which palliative sedation would be appropriate. The treatment should be used for terminally ill patients with cancer and refractory symptoms, including intolerable pain, dyspnea, unrelenting vomiting and nausea, or neuropsychological issues such as agitated delirium, in whom aggressive treatment has failed, she said.
Symptoms are determined to be refractory when they are not adequately controlled using standard palliative interventions without inducing sedation. Unfortunately, Wold said, these symptoms are often subjective in nature, and adequate relief and intolerability cannot be easily measured, so medications are administered and titrated based on patient-reported symptom control.
Because of significant variation in the literature, it is difficult to determine how often palliative sedation is used, according to Wold. What remains consistent, however, is the need for palliative sedation, the common symptoms, and its ethical acceptability.
Wold also addressed the ethical and legal concerns associated with the decision to pursue this course of action. First, palliative sedation should only be used in terminally ill patients who have given informed consent, whose primary goal of care is comfort, and who have a do-not-resuscitate order. Efforts should be made to reach a consensus among patients and their loved ones, Wold said, but respecting the patient’s wishes remains paramount.
Legally, medical interventions such as palliative sedation are deemed morally permissible if they meet four criteria. The action must not be immoral itself; it must be undertaken with the intention of only achieving a good effect; it must not achieve a good effect by means of a bad effect; and in grave circumstances, the good effect outweighs the adverse effects.
In this way, Wold said it is important to distinguish palliative sedation from euthanasia or physician-assisted suicide because the intention is to achieve comfort and not hasten death. Studies show that some can misuse palliative sedation in this manner, so documentation of the process is incredibly important.
Another important aspect of this treatment course is informing all the key members of a health care team that palliative sedation is occurring, but no physician is required to participate if he or she conscientiously objects.
Also, the treatment plan should be reviewed. All distressing symptoms should be addressed, and the treatment provided for those symptoms as well as patient response should be examined to ensure that medications are given in the appropriate doses. Care should be expanded to include psychiatric health care professionals, an ethics committee, and possible pain services, and a family meeting with the patient and their loved ones should occur so that all ramifications of palliative sedation can be discussed.
To illustrate the experiences of the project initiated at Massachusetts General Hospital, Wold presented a case study of a 65-year-old man with metastatic thyroid cancer. The patient received thyroidectomy, multiple rounds of chemotherapy, and radiation, but he eventually developed excruciating pain. Palliative neurosurgery was unsuccessful, and the patient was often readmitted for pain control and infectious management.
After 7 years, Wold said, the patient opted to pursue palliative sedation as comfort became the primary goal of care and all other treatment options for pain control had been exhausted. His health care team took a multidisciplinary approach, thoroughly discussed the ramifications of palliative sedation with the patient and his family, and initiated treatment at the patient’s next pain crisis. Although devastating, the family expressed relief that palliative sedation was an option.
Wold and her colleagues concluded that having a well-described process in place for such events that includes the contributions of multiple providers helps to alleviate concerns about inappropriately using palliative sedation.
“With the greatest respect for life, after continuing to reflect on these cases, we still feel that palliative sedation should be used as a last resort on a case-by-case basis and that interdisciplinary discussions aided the health care team in processing these difficult patient situations and provided a forum for education,” Wold said.
Wold M. The pain stops here. Presented at: Oncology Nursing Society (ONS) 39th Annual Congress. May 1-4, 2014; Anaheim, CA.