Oregon Hospice & Palliative Care Association



SAMARITAN EVERGREEN HOSPICE ?(SEH) PALLIATIVE SEDATION PROTOCOL Definition of Palliative Sedation (PS): Palliative Sedation is the monitored use of medications to reduce the level of consciousness to relieve a refractory symptom or symptoms in a patient who is at the end of life. PS is used when all other available treatments have failed to provide relief. The purpose of the medication(s) is to provide comfort and relieve suffering, and not to hasten death.Refractory Symptoms are symptoms that cannot be adequately controlled despite aggressive efforts by the Hospice Interdisciplinary Team to provide timely, tolerable therapies that do not compromise consciousness. A symptom is deemed refractory if all other measures usually used to control the symptom have failed.Refractory symptoms that justify the use of Palliative Sedation can include:PainSevere DyspneaTerminal DeliriumSevere MyoclonusSevere Nausea and/or VomitingExistential Distress/Spiritual SufferingOther (Ex: bleeding, intractable hiccups)Sedation that is not considered “Palliative Sedation”:For the purposes of this protocol, PS should be distinguished from two other forms of sedation: Temporary use of sedation occurs when the underlying causes of the symptom are reversible and attempts are being made to treat these causes. Once it is felt that these underlying causes have been reversed, sedation is withdrawn.Respite temporary sedation occurs when a patient receives deep sedation for a predetermined interval, such as 12-48 hours, then downwardly titrate the sedative dose until consciousness reappears.Ethical Issues/Justification:The justification for PS is based on the principles of beneficence, non-maleficence, autonomy, and fidelity. ?These principles are invoked in the Principle of Double Effect.Principle of Double Effect:For most patients needing PS, the symptoms severity is related to their proximity to death. ?Thus the death occurs from an underlying disease and not the use of sedation. The principle of double effect states that a therapy which provides both a good and bad effect is ethical as long as the intention of the therapy is to produce a good effect, even though a harmful effect is possible or even expected. ?The intent of PS is the relief of suffering and not to end the patient’s life. Congruent to this intent, the outcome is that the patient is made unaware of distressing, refractory symptoms through sedation, according to Principle of Double Effect.Prerequisites for Initiation of Palliative Sedation:The presence of a terminal illness with a prognosis of days to weeks;A Do-Not-Resuscitate (DNR) order and review of the Healthcare Directive;Refractory symptoms that have failed all other treatment options;Consultation with hospital Ethics Committee and/or hospice MSW or Chaplain is recommended if a provider, staff member, patient , or family member has any conflicts or concerns with the decision to pursue PS;Discussion with patient or surrogate decision maker (SDM) regarding future nutrition, hydration or any other Health Care Directives;Informed consent is obtained from the patient or SDM and documented;Consideration is given for a trial of respite sedation with a predetermined stop date;Patient/Family/SDM is provided with SEH educational handout;Guidelines for Administration of Palliative Sedation:Pain Control Protocol- Opioids should be initiated, continued, and titrated to manage underlying pain. ??However, they should not be the agent titrated for sedation. ??If currently on opiate therapy, convert to long acting equal analgesic dosing. If not on opiate therapy, initiate long acting analgesic such as morphine continuous infusion at 1-2 mg/hour or low dose fentanyl transdermal patch.The guideline for using sedation will be the Richmond Agitation Sedation Scale (RASS) with the goal of -2 to -3. ??See monitoring section for procedural use of RASS scale.Richmond Agitation Sedation Score (RASS) Term Description:+4 ??- Combative: Overtly combative or violent, immediate danger to staff+3 ??- Very agitated: Pulls on or removes tubes or catheters, aggressive behavior+2 ??- Agitated: Frequent non purposeful movement or patient-ventilator dys-synchrony+1 ??- Restless: Anxious or apprehensive but movements not aggressive or vigorous??0 ??--Alert and calm---1 ??- Drowsy: Not fully alert, sustained (>10 seconds) awakening, eye contact to voice -2 ??- Light sedation: Briefly (<10 seconds) awakens with eye contact to voice-3 ??- Moderate sedation: Any movement (but no eye contact) to voice-4 ??- Deep sedation: No response to voice but has any movement to physical stimulation-5 ??- Unarousable: No response to voice or physical stimulation ????(UpToDate 2016)Sedation Medication Protocol- Generally, subcutaneous or intravenous administration of sedatives is preferred, using the following schedule: Midazolam: is the drug of choice for PS because of its potency, short half-life, the ability for rapid titration and amnesic properties. ?Administer a loading dose of Midazolam: 2 mg or 5 mg SQ or IV. Then start a continuous infusion of midazolam at 2 mg/hour SQ or IV via an infusion pump. ?A typical initial infusion pump setting: 2 mg/hr, 2mg breakthrough dose, every 15 minutes at 4x an hour.Bolus by 1-2 mg every 15 minutes as needed until the RASS goal is achieved. ?At 30-60 minutes, evaluate patient medication needs and increase rate by 0.5-1 mg/hr if bolus dosing was used in the prior 30-60 minute time period. Once the goal is achieved, the dose is maintained.If crises occur, may give a bolus dose of midazolam 2 mg- 5mg SQ/IV every 30 minutes as needed. Sedation is usually achieved at a dose of 2-20 mg/hour, usually at the lower end of this range. If doses of greater than 10 mg/hour SQ/IV are required, then consider adding adjuncts below. Phenobarbital: is usually not considered a first‐line medication for initiating PS. ?Phenobarbital may be considered as an adjunct if midazolam is not adequate to maintain target RASS. ?However, Phenobarbital may be considered as first line, if the patient has been experiencing seizures, history of extrapyramidal symptoms, tolerance to benzodiazepines, or the patient is in a setting where there is no access to a pump. 100 to 300 mg bolus PO/SQ/ PR/ IV followed by 130 mg every 4-6 hours. Option to use weight base: Propofol: is usually not considered a first-line medication for initiating PS. It is considered a second-line option for lack of adequate response to benzodiazepines. Propofol acts as a sedative and amnestic but provides no analgesia. ?It can also act as an antiemetic. ?It is useful in patients who have developed extreme tolerance to benzodiazepines. Propofol formulation contains egg lecithin and soybean oil and thus has a small but present caloric burden. Additionally, there is a stronger incidence of infusion site pain and phlebitis as well as hypotension. ??Propofol requires IV administration. Tubing must be changed Q12 hours.Initiate 20-50 mg bolus Q15 minutes.Start continuous infusion at 5-10 mg/hour, titrate Q15 minutes by 5-10 mg/hour.Ketamine: is usually not considered a first-line medication for initiating PS. Ketamine induces a dissociative sedation which is a trance-like cataleptic state in which the patient experiences profound analgesia and amnesia but retains airway protective reflexes, spontaneous respirations, and cardiopulmonary stability. ??Consider prophylactic use of a benzodiazepine or haloperidol to mitigate dissociative effects of ketamine.Ketamine can be used PO/SL/SQ/IM/IV/PR/intranasal.Ketamine does have anesthetic properties and thus patient may need opiate dose reduction of 30-50%.For PS generally route is SQ or IV. Initiate 4mg/kg (typically 100-200 mg), may repeat every 15-30 minutes for sedation. Start continuous infusion at the dose that was required for successful induction in the prior hour. Titrate by 50 mg/hour every 30 minutes.Monitoring ?of Palliative SedationThe guideline for using sedation will be the Richmond Agitation Sedation Scale (RASS) with the goal of a score -2 to -3.Procedure for RAAS AssessmentObserve the patient-If Patient is alert, restless, or agitated. ??Score: 0 to +4If not alert, state patient’s name and ask them to open eyes and look at speaker.-If Patient awakens with sustained eye opening and eye contact ?Score: -1-Patient awakens with eye opening and eye contact, but not sustained.Score: -2-Patient has any movement in response to voice but no eye contactScore -3When no response to verbal stimulation, physical stimulate by shaking shoulder and/or rubbing sternum-Patient has any movement to physical stimulationScore -4-Patient has not response to any stimulationScore -5Nursing Monitoring: If PS is initiated at home, an RN will stay in home the first 12-24 hours for continuous care.Nursing assessment and documentation of RASS, RR, HR, every 15 minutes until stable at goal. ??Then every hour for first 24 hours and every 2 hours thereafter. When titrating occurs, restart monitoring frequency and readdress pain control.Once the patient is sedated, medications are not increased unless there is evidence of renewed distress. A lowering of the dose of the sedatives may be attempted at the discretion of the provider or at the request of the SDM. Goal of RASS is less than -2.Hypotension, decreased respiratory rate, or other abnormal vital signs should not lead to reduction of the sedation as these changes are expected in terminal patients and should not alone constitute a reason to decrease sedation.Bladder Fullness Assess bladder fullness twice a shift. ?This may be done by bladder palpation or ultrasound. ?If not catheterized, consider an in and out catheter daily-individualize per patient. ?An indwelling urinary catheter may be considered if unable to use less invasive means as above.Bowel CareThis should be individualized to each patient’s level of comfort and prognostication.Consider daily rectal exam and suppository/enema. ??Staff Education: Palliative Sedation Clinical CompetencyCompletion of competency based training with demonstration in the provision of PS. ?See RN clinical competency guide.DocumentationProviders are to document that core measures were discussed with family and/or patient prior to sedation and all questions were answered to their satisfaction.RN documentation to include medication used, titration needed, patient status and documentation of RAAS score per monitoring guidelines above.References available in fileCompleted 9/2017 ................
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