Rietjens, J.A., van Zuylen, L., van Veluw, H., van der Wijk, L., van der Heide, A., & van der Rijt, C.C. (2008). Palliative sedation in a specialized unit for acute palliative care in a cancer hospital: Comparing patients dying with and without palliative sedation. Journal of Pain and Symptom Management, 36(3), 228-234.

The primary aim of the study was to describe the practice of palliative sedation for patients with cancer and compare patients who were sedated prior to death with patients who were not sedated. The secondary aim was to explore clinical implications of palliative sedation for symptom management at the end of life.

• Medical and nursing records of 157 (of the 753 admitted) patients with cancer who died at an acute palliative care unit (PCU) were analyzed.
• For patients who underwent palliative sedation, “continuous deep sedation” was warranted and titrated until the “cessation of symptoms.\"
• Records of patients’ characteristics and decision-making process (i.e., discussion with patient, relative, and other caregiver; indication for initiating palliative sedation; sedatives used and duration of sedation) were analyzed.
• Patients who received palliative sedation were compared with patients who hadn’t based on sex, age, primary tumor site, survival after admission, survival after identification of primary tumor, and survival after identification of metastases.

• The study reported on a sample of 157 patients.
• The mean age of sedated patients was 55 years, and the mean age of nonsedated patients was 59 years.
• Of the sample, 86 were females [37 (54%) were sedated, and 49 (55%) were nonsedated]. Seventy-one were males [31 (46%) were sedated, and 40 (45%) were nonsedated].
• The cancer types in the sample were lung (35%), gastrointestinal (27%), breast (41%), genitourinary (29%), head and neck (13%), melanoma (19%), sarcoma (15%), and other (21%).
• Patients with cancer who died at the acute PCU between 2001 and 2005 were included.
• Versed, often combined with propofol, was the commonly utilized sedative.

The single-site study was conducted on an inpatient PCU in the Netherlands.

Patients were undergoing end-of-life and palliative care.

Retrospective, descriptive study

Checklist for data retrieval from medical records

Sixty-eight patients (43%) had received palliative sedation. Palliative sedation for the majority of patients (68%) started on the last day before death, with an average duration of 19 hours (range of 1–125 hours). No difference was seen between sedated and nonsedated patients with regards to sex or survival after admission to the acute PCU (mean of 8 and 7 days respectively, P = 0.12). Within 48–25 hours prior to death, sedation was initiated in 13 patients, while 45 patients received sedation 24–0 hours before death. The experience of pain, dyspnea, and delirium during the interval 48–25 hours before death in both sedated and nonsedated groups had decreased during the interval 24–0 hours before death (P = 0.54). Midazolam, sometimes combined with propofol, was the most commonly used sedating drug.

• Findings suggest that palliative sedation does not hasten death when used for patients with limited life expectancy.
• Use of sedation did not appear to be associated with differences in symptom severity shortly before death.

• To what degree nursing and medical records are reflective of clinical practice and how thoroughly they were filled out are questionable.
• No insight was provided into the severity of symptoms or decision-making process regarding palliative sedation because data reviewed were in summary format.
• Generizability of data to other palliative care settings is questionable.
• Validity of patients’ experiences of symptoms is questionable because patients are under palliative sedation.

• Delirium and dyspnea in the last few days of life are common and should be anticipated early, especially at the onset of sedation, so that they can be appropriately managed.
• This retrospective analysis suggests that palliative sedation does not hasten death.