palliative sedation palliative sedation in medicine, specifically in end-of-life care, palliative sedation (also known as terminal sedation, continuous deep sedation, or sedation for intractable distress of a dying patient) is the palliative practice of relieving distress in a terminally ill person in the last hours or days of a dying person's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route. as of 2013, approximately tens of millions of people a year were unable to resolve their needs of physical, psychological, or spiritual suffering at their time of death. due to the amount of pain a dying person may face, palliative care is considered important. proponents caim palliative sedation can provide a more peaceful and ethical solution for such people. palliative sedation is an option of last resort for the people whose symptoms cannot be controlled by any other means. it is not considered a form of euthanasia or physician-assisted suicide, as the goal of palliative sedation is to control symptoms, rather than to shorten or end the person's life. palliative sedation is legal everywhere and has been administered since the hospice care movement began in the 1960s. the practice of palliative sedation has been a topic of debate and controversy as many view it as a form of slow euthanasia or mercy killing, associated with many ethical questions. discussion of this practice occurs in medical literature, but there is no consensus because of unclear definitions and guidelines, with many differences in practice across the world. definition palliative sedation is the use of sedative medications to relieve refractory symptoms when all other interventions have failed. the phrase "terminal sedation" was initially used to describe the practice of sedation at end of life, but was changed due to ambiguity as to what the word 'terminal' meant. the term "palliative sedation" was then used to emphasize palliative care. the level of sedation via palliative sedation may be mild, intermediate or deep and the medications may be administered intermittently or continuously. the term "refractory symptoms" is defined as symptoms that cannot be controlled despite the use of extensive therapeutic resources, with such symptoms having an intolerable effect on the patient's well-being in the final stages of life. the symptoms may be physical, psychological, or both. general practice palliative care main article: palliative care palliative care is aimed to relieve suffering and improve the quality of life for people with serious and/or life-threatening illness in all stages of disease, as well as for their families. it can be provided either as an add-on therapy to the primary curative treatment or as a monotherapy for people who are on end-of-life care. in general, palliative care focuses on managing symptoms, including but not limited to pain, insomnia, mental alterations, fatigue, difficulty breathing, and eating disorders. in order to initiate the care, self-reported information is considered the primary data to assess the symptoms along with other physical examinations and laboratory tests. however, in people at the advanced stage of the disease with potential experience of physical fatigue, mental confusion or delirium which prevent them from fully cooperating with the care team, a comprehensive symptom assessment can be utilized to fully capture all symptoms as well as their severity. there are multiple interventions that can be used to manage the conditions depending on the frequency and severity of the symptoms, including using medications (i.e. opioid in cancer-related pain), physical therapy/modification (i.e. frequent oral hygiene for xerostomia/dry mouth treatment), or reversal of precipitating causes (i.e. low fiber diet or dehydration in constipation management). palliative sedation palliative sedation is often the last resort if the person is resistant to other managing therapies or if the therapies fail to provide sufficient relief for their refractory symptoms, including pain, delirium, dyspnea, and severe psychological distress. in terms of the initiation of palliative sedation, it should be a shared clinical decision initiated preferably between the person receiving treatment and the care team. if severe mental alterations or delirium is the concern for the person to make an informed decision, consent can be obtained in the early stage of the disease or upon the admission to the hospice facility. family members can only participate in the decision-making process if explicitly requested by the person in care. palliative sedation can be used for short periods with the plan to awaken the person after a given time period, making terminal sedation a less correct term. the person is sedated while symptom control is attempted, then the person is awakened to see if symptom control is achieved. in some extreme cases (i.e. for those whose life expectancy is hours or days at the most), palliative sedation is begun with the plan to not attempt to reawaken the person. assessment and obtaining consent though people may receive palliative care, pharmacologically decreasing a one's consciousness may be the only remaining option to help alleviate intolerable disease symptoms and suffering. prior to receiving palliative sedation, persons should undergo careful consideration along with their health care team to make sure all other resources and treatment strategies have been exhausted. in the case the person is uncommunicable due to severe suffering, the individual's family member should be consulted as the decreasing the distress of family members is also key component and goal of palliative care and palliative sedation. the first step in consideration of palliative sedation is assessment of the person seeking the treatment. there are several states that one may be in that can make palliative sedation the preferred treatment, including but not limited to physical and psychological pain and severe emotional distress. more often than not, refractory or intolerable symptoms give a more sound reason to pursue palliative sedation. though the interdisciplinary health care team is there to help each person make the most sound medical decision, the individual's judgement is considered to be the most accurate in deciding whether or not their suffering is manageable. according to a systematic review encompassing over thirty peer-reviewed research studies, 68% of the studies used stated physical symptoms as the primary reason for palliative sedation. the individuals involved in the included studies were terminally ill or suffering from refractory and intolerable symptoms. medical conditions that had the most compelling reasons for palliative sedation were not only limited to intolerable pain, but include psychological symptoms such as delirium accompanied by uncontrollable psychomotor agitation. severe trouble breathing (dyspnea) or respiratory distress were also considered a more urgent reason for pursuing palliative sedation. other symptoms such as fatigue, nausea, and vomiting were also reasons for palliative sedation. once assessment is completed and palliative sedation has been decided for the person, a written consent for administration to proceed must be given by the individual. the consent must state their agreement for sedation and lowering their consciousness, regardless each individual's stage in illness or the treatment period of palliative sedation. in order to make a decision, one must be sufficiently informed of their disease state, the specificities and implications of treatment, and potential risks they may face during the treatment. at the time of consent, the person should fully be aware of and understand all necessary legal and medical consequences of palliative sedation. it is also critical that the individual is making the decision upon their own free will, and not under coercion of any sort. the only exception where the individual's consent is not obtained would be in emergency medical situations where one is incapable of making a decision, in which the individual's family or caregiver must give the consent after adequate education, as one would have been given. continuous vs. intermittent sedation palliative sedation can be administered continuously, until the person's death, or intermittently, with the intention to discontinue the sedation at an agreed upon time. although not as common, intermittent sedation allows family members of the person to gradually come to terms with their grief and while still relieving the individual of their distress. during intermittent palliative sedation, the person is still able to communicate with their family members. intermittent sedation is recommended by some authorities for use prior to continuous infusion to provide the person with some relief from distress while still maintaining interactive function. sedative medications sedating agents benzodiazepines: this a drug class that works on the central nervous system to tackle a variety of medical conditions, such as seizure, anxiety, depression. as benzodiazepines suppress the activities of nerves in the brain, they also create a sedating effect which is utilized for multiple medical procedures and purposes. among all benzodiazepine agents, midazolam (versed) is the most frequently used medication for palliative sedation for its rapid onset and short duration of action. the main indications for midazolam in palliative sedation are to control delirium and alleviate breathing difficulties so as to minimize distress and prevent exacerbation of these symptoms. opioids: opioid agents - which relieve pain primarily via modulation of receptor activity in the central nervous system - also commonly induce sedation or drowsiness. however, they are more frequently used for analgesia than sedation. even though opioids tend to provide a comforting effect for recipients, there exists the risk of drug dependence and - to a lesser extent - substance use disorder and diversion of medications. therefore, the clinical practice guidelines for quality palliative care from the national consensus project recommends a comprehensive assessment of symptoms prior to initiating pharmacological therapy; ongoing monitoring to determine efficacy and any adverse effects; and educating the patient and family. administration and monitoring palliative sedation is administered commonly in hospital or inpatient settings, but also reported to be performed in home care settings. the medication prescribed for palliation will need dose titration to initially manage the refractory symptoms and relieve suffering, and therapy will continue to maintain adequate effect. prescribed sedatives can be administered intravenously, rectally, etc. on a continuous and/or intermittent basis. when breakthrough symptoms occur, emergency bolus therapy will be needed to maintain symptom management. both mild and deep levels of sedation may be used to provide relief from suffering, with deeper levels used when death is imminent and a catastrophic event has occurred. the person being treated will be monitored during palliative sedation to maintain adequate symptom relief, but the following clinical situations will determine a need for dose titration: person is at end-of-life: vitals are not monitored except for respiratory rate to assess respiratory distress and tachypnea. the goal is to achieve comfort, so downward titration of sedation is not recommended due to risk of recurrent distress. person is nearing end-of-life: vitals such as heart rate, blood pressure, and oxygen saturation, are monitored to maintain physiological stability through sedation. depending on the risk of a person to have respiratory depression or become unstable, the treatment dose may need to be adjusted or a benzodiazepine antagonist may be administered. suffering managed and symptom controlled: sedation may be carefully lowered for lucidity. this would provide possibility of reevaluating the person's preferences for care or allow family communication. nutrition and fluids as people undergoing terminal sedation are typically in the last hours or days of their lives, they are not usually eating or drinking significant amounts. there have not been any conclusive studies to demonstrate benefit to initiating artificial nutrition (tpn, tube feedings, etc.) or artificial hydration (subcutaneous or intravenous fluids). there is also a risk that iv fluids or feedings can worsen symptoms, especially respiratory secretions and pulmonary congestion. if the goal of palliative sedation is comfort, iv fluids and feedings are often not consistent with this goal. a specialized rectal catheter can provide an immediate way to administer small volumes of liquids for people in the home setting when the oral route is compromised. unlike intravenous lines, which usually need to be placed in a hospital environment, the rectal catheter can be placed by a clinician, such as a hospice nurse or home health nurse, in the home. this is useful for people who cannot swallow, including those near the end of life (an estimated 1.65 million people are in hospice care in the us each year). before initiating terminal sedation, a discussion about the risks, benefits and goals of nutrition and fluids is encouraged, and is mandatory in the united kingdom. sedation vs. euthanasia titrated sedation