SAVING. USUALLY LESS. NEVER MORE X OSANDI X PALLISED M

 

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COLD WET MISERY

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ONLY CA PTS HAVE REASONABLE TIME TO PLAN FOR DTH

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PALLISED M 

Palliative sedation is a measure of last resort used at the end of life to relieve severe and refractory symptoms. It is performed by the administration of sedative medications in monitored settings and is aimed at inducing a state of decreased awareness or absent awareness (unconsciousness). The intent of palliative sedation is to relieve the burden of otherwise intolerable suffering for terminally ill patients and to do so in such a manner so as to preserve the moral sensibilities of the patient, the medical professionals involved in their care, and concerned family and friends

Palliative sedation may be utilized in both adults and children [2-6] with advanced incurable (ie, terminal) illness in order to alleviate severe symptoms that are refractory to other forms of treatment. It is most commonly utilized for the treatment of 

refractory pain, 

dyspnea, 

agitated delirium, 

and convulsions.

Some emergency situations for which palliative sedation could be considered may include 

massive hemorrhage, 

asphyxiation, 

an overwhelming pain crisis, 

and severe terminal dyspnea

Still, other than in emergency situations, intermittent or mild sedation should generally be attempted before palliative sedation. For some patients, a state of "conscious sedation," in which the ability to respond to verbal stimuli is retained, may provide adequate relief without total loss of interactive function.

Defining refractory symptoms — A symptom is considered "refractory" when it cannot adequately be controlled by therapies that do not seriously compromise consciousness. The diagnostic criteria for "refractoriness" are based on the clinician’s determination that further invasive and noninvasive interventions meet any of the following [1]:

●Incapable of providing inadequate relief

●Associated with excessive and intolerable acute or chronic adverse effects

●Unlikely to provide relief within a tolerable time frame

A refractory symptom may also be defined as one that is associated with intolerable suffering on the part of the patient.

1. Pain, dyspnea, persistent emesis, and agitated delirium are the symptoms most commonly requiring sedation.    

PDEAD   - PAIN DYSPNEA  EMESIS   AGIT DELIRIUM 

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PALLISED BY C MIDAZ

1. Midazolam 0.5-5 mg bolus IV/SC, then CII/CSI at 0.5-1 mg/h; usual maintenance dose, 20-120 mg/d is the drug most commonly used for palliative sedation.

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The concept of respite sedation involves sedating a patient for a predetermined interval, such as 24-48 hours, then downwardly titrating the sedative dose until consciousness reappears

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1. Suffering from existential anguish can be just as significant and distressful as refractory physical symptoms, thus endorsing consideration of palliative sedation in refractory cases.

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1. Most patients requiring palliative sedation demonstrate more than one refractory symptom.

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Medications and Suggested Doses for Palliative Sedation
Drug	Suggested Dose (a)
Midazolam	0.5–5 mg bolus IV/SC, then CII/CSI at 0.5–1 mg/h; usual maintenance dose, 20–120 mg/d
Lorazepam	0.5–2 mg PO, SL, or SC every 1–2 hours or 1–5 mg bolus IV/SC, then CII/CSI at 0.5–1 mg/h; usual maintenance dose, 4–40 mg/d
Chlorpromazine	10–25 mg PO, IV, or PR every 2–4 hours
Haloperidol	0.5–5 mg PO or SC every 2–4 hours or 1–5 mg bolus IV/SC, then CII/CSI at 5 mg/d; usual maintenance dose, 5–15 mg/d
Pentobarbital	60–200 mg PR every 2–4 hours or 2–3 mg/kg bolus IV, then CII at 1 mg/h; titrate upward to maintain sedation
Phenobarbital	200 mg IV/SC bolus, then CII/CSI at 600 mg/d; usual maintenance dose, 600–1,600 mg/d
Thiopental	5–7 mg/kg bolus IV, then CII at 20 mg/h; usual maintenance dose, 70–180 mg/h
Propofol	10 mg/h as CII; may titrate by 10 mg/h every 15–20 minutes; bolus of 20–50 mg may be used for emergency sedation
a Clinicians should consult pharmacy textbooks, pharmacists, and other knowledgeable professionals for further dosing suggestions. PO = oral; PR = per rectum; SL = sublingual; IV = intravenous; SC = subcutaneous; CII = continuous intravenous infusion; CSI = continuous subcutaneous infusion
Source: Rousseau P. Palliative sedation in the management of refractory symptoms. J Support Oncol. 2004 Mar-Apr;2(2):181-6.

Department of Veterans Affairs position on palliative sedation for intractable psychological and existential suffering: Permitted Palliative sedation is permitted in terminally ill patients for alleviation of refractory physical symptoms.   Instituting palliative sedation for alleviation non-physical refractory symptoms is contraindicated in all VA facilities.

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People APM, even more than things,have to be restored, renewed,revived, reclaimed, and redeemed;never throw out anyone.~ Audrey Hepburn

BLOCKING GRBG LORRY

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People who learn information more quickly also retain it for longer.  PSYD