palliative sedation
Contents
Proportionate reduction of consciousness for refractory symptoms in terminal illness. Strict criteria, structured protocol, and the distinction between sedation and analgesia.
criteria (calgary framework)
All three must be met:
- terminal illness established — death expected within days to weeks
- refractory symptoms confirmed — all tolerable interventions exhausted or declined; symptom is refractory, not merely difficult
- active DNR order in place
Common indications: intractable agitated delirium, catastrophic dyspnoea crisis, refractory status epilepticus, catastrophic haemorrhage.
A symptom is refractory only when further interventions either cannot provide relief within an acceptable timeframe or carry unacceptable adverse effects. Ensure adequate trial of conventional management before initiating sedation.
medication strategies
| Depth | Agent | Details |
|---|---|---|
| light | methotrimeprazine | low dose; may be sufficient for mild refractory agitation |
| intermediate–deep | midazolam (preferred 1st-line) | continuous SC/IV infusion; rapid onset, titratable |
| refractory to midazolam | phenobarbital / barbiturate infusion | when midazolam fails to achieve adequate symptom control |
midazolam protocol
- bolus: 2.5–5 mg SC/IV, repeat q15–30min until comfortable
- infusion: start 1–2 mg/h SC/IV, titrate to symptom control
- no ceiling dose — titrate to effect
Never escalate opioids as the primary agent to achieve sedation. Maintain baseline analgesia to prevent withdrawal and uncontrolled pain, but use a dedicated sedative (midazolam, phenobarbital) for sedation.
practical considerations
- continue baseline opioids — withdrawal pain will cause distress even in sedated patients
- document goals, consent, and refractory symptom assessment
- reassess depth of sedation regularly — proportionality is the ethical standard
- family counselling: sedation ≠ euthanasia; death results from the underlying disease, not the medication
- intermittent sedation (scheduled drug holidays to reassess) is an option when prognosis is less certain