Соңғы демдегі науқастарға тыныштандыру терапиясы

Sedation of the terminally ill
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 claim 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. 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.

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 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. 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.

Though people may receive palliative care, pharmacologically decreasing 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 decreasing the distress of family members is also a 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.

Benzodiazepines: These are a drug class that works on the central nervous system to tackle a variety of medical conditions, such as seizures, anxiety, and 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 which relieve pain primarily via modulation of receptor activity in the central nervous 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 to a lesser 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.

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. 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. 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.

Titrated sedation might speed up death, although death is considered a side effect and sedation does not equate with euthanasia. A survey of 663 physicians in the United States, found half had an experience of their treatment being characterised as murder, euthanasia, or killing in the preceding five years with palliative sedation (along with stopping of hydration and nutrition) being the most common act in palliative care interpreted as killing. The primary difference between palliative sedation, relief of severe pain and symptoms, and euthanasia (the intentional ending of a person's life) is both their intent and their outcome. At the end of life sedation is only used if the individuals perceives their distress to be unbearable, and there are no other means of relieving that distress. The intended goal is to provide them some relief of their suffering through the use of benzodiazepines and other agents which inadvertently may increase the risk of death. Studies have been conducted however, showing that the risk of death through palliative sedation is much lower than earlier perceived. This has raised the argument that palliative sedation does not cause or hasten death and that an individual's death following palliative sedation is more likely to be due to their the measure of success of palliative sedation remains relief of a person's symptoms until their end of life. On the other hand, euthanasia is performed with the intent to permanently relieve the person of their pain through the measure of success being their death. People (or their legal representatives) only have the right to refuse treatments in living wills; however the demand of life saving treatments, or any treatments at all is controversial among states and heavily depends on each specific situation. However, once unconsciousness begins, as the person is no longer able to decide to stop the sedation or to request food or water, the clinical team can make decisions for the individual. A living will made when competent, can, under UK law, give a directive that the person refuses "Palliative Care" or "Terminal Sedation", or "any drug likely to suppress my respiration." The use of sedation for palliative care in the UK was considered as part of an independent review of the Liverpool Care Pathway for the Dying Patient. Families of patients in some instances said that they thought the doses of sedatives prevented patients from asking for water leading to death from dehydration, there were many accounts of subcutaneous infusions being started as a matter of course rather than to control a specific symptom, there were many reports of patients being left alone for a short period of time by their families only to find that sedation had been administered leaving them unable to speak to their relatives;

In a review of research articles on various aspects of palliative care, the prevalence of palliative sedation was reported as highly varied. In palliative care units or hospice, the prevalence ranged between 51%. In the home care setting, two Italian studies reported a prevalence of 25% and 52.5%. Hospital based palliative support teams vary in prevalence, with reports of 1.33% and also 26%. Different countries also report large differences in prevalence of palliative sedation:
+CountryPrevalenceNetherlands10%Belgium8.2%Italy8.5%Denmark2.5%Switzerland4.8%Sweden3%
A 2009 survey of almost 4000 U. K. people whose care had followed the Liverpool Care Pathway for the Dying Patient found that while 31% had received low doses of medication to control distress from agitation or restlessness, only 4% had required higher doses. Almost half of the studies reviewed differentiated intermittent versus continuous palliative sedation. The prevalence of intermittent sedation was 67% of cases and continuous sedation was 68% of cases. People starting intermittent sedation may progress to use of continuous sedation in 27% of cases. The prevalence of mild versus deep sedation was also reported: one study reported 51% of cases used mild sedation and 49% deep sedation; a second study reported 80% of cases used mild sedation and 20% deep sedation.

There are reports that after initiation of palliative sedation, 38% of people died within 24 hours and 96% of people died within one week. Other studies report a survival time of < 3 weeks in 94% of people after starting palliative sedation. Some physicians estimate that this practice shortens life by ≤24 hours for 40% of people and > 1 week for 27% of people. Another study reported people receiving sedation in their last week of life survived longer than those who did not receive sedation, or only received sedation during last 48 hours of life. According to 2009 research, 16.5% of all deaths in the United Kingdom during 2007–2008 took place after continuous deep sedation.

Hospice care emphasizes palliative, rather than curative, treatment to support individuals during end of life care when all other alternatives have been exhausted. It differs vastly from other forms of healthcare because both the person and the family are included in all decision making and aims to treat the individual, not the disease. The Hospice Care Movement began in the United States during the 1960s and was influenced heavily on the model published by St. Christopher's Hospice of London located in Great Britain. Despite differing setting, services, and staffing, the U. S. hospice care movement still sought to maintain the goals and philosophy of St. Christopher's model which centered on symptom control to allow the person to die with freedom, rather than attempting curative treatment. The first Hospice in the United States, Connecticut Hospice, was founded by Florence Wald and opened in 1974. Supporters of the movement faced many challenges early on, the biggest being the lack of insurance coverage for hospice care services. Initiatives to increase public awareness of the movement were created to combat this obstacle and supply the movement with public funding in order to maintain their services. One of the greatest accomplishments made by the movement was in the inclusion of hospice care in services covered under Medicare in 1982. This victory prompted the creation of National Hospice Week by President Reagan to take place from November 7–14 as a form of recognition to the vital impact nurses and caregivers have on these individuals and their families. Less than five decades after the first hospice program began, there are now over 4,000 programs in place under the umbrella of a multi billion dollar industry. The cumulative budget for hospice programs nationwide increased from 10 million in the late 1970s, to 2.8 billion dollars in 1995, and 10 billion in 2008. There is no specific law in barring the practice of palliative sedation, and the U. S. Conference of Catholic Bishops is reported to accept the practice of keeping people pain free at end of life.

In October 2010 Svenska Läkaresällskapets, an association of physicians in Sweden, published guidelines which allowed for palliative sedation to be administered even with the intent of the terminally ill person not to reawaken.