Mrs. D, an elderly widow admitted to the ICU from the bone marrow transplant unit, had received a transplant 14 days prior and had developed acute respiratory distress. She was admitted to the ICU, sedated, intubated, and placed on mechanical ventilation. Arterial blood gases revealed acute respiratory failure, and a chest X-ray demonstrated acute bilateral infiltrates. Mrs. D was started on a propofol infusion for sedation and I.V. morphine for analgesia. As time progressed, she continued to have a rocky course. With PaO2 levels ranging 50 to 60 mm Hg, end organ perfusion was compromised, and renal and cardiac failure ensued. After 3 weeks of aggressive management, Mrs. D's son decided to withdraw life-sustaining measures. The propofol infusion was continued, and orders to wean and extubate the patient were written. The staff, uncomfortable with these orders, questioned the physician, and a palliative care consult was obtained.
Definition
Palliative sedation is defined as the monitored use of sedative medications intended to induce varying degrees of unconsciousness, but not death, in order to relieve refractory and unendurable symptoms in imminently dying patients.1 The frequency of palliative sedation use is not known; however, estimates range between 15 to 30% of dying patients. Palliative sedation is different from procedural sedation and respite sedation. Ethical principles cited as supporting the use of palliative sedation include patient autonomy, fidelity, beneficence, and the rule of double effect. These principles support the individual's right to humane and compassionate care consistent with professional and societal norms.1
Use of medications to relieve pain, control other symptoms, and promote comfort is supported by professional nursing organizations such as the American Nurses Association (ANA), the Hospice and Palliative Care Nurses Association (HPNA), and the American Association of Critical-Care Nurses.1-3 The adequate control of symptoms is supported, even at the expense of possibly hastening death, if the goal is patient comfort and relief of symptoms. This action is supported through the ANA Code of Ethics for Nurses, which also states that nurses may not act with the sole intent to end a patient's life.2 Similar statements have been published by HPNA. With the intent of providing for patient symptom relief, palliative sedation is viewed as a separate issue from euthanasia, or assisted suicide. Instead, palliative sedation is a therapy used to provide compassionate care for a dying individual and aggressive symptom management. Additionally, the HPNA supports the use of palliative sedation for refractory and intractable symptoms in imminently dying patients; competent, safe practitioners who are knowledgeable and proficient in informing patients and other health care providers about the use of palliative sedation; allowing nurses who are uncomfortable with palliative sedation to sign over care to another competent nurse; using an interdisciplinary approach to managing patient symptoms; and opposing euthanasia and assisted suicide as a means of relieving suffering.1
Resolution
After discussion with Mrs. D's son, Mrs. D remained intubated. The propofol infusion was weaned and a benzodiazepine infusion initiated. Oxygen and medications were also continued to ease dyspnea. The family was present when Mrs. D died, and left knowing they had kept their mother's goal of comfort as a priority.
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