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08-11-2011 | Article

Half of patients receive sedatives in last 24 hours of life


Free abstract

MedWire News: UK data show that just over half of patients in the last 24 hours of life will be prescribed sedatives to alleviate symptoms of agitation and restlessness.

However, the data also reveal that doses of medication are low compared with those recommended for continuous deep sedation, suggesting that there is no "blanket" policy for treatment of patients whose care is supported by the Liverpool Care Pathway for the Dying Patient (LCP).

Maureen Gambles (Liverpool University) and colleagues explain that the LCP is designed to promote patient comfort in the last days of life as well as provide appropriate support to relatives and carers. This includes prescribing medication when the symptoms become too burdensome.

However, many recent studies have investigated the issue of palliative sedation in light of the ethical implications of intentionally lessening patient's consciousness to treat refractory symptoms.

Therefore Gambles et al assessed the proportion of patients, in a cohort of 3893 under the LCP during 2009, who received any medication to relieve the symptoms of agitation and restlessness, and evaluated the median total doses administered in the last 24 hours of life.

Overall, patients were treated at 155 hospitals, were a median 81 years old, and were supported by the LCP for a median 33 hours before death.

A total of 51% of patients received medication during the last 24 hours of life, with 31% given as needed, and 40% given via subcutaneous infusion (CSCI). Twenty-nine percent of patients were given sedatives in a combination of these two methods.

Interestingly, note Gambles and co-workers, patients who received some medication were younger, were supported by the LCP for longer, and were more likely to have received a primary diagnosis of cancer.

A sample of 491 cases showed good agreement, between two auditors, for whether a medication was used or not (eg, a significant κ coefficient of 0.89 for midazolam as needed, and 0.94 for midazolam CSCI).

Where the auditors agreed which medications had been used, they also showed high levels of agreement with what doses had been given.

This high level of inter-auditor agreement "should give confidence in the reliability of the data submitted," write Gambles and co-authors in the BMJ Supportive and Palliative Care.

"Patients in this audit were not automatically receiving medication for the alleviation of agitation and restlessness in the last 24 hours of life," they add.

Information concerning the amount of opioids administered, the level of patient consciousness, and the amount of medication given prior to the last 24 hours of life are all matters for further research, suggests the team.

More work is merited on the topic since statistical significance "may not necessarily equate to clinical importance," conclude Gambles et al.

By Sarah Guy