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16-08-2011 | Article

Palliative sedation induces varying effects on consciousness


Free abstract

MedWire News: Palliative sedation is an intentional medical treatment for refractory suffering and should not be considered a form of slow euthanasia, suggest study findings showing differing levels of patient consciousness depending on physician intent.

In addition, the study found that once palliative sedation is administered, there is a gradual decline in the level of consciousness up until the day of death.

"Although this study yields a clear effect of palliative sedation on the level of consciousness, sedatives are titrated up according to the intensity of symptoms," say Patricia Claessens (Catholic University Leuven, Drongen, Belgium) and co-authors.

"This proportional approach enables the patient to remain conscious for as long as possible given his specific situation, and to continue to participate in the decision-making process for as long as possible."

For the study, the team performed a prospective longitudinal study of 266 patients aged over 18 years with incurable cancer (<3 months' life expectancy) admitted to one of eight participating units. Data were collected from patient charts once every 2 weeks.

Nurses used the Glasgow Coma Scale (GCS) to evaluate level of consciousness, ranging from a score of 15 for normal consciousness to 3 for deeply comatose, three times per week until the day of death.

In total, 7.5% of patients received some form of palliative sedation, with 70.0% of these patients having received some form of benzodiazepines, narcoleptics, or neuroleptics prior to sedation. Palliative sedation began on average 2.5 days before death, with 40.0% of patients commencing with mild-continuous sedation and 40.0% with deep-continuous sedation.

On the day of death, 85% of patients received deep continuous sedation for non-acute situations, indicating that the nature of palliative sedation evolved over time.

When the team looked at the group of non-sedated patients (n=246), all were fully conscious when admitted to the primary care unit. From around day 10 before death the GSC score progressively declined to a median of 9 on the day of death, indicating a state of near-coma (8 being the cut-off score).

Analysis of sedated patients showed that 90% were fully conscious, and remained so up until the day palliative sedation was initiated (on average 2.5 days before death). For patients who received deep continuous sedation during the last days of their life, the level of consciousness dropped from GSC 15 to 3 once sedation was initiated.

However, administration of intermittent sedation resulted in a consciousness drop to a GSC score of 12, suggesting that patients had a reduced level of consciousness, but were not comatose.

"Though it is and should be an option of last resort only, as the intentional lowering of consciousness is a very serious thing, one should realize at the same time that having a low or very low level of consciousness at the end of life is not an extraordinary or unnatural situation at all," write the researchers in the American Journal of Hospice and Palliative Medicine.

By Ingrid Grasmo