Practice of palliative sedation in patients followed by a palliative home care team.

Abstract

Context: Information about the use of palliative sedation (PS) at home is limited OBJECTIVES: The aim of this study was to assess the frequency, indications, and modalities of PS in patients with incurable disease, including cancer and non cancer patients, followed at home.

Methods: A consecutive sample of patients who were admitted to home palliative care was prospectively assessed. From the entire sample, patients who underwent PS were selected. Data regarding indications for PS, drugs and their maximum doses, intent (proportional and deep PS), and duration of PS were collected. The level of satisfaction of doctors and caregivers, evaluated one week after death, was classified in four catagories: satisfied, satisfied, not very satisfied, unsatisfied.

Results: Fifty-seven of patients of 176 patients (32%) received PS in the last days of life. The mean duration of PS was 34 hours (SD 32). Indications for PS were in a rank order: agitated delirium (n.43, 75.4%), dyspnea (n.9, 15.8%), psychoexistential distress (n.4, 7%), pain (n.1, 1.8%). Proportional and deep sedation were used in 38 (66.6%) and 19 (33,4%) cases, respectively. The most frequent drug used for PS was chlorpromazine at mean doses of 128 mg/day. The mean interval between proposal of PS and effective start of PS was 31(SD 84) hours. In six cases there there was a delay in starting PS, due to resistance on behalf of caregivers. Patients with a cancer diagnosis and a lower Karnofsky status at home care admission were more likely to be sedated (p=0.009 and p=0.002, respectively). Physicians were highly satisfied, satisfied, and not very satisfied in 38 (66.7%), 16 (28.1%), and 3 (5.3%) cases, respectively. Similar figures were provided by caregivers, who were highly satisfied, satisfied, and not very satisfied in 36 (63.2%), 14 (24.6%) and 7 (12.3%) of cases, respectively.

Conclusion: PS was feasible at home by using an individual treatment. Timing may depend on various factors, including agreement with caregivers, logistics or drug supply. Further research is necessary to compare attitudes regarding PS in countries with different sociocultural profiles and organization models.