Palliative sedation

In medicine, specifically in end-of-life care, palliative sedation (also known as terminal sedation, continuous deep sedation, or sedation for intractable distress in the dying/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 patient'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.

Palliative sedation is an option of last resort for patients whose symptoms cannot be controlled by any other means. It is not a form of euthanasia, as the goal of palliative sedation is to control symptoms, rather than to shorten the patient's life.

Palliative sedation is legal everywhere and has been administered since the hospice care movement began in the 1960s. [1]

According to 2009 research, 16.5% of all deaths in the United Kingdom during 2007–2008 took place after continuous deep sedation.[2][3][4]

On the other hand, a 2009 survey of almost 4000 U.K. patients 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.[5]

General practiceEdit

Palliative sedation is often initiated at the patient's request. It can also be initiated by the physician who would discuss the option with the patient and family. Palliative sedation can be used for short periods with the plan to awaken the patient after a given time period, making terminal sedation a less correct term. The patient is sedated while symptom control is attempted, then the patient is awakened to see if symptom control is achieved. In some cases, palliative sedation is begun with the plan to not attempt to reawaken the patient.

One such common example is a patient with an enlarging cancer in the throat that compresses the trachea in a patient who does not want intubation or a tracheostomy, so that eventually symptom control is impossible. Instead of experiencing death by suffocation, once symptoms are intolerable some patients will request palliative sedation to ease their symptoms as death approaches.

Some emergency instances in which palliative sedation should be considered when the patient experiences: massive hemorrhage, asphyxiation, an overwhelming pain crisis, and severe terminal dyspnea.[6]

Drugs usedEdit

A typical drug is midazolam, a short acting benzodiazepine. Opioids such as morphine are not used as the primary medicine since they are not effective sedative medications compared to benzodiazepines. However, if a patient was already on an opioid for pain relief, this is continued for pain relief while sedation is achieved. Other medications to be considered include haloperidol, chlorpromazine, pentobarbital, or propofol.

However, in terms of medications uses, the National Hospice and Palliative Care Organization recommends doctors "use as little medication as needed to achieve “the minimum level of consciousness reduction necessary” to make symptoms tolerable." [7]


While the intent of palliative sedation is to eliminate pain and suffering, a significant minority of patients "continue to experience pain, dysphoria, or nausea".[8]

Nutrition and fluidsEdit

As patients undergoing terminal sedation are typically in the last hours or days of their lives, they are not usually eating or drinking significant amounts. There have not been any conclusive studies to demonstrate benefit to initiating artificial nutrition (TPN, tube feedings, etc.) or artificial hydration (subcutaneous or intravenous fluids). There is also a risk that IV fluids or feedings can worsen symptoms, especially respiratory secretions and pulmonary congestion. If the goal of palliative sedation is comfort, IV fluids and feedings are often not consistent with this goal.[9]

A specialized rectal catheter can provide an immediate way to administer small volumes of liquids for patients in the home setting when the oral route is compromised. Unlike intravenous lines, which usually need to be placed in an inpatient environment,[10] 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 patients who cannot swallow, including those near the end of life (an estimated 1.65 million people are in hospice care in the US each year[11]).

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.[citation needed]

Sedation vs. euthanasiaEdit

Titrated sedation might speed death but death is considered a side effect and sedation does not equate with euthanasia.[9][12]

At the end of life sedation is only used if the patient perceives their distress to be unbearable, and there are no other means of relieving that distress. In palliative care the doses of sedatives are titrated (i.e., varied) to keep the patient comfortable without compromising respiration or hastening death. Death results from the underlying medical condition. For more information on the palliative care use of sedatives and the safe use of opioids see Opioids.[citation needed]

Patients (or their legal representatives) only have the right to refuse treatments in living wills; they cannot demand life saving treatments, or any treatments at all.[where?] However, once unconsciousness begins, as the patient is no longer able to decide to stop the sedation or to request food or water, the clinical team can make decisions for a patient. A Living Will, made when competent, can, under UK law, give a directive that the patient refuses 'Palliative Care' or 'Terminal Sedation', or 'any drug likely to suppress my respiration'.[citation needed]


United StatesEdit

In 2008, the American Medical Association Council on Ethical and Judicial Affairs approved an ethical policy regarding the practice of palliative sedation.[13][14]


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 patient not to reawaken.[15]

See alsoEdit


  1. ^ "Palliative Sedation, an End-of-Life Practice That Is Legal Everywhere". Retrieved 2020-05-12.
  2. ^ Seale C. (2009). "End-of-life decisions in the UK involving medical practitioners". Palliative Medicine. 23 (3): 198–204. doi:10.1177/0269216308102042. PMID 19318459.
  3. ^ Seale C (2010). "Continuous Deep Sedation in Medical Practice: A Descriptive Study". Journal of Pain and Symptom Management. 39 (1): 44–53. doi:10.1016/j.jpainsymman.2009.06.007. PMID 19854611.
  4. ^ Adam Brimelow, The alternative to euthanasia?, BBC News, August 12, 2009.
  5. ^ National Care of the Dying Audit 2009, Royal College of Physicians, September 14, 2009.
  6. ^ "UpToDate". Retrieved 2020-05-12.
  7. ^ "Palliative Sedation, an End-of-Life Practice That Is Legal Everywhere". Retrieved 2020-05-12.
  8. ^ Kon, Alexander A. (June 2011). "Palliative Sedation: It's Not a Panacea". American Journal of Bioethics. 11 (6): 41–42. doi:10.1080/15265161.2011.577513. PMID 21678216.
  9. ^ a b Maltoni M, et al. (2009). "Palliative sedation therapy does not hasten death: results from a prospective multicenter study". Annals of Oncology. 20 (7): 1163–69. doi:10.1093/annonc/mdp048.
  10. ^ Plumer AL. 2007. Plumer's Principles and Practices of Intravenous Therapy. Lippincott Williams & Wilkins.
  11. ^ "National Hospice and Palliative Care Organization's Facts and Figures: Hospice Care in America, 2013 Edition" Archived 2017-06-17 at the Wayback Machine,; accessed January 5, 2018.
  12. ^ Beller, EM; van Driel, ML; McGregor, L; Truong, S; Mitchell, G (January 2, 2015). "Palliative pharmacological sedation for terminally ill adults" (PDF). The Cochrane Database of Systematic Reviews. 1: CD010206. doi:10.1002/14651858.CD010206.pub2. PMID 25879099.
  13. ^ Kevin B. O'Reilly, AMA meeting: AMA OKs palliative sedation for terminally ill, American Medical News, July 7, 2008.
  14. ^ American Medical Association (2008), Report of the Council on Ethical and Judicial Affairs: Sedation to Unconsciousness in End-of-Life Care,; accessed January 5, 2018.
  15. ^ Österberg, Lina (October 11, 2010). "Sjuka får sövas in i döden". Dagens Medicin (in Swedish). Retrieved October 19, 2010.

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