Les recommandations élaborées ont pour objectif de s’assurer de la validité médicale et éthique de cette pratique, notamment en … La sédation profonde et continue associée à une analgésie ne peut cependant être mise en œuvre que dans le cadre d’une procédure collégiale. Among the policies that health care institutions adopt, at least one will concern the use or rejection of palliative sedation for patients in extremis. He requests that a CSCI of midazolam be started, and it is titrated to effect to alleviate his dyspnea. 6127 0 obj <>/Filter/FlateDecode/ID[<32CE6A779AF549FAABAD1F67DC7A565B><1421579E8C872541908637F3248C63BC>]/Index[6102 45]/Info 6101 0 R/Length 120/Prev 872819/Root 6103 0 R/Size 6147/Type/XRef/W[1 3 1]>>stream La sédation palliative consiste à utiliser des médicaments sédatifs pour soulager des symptômes réfractaires en abaissant le niveau de conscience, de façon continue jusqu’au décès. �`7�;�� ���'���S)�di�r��$��+9��� #G&z�6��d?��^S��f�C�,�X�� iZ��KgQ�-��,�.�D�'�-Q�Fi\�dw��iF��_hQ$���H�w'ʄYa�h`�֟�Т��p�s��:�M���A9�Y��T��lR9����I2I��������&?wU�Ĕ��hdO{L�. Sédation palliative continue. He is started on oxycodone ATC and every hour as needed for dyspnea, and a fan is directed toward his face. From sedation to continuous sedation until death: how has the conceptual basis of sedation in end-of-life care changed over time? Sign In to Email Alerts with your Email Address. 0 Aide médicale à mourir. Discussions are held with her husband about changing the medication for sedation to a continuous subcutaneous infusion (CSCI) of midazolam. During the next 2 days, his oxygen requirements increase to 15 L/min. Her medication list is reviewed for drug interactions; none is found. Although he does not appear to be in respiratory distress, he rates his dyspnea as 8 out of 10 on a visual analogue scale. has a nonreversible refractory agitated delirium that is not responding to haloperidol, methotrimeprazine is tried. Mrs A.Z. de la sédation palliative, Principes et pratique [Quebec recommendations for palliative sedation therapy, principles and practice] and its abridged version, Outil pratique [Practical tool], as well as on the reflection undertaken at the CMQ, which focused on controversial issues. In addition, there is some evidence to support a trial of low-dose neuroleptic medications, such as phenothiazines, for dyspnea.12 Unlike patients with nonreversible refractory agitated deliriums, patients with dyspnea considered for CPST are often alert and might be able to participate in decision making. - Duration: 1:12. On parlera généralement dans ce cas de « sommeil » ou de « time-out ». When considering CPST, consultation with a palliative care specialist is strongly recommended. He undergoes a thoracentesis, but this fails to alleviate his dyspnea; 3 days after admission, he rates his dyspnea as 9 out of 10. ‘Palliation sedation’ is a widely used term to describe the intentional administration of sedatives to reduce a dying person’s consciousness to relieve intolerable suffering from refractory symptoms. 6146 0 obj <>stream Palliative Care Files is a quarterly series in Canadian Family Physician written by members of the Palliative Care Committee of the College of Family Physicians of Canada. Directives médicales anticipées. Availability of a CSCI of midazolam is explained to him, including its intent and goal for symptom management. La sédation en médecine palliative vise à diminuer la perception d’une situation de détresse vécue comme insupportable par le patient. 1 2 This refers to all subtypes of sedation: intermittent and continuous as well as deep and superficial. Please send any ideas for future articles to palliative_care{at}cfpc.ca. La sédation en fin de vie à domicile nous confronte à deux points essentiels : l'usage de la sédation en médecine palliative et la pratique des soins palliatifs au domicile du patient. terme à sa vie. His ATC oxycodone dose is increased, and upon his request, he receives increased doses of oxycodone for breakthrough episodes. Family members or an SDM should be involved in decision making regarding CPST and should be advised of the intent and aim of CPST. Soins palliatifs et soins de fin de vie. Her delirium is likely related to her brain metastases. Her husband’s questions are addressed, and he continues to receive support from the staff throughout the process. She received whole-brain radiation therapy 2 months ago. dies 3 days after the CSCI of midazolam is started. Guidelines and recommendations have been proposed in palliative care. His personal care is maintained, and he dies 1 day after starting the CSCI of midazolam. Similarly, initiation, continuation, or discontinuation of hydration and artificial feeding should be considered separate issues3 and are also not discussed. A do-not-resuscitate order should be in place, and informed consent should be obtained from the patient or the substitute decision maker (SDM) after having a discussion about CPST. endstream endobj startxref Mrs A.Z. ��H�� ���? The discussion with input from the team is documented in his chart. Although various definitions of palliative sedation exist, in general, it is accepted to be She is started on haloperidol around the clock (ATC) and every hour as needed. Même s’il existe diverses définitions de la sédation palliative , on s’entend généralement pour dire: 1) qu’elle désigne le recours à un ou plusieurs agents pharmacologiques pour réduire l’état de conscience; 2) qu’elle est réservée au traitement des symptômes intolérables et Because Mrs A.Z. The series explores common situations experienced by family physicians doing palliative care as part of their primary care practice. The option of CPST is discussed in detail with him again, including its intent and goal. He was living in a rooming house, has no immediate family, and has a do-not-resuscitate order, but no advanced directive. Raus, Kasper and Sterckx, Sigrid 2016. A chest x-ray scan reveals hilar lymphadenopathy, loss of right lung volume with no evidence of pneumonia, and a moderatesized left pleural effusion. A primary objective of palliative medicine is the easing of suffering via pharmacologic and non-pharmacologic techniques. Continuous Palliative Sedation Therapy (PST) is the intentional induction and continuous maintenance ... • Review medications to determine which medications are essential to continue (e.g. Some of these might include pleural effusions, pneumonia, pulmonary embolism, or anemia. Continuous deep sedation until death is the most far-reaching subtype. As in case 1, health care providers should look for and treat potentially reversible causes of dyspnea that the patient agrees to have treated. Enter multiple addresses on separate lines or separate them with commas. As with any medical procedure, PS must satisfy the criteria of having a specific clinical indication, a target outcome, and a benefit/risk ratio that is acceptable to both the clinician and patient. Il est vrai que la sédation palliative continue pourrait abréger la vie d’un malade si celle-ci est administrée chez un patient qui a un long pronostic de survie (plusieurs semaines) et qui est encore capable de s’alimenter et de s’hydrater. Palliative sedation should be a last resort for patients who have intolerable, refractory symptoms.3 The term refractory describes a symptom that “cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness.”4, Health care providers, including family physicians, might be uncomfortable with CPST owing to unfamiliarity, differing terminology (eg, previous use of the term terminal sedation5), ethical and legal challenges,6 and misconceptions about it being a form of euthanasia or physician-assisted suicide.2,5,7,8 Consultation with a physician who has knowledge of and expertise in both symptom management and CPST is strongly advised when considering CPST.1,6 Interprofessional team members, where available, can provide valuable input and important assistance with decision making regarding CPST.3. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. It involves therapy targeted at resolving or alleviating refractory symptoms at the end of life. Neuroleptics and benzodiazepines, and less often barbiturates and propofol, are used for CPST. In an earlier post on the EAPC blog, we heard about a European-funded Horizon2020 Research Project, Palliative Sedation, which is investigating clinical and ethical aspects of providing palliative sedation to dying patients across Europe. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Centre intégré universitaire de santé et de services. Background: Published reports of continuous palliative sedation therapy (CPST) suggest heterogeneity in practice. h��V}TS�nn>I���J>L ��!ZJ�MH!2�P��.ZZ�����s���v��ؖ���(α�M��hkO�:��k{��ٛs��>��{�~��� `��A�a��oH�`���LE@�,�J�I(5[��&�ў���,W��dAM���� ���oc�� I�E�:�M�1^ k;�W��\��Z�+K�TٰF� Dosing and proportionate titration are discussed with her husband. His dyspnea rating is now 10 out of 10. It is important to look for and consider treatment of reversible factors, such as medication side effects, drug interactions, infections, metabolic disturbances (particularly hypercalcemia), and hypoxia. In the Dutch national guideline, palliative sedation is defined as ‘the intentional lowering of consciousness of a patient in the last phase of life’. On palliative care units, 49% of delirium episodes are reversible.10 More than 80% of patients with advanced cancer develop delirium or cognitive impairment in the last weeks before death.10,11 Thus, consultation with a palliative care specialist can assist in screening for potentially reversible causes. Frequent as-needed doses of haloperidol are not effective in treating her refractory agitated delirium. La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de septembre 2014 à la page e436. Main navigation. Mr B.Y. The use of CPST when symptoms are nonphysical (eg, existential distress) remains controversial2,9 and is not discussed. She is regularly checked for level of consciousness and side effects of the sedation therapy. It is indicated for a variety … PS is classified into continuous and intermittent sedation by sedation type. His tachypnea increases, and he is now tripoding with increased work of breathing and use of accessory muscles. An infusion of midazolam is started and the dose is titrated proportionately to an amount that alleviates her agitation. It is filled with articles from 500+ journals and chapters from … 1) the use of (a) pharmacological agent(s) to reduce consciousness; 2) reserved for treatment of intolerable and refractory symptoms; and 3) only considered in a patient who has been diagnosed with an advanced progressive illness.1Although there are various types of sedation, including intermittent and respite sedation, and sedation as a side effect of medications such as opioids,2 continuous palliative sedation therapy (CPST) at or near the end of life is the focus of this article. You are currently viewing the International edition of our site.. You might also want to visit our French Edition.. Mrs A.Z. will ultimately die of her underlying disease. The most common refractory symptoms for palliative sedation are delirium, intractable p … At home, she was taking morphine ATC and as needed for pain (averaging 1 to 2 breakthrough episodes per day) and low-dose dexamethasone for her brain metastases. He is becoming tachypneic and is unable to recline in bed. %%EOF 6102 0 obj <> endobj Continuous Sedation at the End of Life - August 2013. Her husband provides informed consent after discussion of the intent and side effects of methotrimeprazine, which is then started ATC and every hour as needed for her agitated delirium. Her delirium is ultimately considered nonreversible. unesdoc.unesco.org. Year of Added Competency resident with the Edmonton Zone Palliative Care Program in Alberta at the time of writing. He is reassured, as before, that this will not shorten her life, but rather, Mrs A.Z. Ce soin désigne l’administration de médicaments pour soulager les souffrances en abaissant le niveau de conscience de façon continue jusqu’au décès. C’est pourquoi la sédation palliative continue Research studies generally focus on either ‘continuous sedation … Continuous Palliative Sedation Therapy (CPST) is a specialized medical intervention leading to the intentional induction and continuous maintenance of a reduced level of consciousness to relieve refractory symptom(s) that have not responded to other treatments during the last His medication is rotated to hydromorphone without improvement in his dyspnea and he then starts receiving low-dose ATC methotrimeprazine. Purpose: This study investigated the effect of two types of palliative sedation defined using intervention protocols: proportional and deep sedation.
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