Palliative sedation at home
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.97477
Source of Support: None, Conflict of Interest: None
Patients with advanced cancer often suffer from multiple intractable physical symptoms. Though majority of the symptoms can be controlled, in some of the patients these symptoms remain refractory and uncontrolled till the end. Palliative sedation (PS) is one of the ways to relieve intractable suffering of the dying cancer patients. The main concern while using PS is its life-shortening effect. This case report describes the feasibility of administering PS in Indian home settings.
Keywords: End of life, Intractable suffering, Palliative sedation
Patients with advanced cancer often suffer from multiple intractable physical symptoms like delirium, pain, dyspnea, and vomiting. ,,,, The symptom prevalence in advanced cancer is considered to be high. The number of individual refractory symptoms in advanced cancer ranges from 1 to 27. 
Though majority of the symptoms can be controlled, in some of the patients these symptoms remain refractory and uncontrolled till the end. ,
The refractory symptom has been defined as the "symptom for which all possible treatment has failed, or it is estimated that no methods are available for palliation within the time frame and the risk-benefit ratio that the patient can tolerate." 
According to Cherny and Portenoy, "the diagnostic criteria for the designation of a refractory symptom includes that the clinician must perceive that further invasive and noninvasive interventions are either (1) incapable of providing adequate relief, (2) associated with excessive and intolerable acute or chronic morbidity, or (3) unlikely to provide relief within a tolerable time frame." 
The refractory symptoms which remain unrelieved led the clinician to explore various methods of relieving the intractable suffering of the dying patients. And palliative sedation (PS) is found to be one of the few options to relieve the intractable suffering at the end of life. ,
According to European Association of Palliative Care, PS is defined as "monitored use of medications intended to induce a state of decreased or absent consciousness in order to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family and health care providers." 
PS and its use in dying cancer patients is a much debated and a controversial issue. The main concern of administering PS among health care professionals is whether PS would shorten the life span of patients. One of the earliest prospective study  conducted in 1990, in an Italian home setting, found that there was no difference in survival time in patients receiving PS when compared with those who did not (P = 0.57). 
There is no literature available on the prevalence of PS in India. Administering PS in Indian home settings is not reported yet. This case report describes an advanced cancer patient who required PS for control of intractable symptoms in a home care setting.
Mr. M, a 74-year-old gentleman, was diagnosed with advanced stage lung cancer with malignant pleural effusion. He also had a past history of NHL 13 years back which was completely cured after chemotherapy. Mr. M underwent pleurodhesis for malignant pleural effusion. He and his family were explained about the nature of the disease and given the option of palliative chemotherapy. But Mr. M chose not to undergo chemotherapy and opted for palliative care. He was doing well for 2 months followed pleurodhesis though his general condition and daily activity started declining. He started having mild right-sided chest pain which was responding to paracetamol and NSAID.
When Mr. M came to palliative care, he suffered with grade IV dyspnea, severe right-sided chest pain, dry cough, reduced appetite, and nausea. He was started on oral morphine 10 mg every 4 hourly and SOS (as needed) for right-sided chest pain, and later on switched over to the fentanyl patch as he developed dysphagia secondary to intractable dyspnea. Cough was under control with cough suppressants and Ondansetron 4 mg three times a day took control of nausea.
Dyspnea was treated with broncholdilators (Salbutamol nebulization) and oxygen through nasal prongs 6 l/min as he developed cyanosis. He had anxiety attacks during severe dyspneic attacks for which he was started on T. Lorazepam 1 mg at bedtime.
Mr. M was aware of his diagnosis and the incurable nature of his disease. His only wish was to have a peaceful death at home. He had a very strong family support and family members were willing to take care of him at home as he wished. He did not express any psychological problem except his grief of permanent separation from his loving family.
The palliative care team planned for organized home care at regular intervals. Out-of-hours care was coordinated over phone and if required one of the team members would pay a visit to home during emergency.
Few weeks later, Mr. M developed delirium. The various causes of delirium including metabolic causes were ruled out. He was administered Haloperidol 5 mg subcutanoues (SC) every 8 h through a SC line. The family member was taught to administer SC medication under supervision during subsequent home visits.
Mr. M's dyspnea worsened despite administering all possible measures and he became increasingly delirious. As he was suffering with refractory dyspnea and delirium, that was not responding to the conventional treatment, the team decided that PS could be the option to relieve these intractable symptoms.
Family members were explained about the refractory nature of dyspnea and delirium and the fact that all the options of treatment failed to relieve them. Therefore, the need to administer PS at this moment to relieve Mr. M's intractable dyspnea and delirium was discussed with his family. The terminality of patient's condition was explained and DNR consent was obtained. The family agreed and gave informed consent to administer PS. Also, they were willing to administer PS medications through SC line during out of hours. The out-of-hours care was coordinated by the author.
Mr. M was started on PS with Haloperidol 2 mg SC every 2 nd hourly and Midazolam 2 mg SC every 2 nd hourly. Mr. M's dyspnea and delirium was well controlled with sedation. Although Mr. M slept most of the time, he woke up in between to take oral fluids until the last day. The sedatives were maintained at the same dose as this dose was found to be adequate to achieve conscious sedation. Fentanyl patch 25mcg per hour was continued for pain and Metaclopramide 10 mg SC three times a day for nausea was administered. Mr. M developed death rattle on the day of starting sedation and hyoscine butyl bromide 20 mg SC three times a day was given to dry up the secretion. Mr. M passed away peacefully 1.5 days after starting palliative sedation at home in the presence of his loving family.
Palliative sedation in India is still not an established and accepted practice of relieving intractable suffering at the end of life. Strong sociocultural and religious reasons might be contributing to this scarce practice of PS in India.
Another strong reason could be that PS might have an impact on the life span of patients receiving it. In a recent study conducted in India assessed the attitudes of palliative care doctors and nurses toward administering PS. This study found that while some of the interviewees agreed to administer mild sedation, most of them opposed deep continuous sedation fearing the side effects and the possible death-hastening effect of PS.  A systematic review which also reported the feasibility of administering PS in home settings showed that the survival in sedated patients is the same or higher than that in patients who did not receive PS. Therefore, the review had drawn the conclusion that PS did not hasten death in sedated patients, if carefully administered. 
The total duration of PS in this case study was 1.5 days. A systematic review  conducted in 2011 found that the duration of PS in six of the included studies ranged from 1 to 3.5 days. This review also found that more than 65% of sedated patients needed PS for a day or lesser. However, this case study cannot draw any conclusion on the life-shortening effect of PS. This would require a prospective study with a good sample size to be conducted in home care settings.
In this case study, the main indication for PS was intractable dyspnea and delirium. Ventafridda et al. found that the main indications for PS were dyspnea and pain. Porzio et al.  conducted a retrospective study at home setting in Italy and reported that delirium and dyspnea were the main indications for PS. A recent study in Spain also reported that dyspnea and delirium were the common indications for PS in home settings. 
This case report found that PS is a feasible option to relieve intractable symptoms at the end of life. Ventafridda et al.  who first reported PS found that it was a feasible option to treat intractable symptoms in home settings. This prospective study that investigated one hundredand twenty patients who died at home had a good symptom relief with the administration of PS. The most recent retrospective study in Spain  revealed that administering PS to 29 of 245 patients achieved a good control of intractable symptoms, and therefore recommended that PS is feasible at home settings.
A systematic review  which investigated the feasibility of administering PS in home settings found that PS is feasible and successful in home settings to improve the care of the dying who choose to die at home.
The Indian Association of Palliative Care (IAPC), in its position statement on administering essential medications at home, has stated that, "Administering essential medications through subcutaneous route by the family members with proper guidance and supervision from the palliative care team is an accepted practice."  And this is an "accepted practice in palliative care" as stated by the IAPC.  Therefore, patients should not be denied of an option to have a peaceful death at home because of the practical difficulties of administering essential medications during end of life in home settings.
This case study shows that PS is a feasible option to relieve intractable suffering during end of life in Indian home care settings. However, a multicenter, prospective study with a large sample size needs to be conducted in Indian home care settings to have strong evidence to prove that PS is feasible in home care settings.
The author would like to sincerely thank Dr. M. R. Rajagopal for his kind guidance in successfully treating this patient. The author would also like to acknowledge the entire staff of the Department of Pain and Palliative Care, St. John's Medical College Hospital, Bangalore, Karnataka, for their great support.