Refractory distress in the last days of life

Cherny, 2009Juth, 2010

Note: Immediately seek specialist palliative care advice for patients with complex or difficult-to-control symptoms in the last days of life.

For patients in the last days of life who have symptoms that are complex or difficult to control, it is essential to seek specialist palliative care advice immediately. Most patients can achieve adequate symptom control with specialist input.

Rarely, some patients in the last days of life may experience distress caused by severe refractory symptoms. In these circumstances, sedation to treat refractory distress (palliative sedation) may be considered. The intent of sedation is to manage refractory distress, not to hasten death. It is considered a measure of last resort and is only suitable for a small group of patients1.

A decision to prescribe sedation for refractory distress must not be taken lightly. There are many factors to consider, including the patient’s preferences, prognosis, goals of care and decision-making capacity. A thorough assessment must be made of their clinical, psychosocial and general condition, including the cause of the refractory symptoms, treatments that have been tried, and benefits and limitations of other treatment options. In-depth discussion must occur and include all healthcare professionals involved in the direct care of the patient. Information, care and support must be provided to the patient and their family and carer(s), and all clinicians involved in the patient’s care.

The use of palliative sedation should be limited to palliative care experts, working in a multidisciplinary team. Detailed advice on palliative sedation is beyond the scope of these guidelines. See international, national and state-based statements and guidelines on the use of palliative sedation:

1 Many patients in the last days of life need some degree of sedation to manage agitation or other symptoms; this is not considered palliative sedation.Return