To perform the highest attainable quality in
palliative sedation, carefully developed
evidence- and consensus-based guidelines
are essential. In the last decades, a number
of clinical recommendations have been
compiled in palliative sedation guidelines
across different countries. (3) They have
been developed with variations in quality
and evidence, and also in terms of given
recommendations.
Most known palliative sedation guidelines
across the eight participating European
countries in the project include international
ones like the European Association for
Palliative Care (EAPC), (4) the European
Society of Medical Oncology (ESMO), (5) and
the National Comprehensive Cancer Network
guideline (NCCN). (6) Besides, there are
some regional or local ones, scientific papers
containing clinical recommendations and,
importantly, national guidelines like the one
by the Italian Society for Palliative Care
(SCIP) in Italy, (7) the one by the Royal Dutch
Medical Association in the Netherlands
(KNMG), (8) or the one produced jointly
between the Spanish College of Physicians
and the Spanish Society for Palliative Care
(OMC&SECPAL) in Spain. (9)
A number of commonalities and divergences
exist between guidelines. All main guidelines
recognise palliative sedation as a last-resort
treatment for refractory symptoms, but the
criterion of refractoriness remains a matter
of debate (due to the subjective nature of
suffering and the lack of objective
assessment scales). Most recognize
psychological or existential distress as (part
of) an indication and some make specific
recommendations for such cases. All provide
a more or less precise definition of the life
expectancy for the application of continuous
palliative sedation, but the Dutch guidelines
are the only ones to provide guidance for
situations in which patients with refractory
symptoms and a life expectancy of more
than two weeks decide to limit their life
expectancy by voluntarily stopping eating
and drinking. Likewise, many guidelines
mention that the assessment should be
multi-professional, but differ on the
expertise required by the attending
physician/team. Regarding decisions on
hydration and nutrition, it is proposed that
these should be independent of those for
palliative sedation, but there is no clear
consensus on the decision-making process.
Several weaknesses were highlighted,
particularly in areas of the rigour of
development and applicability of the
guidelines, and should be considered in any
update or revision of the analysed guidelines
to improve the quality of their content and
applicability. (10)
Finally, in general, despite a wide awareness
by the participants of our study of the EAPC
framework, their perception of the use of
any existing palliative sedation guideline
remains extremely low. It is estimated that
less than 20% of clinical staff across
European countries have adopted them.
Exceptionally, in the Netherlands, most
clinicians seem to use the national palliative
sedation guideline and, to a lesser extent, in
Italy (1).
Use of palliative sedation
medicines and equipment
Palliative sedation involves the knowledge
and the use of sedative medications to
alleviate suffering from refractory symptoms
of a patient with a terminal illness by
42
Regulations affecting
palliative sedation