reducing their consciousness (11). As per the
aims of palliative sedation, a great number of
sedative drugs and other medications (given
concurrently for symptom control) are
usually observed. It is commonly accepted
that benzodiazepines (in particular
midazolam) should be used as first-line
treatment for palliative sedation. Likewise, a
neuroleptic (levomepromazine, for example)
could be employed as the second step in
combination with the benzodiazepine or as
the first step in case of delirium. Opioids are
used concomitantly during palliative
sedation to control pain and dyspnoea.
Indeed, across European countries, the most
frequently used medicine in palliative
sedation is midazolam. In the Netherlands,
Belgium and Spain midazolam is used very
often by clinical staff when performing
palliative sedation. In Germany and Italy, it is
perceived to be used a little less (still
predominantly), while in Hungary, Romania
and the United Kingdom, it seems less
employed. Midazolam is normally available
both at the hospital and home settings
although some restrictions on availability are
fundamentally noticeable in Eastern Europe.
Other medications are significantly perceived
to be less used, in general, though variations
across countries can be observed:
Levomeprazine is somewhat used in the
Netherlands, Spain, Germany and the United
Kingdom, propofol is apparently employed
only in Hungary and Spain, and both
phenobarbital and anticonvulsants appear to
be used just in Romania. Together with the
sedatives, only opioid medications are used
to ensure the relief of pain and dyspnoea
[Pozsgai E. Report on palliative sedation
medication usage: a survey of palliative care
experts in 8 European countries (in
progress)].
With regard to the medical devices used,
infusion pumps seemed to be widely used, as
well as syringe drivers (with greater
frequency in Belgium, Germany and
Hungary). Only experts in Spain and Italy use
elastomeric pumps. Other devices include
intravenous drip with flow rate regulator
(Belgium); subcutaneous injections in certain
frequencies (Germany); dip and dripper, drip
subcutaneous or IV and Subcutaneous
infusion (Italy); Continuous Ambulatory
Delivery Device pumps and subsequent
subcutaneous administration of medication
(Netherlands); and elastomeric infuses, two
to five or seven days, subcutaneous
medication (Spain) (1).
Conclusion
In general, the European countries studied
do not find regulatory obstacles to palliative
sedation: it is a normal medical practice.
Sometimes regulated through End-of-life
laws, sometimes through general healthcare
laws, or professional guidelines, palliative
sedation falls under the remits of regular
healthcare practice.
While there is a general agreement on many
elements of the palliative sedation
procedure (including on the sedatives and
other medications to be used to achieve
desired outcomes), some issues such as the
extent to which psychological and/or
existential distress are (part of) an indication
for palliative sedation, the determination of
refractoriness, or ethical issues related to the
decision-making process regarding
hydration, are still unclear amongst clinical
recommendations. This lack of clarity calls
for further efforts to provide evidence- and
consensus-based recommendations on
palliative sedation.
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