In 2009, the EAPC developed a framework on
palliative sedation (1) to inform the
development of local procedural guidelines,
which has been considered a milestone in
the debate surrounding palliative sedation.
Due to ongoing debates, (2,3) new evidence
from the literature (4-6) and some criticisms
of the framework in terms of methodology,
applicability and terminology, (2,4,7-9) the
EAPC instated a task force on Palliative
Sedation, aiming to "provide consensusbased guidance
on palliative sedation for
palliative caregivers and health care
decision-makers in Europe." (11) An update
and revision of the EAPC framework was
carried out as part of the PalSed project
[https://palliativesedation.eu], funded by the
European Union (Horizon 2020 grant no.
825700). The revision considered all relevant
aspects of the Appraisal of Guidelines for
Research and Evaluation (AGREE II), (10) an
international tool to assess the quality and
reporting of practice guidelines.
The revised framework provides
recommendations structured in 42
statements organised into 12 distinct
domains. The full set of recommendations
can be viewed on the EAPC website.
The key points of these revised
recommendations are:
• Palliative sedation aims to relieve
refractory suffering in patients with lifelimiting disease.
The notion of refractory
suffering (see chapter 1.2) is not new but has
been further clarified. Firstly, the term
refractory suffering defined as to encompass
physical and psychological symptoms as well
as existential suffering is used to reflect the
shift towards a broader recognition of
existential suffering as an indication for
palliative sedation. However, experts
recognise that the refractory nature of
existential suffering is much more difficult to
determine and accompany this indication
with special precautions such as a
comprehensive assessment by palliative care
experts and/or other experts competent in
any of the psychological, social and spiritual
areas as well as the initiation of an
intermittent sedation first with planned
downward titration after a pre-agreed
interval. In addition, the role of the different
stakeholders in the determination of
refractoriness has been further defined,
stating that it should be a joint decision
between the physician (and/or the multiprofessional team)
and the patient or their
legal representative/significant other(s); the
former determining the treatable or
untreatable nature of the suffering, the
latter the intolerable nature of their
intensity.
Introduction
The recommendations of the revised
framework on palliative sedation were the
result of a rigorous Delphi consensus
process conducted between June 2020 and
October 2022 among experts with different
professional backgrounds from 28 different
countries and a European patient
organisation, and a literature update. The
aim of these recommendations is to provide
evidence-based guidance on palliative
sedation to health professionals involved in
the care of adult patients with life-limiting
diseases in all settings, as well as to medical
associations and health policymakers.
Summary of
Recommendations
Consensus process
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