recommendations are made across 12
domains: Definition (n=3), indication (n=3),
adverse outcomes and risks (n=2), advanced
care planning (n=3), decision making (n=10),
selection of method (n=5), pharmacological
measures (n=2), monitoring (n=6), hydration
/nutrition (n=1), pharmacologic and nonpharmacologic measures
(n=2), significant
others care (n=3) and staff care (n=1).
The final product strongly endorses and
reflects the 2009 framework document,
however, the few substantive deserve
emphasis.
1. The definition of palliative sedation is
revised to now include a specific reference to
proportionality. This relates to the depth of
sedation to provide adequate relief of the
prevailing symptom which may not need to
be deep in all instances. This definitional
amendment reflects on the 2009 assertion
"In general, the level of sedation should be
the lowest necessary to provide adequate
relief of suffering. Other than in emergency
situations at the end of life, intermittent or
mild sedation should generally be attempted
first."
2. The definition of refractory suffering has
been revised emphasising that it may be
derived from symptoms or a state of
existential distress, or a cluster of symptoms.
There is a further clarification that the
determination refractoriness is a joint
decision between the physician (and/or the
multi-professional team) and the patient or
their legal representative/significant others.
3. The new guidelines explicitly assert that
the aim of palliative sedation is to relieve
refractory suffering, not to shorten life.
4. Regarding advanced care planning,
including the contingency of palliative
sedation, the 2023 version highlights the
imperative that documentation be stored in
a readily accessible and retrievable format
5 for all caregivers.
5. Regarding the process of consent, the new
guidelines add the comments that the
process should be adapted "to the extent
that the patient wishes to be informed."
6. The section on pharmacological measures
has been substantially revised introducing a
tiered approach to 1st, 2nd and 3rd line
options.
7. Recommendations for patient monitoring
have been revised including the introduction
of a range of approaches to evaluate patient
comfort.
Like all such documents, critical evaluation,
feedback and then identification of possible
shortcomings are essential for its further
development. From this perspective, I point
out that the document does not address the
administration of sedating infusions without
the use of pumps, which, in many settings
are not routinely used or available. I am sure
that other readers and users of this
document will find other issues. This is only
for the betterment of this process.
Overall, this is a timely, substantive and
meticulously developed update, that reflects
a high level of consensus across derived from
the global EAPC community. It is a worthy
and important update that helps further
refine the clinical and moral compass of our
work in palliative medicine and end-of-life
care.