psychological symptoms or existential
distress as the primary indication for
palliative sedation, when palliative sedation
is appropriate to the situation, intermittent
sedation should be attempted first with
planned downward titration after a preagreed interval.
• A stepwise pharmacological approach is
provided (Appendix 2), recommending the
first-line use of a well-controllable
benzodiazepine such as midazolam.
Lorazepam can be used as an alternative. As
a second step, a low-potency neuroleptic can
be used in combination with the
benzodiazepine if needed. Levomepromazine
or chlorpromazine may be used. Propofol
can be used as a third step but should be
administered by an anaesthesiologist or a
person with sufficient experience in its use.
Opioids and haloperidol should not be used
to sedate a patient.
• Four monitoring tools (Critical-Care Pain
Observation Tool (CCPOT), Discomfort Scale
- Dementia of Alzheimer Type (DS-DAT), The
Patient Comfort Scale (PCS), Richmond
Agitation Sedation Scale - Palliative Version
(RASS-PAL)) are provided.
Conclusion
The revised framework including proposed
assessment and monitoring tools, as well as
a comprehensive table of medications,
dosages and administration forms, serves as
comprehensive and soundly developed
information for healthcare professionals for
the use of palliative sedation. Since its
development considered all relevant
methodological and content aspects of
AGREE II, it may be used as a guideline or
serve as a basis for cultural adaptation of
guidelines for palliative sedation.
50
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