End of life care sedation for children

PURPOSE OF REVIEW

This article is aimed to review updated research on end-of-life care sedation (EOLC-S) for children and aspects surrounding this issue.

RECENT FINDINGS

Prevalence of EOLC-S for children may vary across countries on account of cultural differences, in terms of settings, legal issues and perceptions about EOLC-S, which lead to variation in patient selection and management. Although home is the preferred place of death for families, research shows hospital settings and ICUs to be the most frequent places where children die. Data on how to define refractory symptoms and update research on drug selection and dosing are lacking. Nature of symptoms at end of life (EOL) is described for cancer patients, but few articles focused on nononcological conditions. Decision making at EOL is commonly discussed with families but children are less frequently involved.

SUMMARY

A thorough search of databases was conducted for articles published in the last year. We found few articles describing EOLC-S as a last resort. But how, when and by whom a symptom is defined as refractory, is not well established. Aggressive symptom management at EOL along with advanced care planning conducted by pediatric palliative care teams could diminish EOLC-S. More research is needed.

Palliative sedation at the end of life at a tertiary cancer center

PURPOSE

The aim of this study was to describe the use of palliative sedation (PS) its indications and outcomes in patients followed up till death by an inpatient palliative care consult team (PCCT) at a tertiary cancer center.

METHODS

All patients referred for 5 years to the PCCT and followed up till death were eligible for the study. Both PCCT recordings and hospital charts were reviewed and a codified assessment was performed.

RESULTS

Over a total of 2,033 consecutive consults, 129 patients died during admission and were eligible. Eighty-three had the indication to PS, 4% of all consults (95% confidence interval [95%CI], 3% to 5%) and 64% of eligible patients (95%CI, 56% to 73%). PS was more frequently indicated in males and in patients with recurrent dyspnea and recurrent agitation, while it was less frequently indicated in older people and in patients with cerebral metastases and recurrent drowsiness. The most frequent indications to PS were dyspnea (37%) and delirium (31%) alone or combined with other symptoms. PS was successfully achieved in 69 patients; the drugs most frequently used for PS were midazolam (46%), haloperidol (35%), and chlorpromazine (32%) and opioid dose escalation was higher in sedated patients (P < 0.01).

CONCLUSIONS

PS is an important intervention in the management of terminal disease by a consulting palliative care team. Improved collaboration and communication between the hospital staff and the PCCT should be offered to meet patients' needs when PS is required.

Ethical issues in palliative care

Ethical problems in medicine are common, especially when caring for patients at the end of life. However, many of these issues are not adequately identified in the outpatient setting. Primary care providers are in a unique and privileged position to identify ethical issues, prevent future conflicts, and help patients make medical decisions that are consistent with their individual values and preferences. This article describes some of the more common ethical issues faced by primary care physicians caring for patients with life-limiting illness.

Continuous deep sedation at the end of life of children in Flanders, Belgium

CONTEXT

Few guidelines have yet been put forth for continuous deep sedation in pediatrics, and empirical data on the use of this practice in minors are rare.

OBJECTIVES

To estimate the incidence of continuous deep sedation in minor patients (aged 1-17) and describe the characteristics of, and the decision-making process before, continuous deep sedation.

METHODS

An anonymous population-based postmortem survey was mailed to all physicians signing the death certificates of all patients aged 1-17 years who died between June 2007 and November 2008 in Flanders, Belgium. The questionnaire concerned whether or not continuous deep sedation was used at the end of life and measured characteristics of sedation and the decision-making process preceding it.

RESULTS

Response rate was 70.5% (n=165). Of all children, 21.8% had been continuously and deeply sedated at the end of life. Duration of sedation was one week or less in 72.4% of cases, and artificial nutrition and hydration were administered until death in 54.3% of cases. Benzodiazepines were used as the sole drug for sedation in 19.4% of cases, benzodiazepines combined with morphine in 50%, and morphine as the sole drug in 25%. In 23.5% of cases, physicians had the explicit intention, or the concurrent intention, to hasten death. Only 3.0% of patients requested sedation and 6.1% consented. Parents consented in 77.8% of cases and requested sedation in 16.7%.

CONCLUSION

Minor patients were commonly kept in continuous deep sedation or coma until death in Flanders, Belgium. Given the high incidence of the practice and indications that it is often used without involving the patient--and sometimes with a life-shortening intention--the development of specific guidelines for sedation in children might contribute to due care practice.

Ethical decision making with end-of-life care: palliative sedation and withholding or withdrawing life-sustaining treatments

Palliative sedation (PS) is the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. Although uncommon, some patients undergoing aggressive symptom control measures still have severe suffering from underlying disease or therapy-related adverse effects. In these circumstances, use of PS is considered. Although the goal is to provide relief in an ethically acceptable way to the patient, family, and health care team, health care professionals often voice concerns whether such treatment is necessary or whether such treatment equates to physician-assisted suicide or euthanasia. In this review, we frame clinical scenarios in which PS may be considered, summarize the ethical underpinnings of the practice, and further differentiate PS from other forms of end-of-life care, including withholding and/or withdrawing life-sustaining therapy and physician-assisted suicide and euthanasia.

Comfort measures: practical care of the dying cancer patient

Most patients with advanced malignancy will die of their disease. Care of the dying is therefore a fundamental skill for the oncologist. Although protocols exist in other countries, there is no established protocol in the United States. We present a protocol for management of the dying that is clinically useful and review the existing evidence-base.

Intractable end-of-life suffering and the ethics of palliative sedation

Palliative sedation (sedation to unconsciousness) as an option of last resort for intractable end-of-life distress has been the subject of ongoing discussion and debate as well as policy formulation. A particularly contentious issue has been whether some dying patients experience a form of intractable suffering not marked by physical symptoms that can reasonably be characterized as "existential" in nature and therefore not an acceptable indication for palliative sedation. Such is the position recently taken by the American Medical Association. In this essay we argue that such a stance reflects a fundamental misunderstanding of the nature of human suffering, particularly at the end of life, and may deprive some dying patients of an effective means of relieving their intractable terminal distress.

Continuous Deep Sedation Until Death: Palliation or Physician-Assisted Death?

Published literature have not discerned end-of-life palliative versus life-shortening effects of pharmacologically maintaining continuous deep sedation until death (ie, dying in deep sleep) compared with common sedation practices relieving distress in the final conscious phase of dying. Continuous deep sedation predictably suppresses brainstem vital centers and shortens life. Continuous deep sedation remains controversial as palliation for existential suffering and in elective death requests by discontinuation of chronic ventilation or circulatory support with mechanical devices. Continuous deep sedation contravenes the double-effect principle because: (1) it induces permanent coma (intent of action) for the contingency relief of suffering and for social isolation (desired outcomes) and (2) because of its predictable and proportional life-shortening effect. Continuous deep sedation should be distinguished from common sedation practices for palliation and characterized instead as physician-assisted death.

Nozick's experience machine and palliative care: revisiting hedonism

In refutation of hedonism, Nozick offered a hypothetical thought experiment, known as the Experience Machine. This paper maintains that end-of-life-suffering of the kind that is resistant to state-of-the-art palliation provides a conceptually equal experiment which validates Nozick's observations and conclusions. The observation that very many terminal patients who suffer terribly do no wish for euthanasia or terminal sedation is incompatible with motivational hedonism. Although irreversible vegetative state and death are equivalently pain-free, very many people loath the former even at the price of the latter. This attitude cannot be accounted for by hedonism. Following these observations, the goals of palliative care are sketched along four circles. The first is mere removal or mitigation of noxious symptoms and suffering. The second targets sufferings that stymie patients' life-plans and do not allow them to be happy, the third targets sufferings that interfere with their pursuance of other goods (palliation as a primary good). The fourth is the control of sufferings that do not allow the person to benefit from any human good whatsoever ("total pain" or critical suffering). Only in the fourth circle are people hedonists.

European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care

The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review.

When cancer symptoms cannot be controlled: the role of palliative sedation

PURPOSE OF REVIEW

Palliative sedation, the intentional lowering of consciousness for refractory and unbearable distress, has been much discussed during the last decade. In recent years, much research has been published about this subject that will be discussed in this review. The review concentrates on: a brief overview of the main developments during the last decade, an exploration of current debate regarding ethical dilemmas, the development of clinical guidelines, and the application of palliative sedation.

RECENT FINDINGS

Main findings are that palliative sedation is mostly described in retrospective studies and that the terminology palliative sedation in now common in the majority of the studies. In addition, life-shortening effects for palliative sedation are scarcely reported, although not absent. A number of guidelines have been developed and published, although systematic implementation needs more attention. Consequently, palliative sedation has become more clearly positioned as a medical treatment, to be distinguished from active life shortening.

SUMMARY

Caregivers should apply palliative sedation proportionally, guided by the symptoms of the patient without striving for deep coma and without motives for life shortening. Clinical and multidisciplinary assessment of refractory symptoms is recommended as is patient monitoring during sedation. Future research should concentrate on proportional sedation rather than continuous deep sedation exclusively, preferably in a prospective design.

Deciding about continuous deep sedation: physicians' perspectives: a focus group study

Although guidelines restrict the use of continuous deep sedation to patients with refractory physical symptoms and a short life-expectancy, its use is not always restricted to these conditions. A focus group study of physicians was conducted to gain more insight in the arguments for and against the use of continuous deep sedation in several clinical situations. Arguments in favour of continuous deep sedation for patients with a longer life-expectancy were that the overall clinical situation is more relevant than life-expectancy alone, and that patients' wishes should be followed. Continuous deep sedation for patients with predominantly emotional/existential suffering was considered appropriate when physicians empathize with the suffering. Further, some physicians indicated that they may consider the use of sedation in the context of a euthanasia request. Arguments were that the option of continuous deep sedation is a better alternative; it may comfort some patients when their thoughts about potential future suffering become unbearable. Further, some considered continuous deep sedation as less burdening or a bother to perform. We conclude that physicians' decision-making about continuous deep sedation is characterized by balancing the interests of patients with their own feelings. Accordingly, the reasons for its use are not unambiguous and need further debate.

Pain management within the palliative and end-of-life care experience in the ICU

In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss.

Controlled sedation for refractory symptoms in dying patients

Terminally ill cancer patients near the end of life may experience intolerable suffering refractory to palliative treatment. Although sedation is considered to be an effective treatment when aggressive efforts fail to provide relief in terminally ill patients, it remains controversial. The aim of this study was to assess the need and effectiveness of sedation in dying patients with intractable symptoms, and the thoughts of relatives regarding sedation. A prospective cohort study was performed on a consecutive sample of dying patients admitted to an acute pain relief and palliative care unit within a cancer center. Indications for sedation, opioid and midazolam doses, level of delirium and sedation, nutrition, hydration, rattle, inability to cough and swallow, pharyngeal aspiration, duration of sedation and survival, and use of anticholinergics or other drugs were recorded. Family members were interviewed. Forty-two of 77 dying patients were sedated, and had a longer survival than those who were not sedated (P=0.003). Prevalent indications for sedation were dyspnea and/or delirium. Twelve patients began with an intermediate sedation, and 38 patients started with definitive sedation. The median sedation duration was 22 hours. Opioid doses did not change during sedation. Agitated delirium significantly decreased with increasing doses of midazolam, whereas the capacity to communicate concomitantly decreased. Interviewed relatives were actively involved in the process of end-of-life care, and the decision to sedate, and the efficacy of sedation, were considered appropriate by almost all relatives. Controlled sedation is successful in dying patients with untreatable symptoms, did not hasten death, and yielded satisfactory results for relatives. This study also points to the importance of palliative care and the experience of professionals skilled in both symptom control and end-of-life care.

The use of palliative sedation for existential distress: a psychiatric perspective

This article introduces a structure for standardization in the ongoing debate about the application of palliative sedation for psychological and existential suffering at the end of life. We differentiate the phenomenon of existential distress from the more general one of existential suffering, defining existential distress as a special case of existential suffering that applies to persons with terminal illness. We introduce both a clinical classification system of existential distress based on proximity to expected death and a decision-making process for considering palliative sedation (represented by the mnemonic, TIRED). Neuropsychiatric clinical cases will be used to demonstrate some of the concepts and ethical arguments.

Palliative sedation: a review of the research literature

The overall aim of this paper is to systematically review the following important aspects of palliative sedation: prevalence, indications, survival, medication, food and fluid intake, decision making, attitudes of physicians, family experiences, and efficacy and safety. A thorough search of different databases was conducted for pertinent research articles published from 1966 to June 2007. The following keywords were used: end of life, sedation, terminal sedation, palliative sedation, refractory symptoms, and palliative care. Language of the articles was limited to English, French, German, and Dutch. Papers reporting solely on the sedatives used in palliative care, without explicitly reporting the prevalence or intensity of sedation, and papers not reporting on primary research (such as reviews or theoretical articles) were excluded. Methodological quality was assessed according to the criteria of Hawker et al. (2002). The search yielded 130 articles, 33.8% of which were peer-reviewed empirical research studies. Thirty-three research papers and one thesis were included in this systematic review. This review reveals that there still are many inconsistencies with regard to the prevalence, the effect of sedation, food and fluid intake, the possible life-shortening effect, and the decision-making process. Further research to clarify all of this should be based on multicenter, prospective, longitudinal, and international studies that use a uniform definition of palliative sedation, and valid and reliable instruments. Only through such research will it be possible to resolve some of the important ethical issues related to palliative sedation.

Ethical issues and clinical expertise at the end of life

Oncology care has changed markedly in the past decade. With new therapies, patients are experienced in living with life-threatening illness and believe in the abilities of science and the health care system to find new therapies. Changes in the treatment paradigm have altered oncology nursing practice. The integration of newer targeted therapies with their specific side-effect profiles also has changed end-of-life care. Strategies used to manage patients during the active treatment phase of illness can inform and improve nursing practice when active care has been set aside. Evidence-based practice provides a guide to identify, critically appraise, and use evidence to solve clinical problems.

Exploring the option of voluntarily stopping eating and drinking within the context of a suffering patient's request for a hastened death

There is an acknowledged difficulty in distinguishing between some morally and legally accepted acts that hasten dying, such as refusing life-sustaining treatment, and other acts that also hasten dying that are labeled as acts of "suicide." Recent empirical findings suggest that most terminally ill and suffering patients who voluntarily chose to stop eating and drinking as a means to hasten their dying generally experienced a "good" death. This paper explores the moral and legal status of a decision to stop eating and drinking as a means to hasten dying that is voluntarily chosen by a competent, terminally ill and suffering patient. The option of voluntarily forgoing food and fluid will be compared to other end-of-life clinical practices known to hasten dying, with emphasis on the issue of whether such practices can or should be distinguished from suicide.

A national guideline for palliative sedation in the Netherlands

The first national guideline on palliative sedation in The Netherlands has been adopted by the General Board of the Royal Dutch Medical Association. By law, the physician is obliged to take this guideline into consideration. In this paper, we present the main principles of the guideline. Palliative sedation is defined as the intentional lowering of consciousness of a patient in the last phase of his or her life. The aim of palliative sedation is to relieve suffering, and lowering consciousness is a means to achieve this. The indication for palliative sedation is the presence of one or more refractory symptoms that lead to unbearable suffering for the patient. Palliative sedation is given to improve patient comfort. It is the degree of symptom control, not the level to which consciousness is lowered, which determines the dose and the combinations of the sedatives used and duration of treatment. Palliative sedation is normal medical practice and must be clearly distinguished from the termination of life.

Palliative sedation in a southern Appalachian community

Of 1200 palliative care patients, 28 received palliative sedation. They were more likely than patients without palliative sedation to have an Eastern Cooperative Oncology Group performance status of at least 3, a cancer diagnosis, an expected survival of weeks or less, to have been monitored by the palliative care team for at least 1 week, to have delirium as the cause of decreased communication, to have dyspnea as a non-pain symptom, and to be less able to communicate symptoms. Almost 90% received palliative sedation for at least 24 hours for a median of 3 days (range, 0 to 24 days). Home patients received palliative sedation longer. Symptoms were controlled in 82% and improved in the rest. Sedation developed in 79% but was not required for symptom control in 5. Patient survival from palliative care consultation was a median of 8 days (range, 0 to 32 days).

Relieving suffering at the end of life: Practitioners’ perspectives on palliative sedation from three European countries

This paper reports findings from visits to palliative care settings and research units in the UK, Belgium and the Netherlands. The aim was to learn about clinicians' (both nurses and doctors) and academic researchers' understandings and experiences of palliative sedation for managing suffering at the end of life, and their views regarding its clinical, ethical and social implications. The project was linked to two larger studies of technologies used in palliative care. Eleven doctors, 14 nurses and 10 researchers took part in informal interviews. Relevant reports and papers from the academic, clinical and popular press were also collected from the three countries. The study took place in a context in which attention has been drawn towards palliative sedation by the legalisation of euthanasia in the Netherlands and Belgium, and by the re-examination of the legal position on assisted dying in the UK. In this context, palliative sedation has been posited by some as an alternative path of action. We report respondents' views under four headings: understanding and responding to suffering; the relationship between palliative sedation and euthanasia; palliative sedation and artificial hydration; and risks and uncertainties in the clinician-patient/family relationship. We conclude that the three countries can learn from one another about the difficult issues involved in giving compassionate care to those who are suffering immediately before death. Future research should be directed at enabling dialogue between countries: this has already been shown to open the door to the development of improved palliative care and to enhance respect for the different values and histories in each.

Palliative Sedation

Concerns about suffering usually arise as patients contemplate end of life. For most, an array of available therapies will alleviate suffering. However, for others, these therapies may not be adequate, despite impeccable assessment and management. In these circumstances, palliative sedation may be an option for the relief of suffering. As patients, families, and clinicians contemplate this option, controversies and concerns about hastening death, euthanasia, and limiting life-sustaining therapies can arise. This article explores some of these concerns.

Palliative Sedation Therapy in the Last Weeks of Life: A Literature Review and Recommendations for Standards

PURPOSE

Palliative sedation therapy (PST) is a controversial issue. There is a need for internationally accepted definitions and standards.

METHODS

A systematic review of the literature was performed by an international panel of 29 palliative care experts. Draft papers were written on various topics concerning PST. This paper is a summary of the individual papers, written after two meetings and extensive e-mail discussions.

RESULTS

PST is defined as the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness, using appropriate drugs carefully titrated to the cessation of symptoms. The initial dose of sedatives should usually be small enough to maintain the patients' ability to communicate periodically. The team looking after the patient should have enough expertise and experience to judge the symptom as refractory. Advice from palliative care specialists is strongly recommended before initiating PST. In the case of continuous and deep PST, the disease should be irreversible and advanced, with death expected within hours to days. Midazolam should be considered first-line choice. The decision whether or not to withhold or withdraw hydration should be discussed separately. Hydration should be offered only if it is considered likely that the benefit will outweigh the harm. PST is distinct from euthanasia because (1) it has the intent to provide symptom relief, (2) it is a proportionate intervention, and (3) the death of the patient is not a criterion for success. PST and its outcome should be carefully monitored and documented.

CONCLUSION

When other treatments fail to relieve suffering in the imminently dying patient, PST is a valid palliative care option.

Palliative Sedierung

Terminal illnesses can cause distressing symptoms such as severe pain, mental confusions, feelings of suffocation, and agitation. Despite skilled palliative care in some cases these symptoms may not respond to standard interventions. After all other means to provide comfort and relief to a dying patient have been tried and are unsuccessful, clinical caregivers and patients can consider palliative sedation. Sedation in the context of palliative medicine is the monitored use of medications to induce varying degrees of unconsciousness to bring about a state of decreased or absent awareness in order to relieve the burden of otherwise refractory suffering. Palliative sedation is not intended to cause death or shorten life. The patient and family should agree with plans for palliative sedation. Because cases involving palliative sedation are emotionally stressful, the patient, family, and health care workers can all benefit from talking about the complex medical, ethical, and emotional issues they raise.

Palliative sedation: an essential place for clinical excellence

The complexities that converge around palliative sedation invite clinicians to work together to differentiate the issues and come to recommendations and decisions that are humane, ethical, legal, and clinically sound. Whether a crisis or long-term situation exists, the work is essentially the same. It must include critical thinking, clinical expertise, multidimensional assessment, and an array of interventions to assist patients and families in situations where symptoms and suffering are sufficiently intense to warrant exploration of sedation. The many issues inherent in the discussion of sedation at end of life require not that we have the answers but rather that we work with our colleagues to raise relevant questions and integrate both expertise and compassion into end-of-life decisions and care.

Unrestricted opiate administration for pain and suffering at the end of life: knowledge and attitudes as barriers to care

BACKGROUND

Pain and symptom management is critical for quality end-of-life care in the hospital. Although guidelines support the use of unrestricted opiate administration to treat refractory pain and suffering in the dying patient, many patients die suffering with symptoms that could have been addressed.

METHODS

A multidisciplinary convenience sample of 381 hospital-based health care providers completed a survey evaluating their understanding of the principles of treating refractory pain and suffering at the end of life in the hospital, knowledge of the institution's policy about how to implement such care, and attitudes about and comfort with such treatment.

RESULTS

Respondents recognized pain and symptom management as a goal of unrestricted opiate use at the end of life, but 12% identified comfort for families or treatment of nonphysical suffering as the principal goal of this modality. Two thirds of respondents felt that unrestricted opiates were used too rarely and 45% felt they were used too late. However, 16% felt uncomfortable administering unrestricted opiates and 21% of physicians and nurses who had used restricted opiates reported having felt pressured to increase dosing of opiates. Knowledge deficits concerning appropriate candidates for unrestricted opiates and the protocol for appropriate implementation were common.

CONCLUSIONS

Knowledge deficits and attitudinal concerns may hamper the administration of unrestricted opiates for refractory pain and suffering at the end of life in the hospital. Clinician education and clarification of the appropriate use of this modality when there are differences in clinician and family perception of discomfort are needed.

Palliative sedation: Nurses’ perceptions

Patients with advanced illnesses suffer from a myriad of distressing symptoms. Palliative care aims to alleviate the distress caused by such symptoms. In extreme circumstances palliative sedation may be implemented to manage symptom distress that is not responsive to standard treatment modalities. Nurses are involved in the care of patients receiving palliative sedation as well as their families. To date, however, little research has been conducted examining the nurses' experiences with, and perceptions about the use of palliative sedation in end-of-life care. In order to redress this gap in the literature a descriptive-exploratory study guided by the theory of symbolic interactionism was conducted. Face-to-face interviews were conducted with 10 nurses working on an adult in-patient palliative care unit within a long-term care facility in Canada. The major theme emerging from content analysis of interview transcripts was that of 'Working your way through the quagmire'. The metaphor of the quagmire captured the difficult and complex issues nurses grappled with in instances where palliative sedation was used, and integrates the major categories into the key analytic model emerging from this study.

[Symptom control and ethics in final stages of COPD]

On the basis of a case study, the complex problems of the final stages of a COPD will be demonstrated and discussed. Dyspnea and anxiousness are the primary symptoms. If they can be adequately brought under control by opiates and benzodiazepines, a palliative sedation is then not necessary. The communicative and ethical demands on the team responsible are high. It is important to be aware of the specific needs of the patient and of his/her family members, and to competently accompany the patient throughout the decision-making process--such as the decision to end respiratory therapy, for example. Clarifying the situation with the patient and finding out his/her wishes, accompanied by the corresponding documentation, is advisable.

[The last phase in the progressive neoplasic disease: care at the end-of-life, refractory symptoms and sedation]

End-of-life is one of the most stressful phases during course of a neoplasic disease. Frequently, death of patients with cancer comes after a continuous and progressive physical impairment. As death approaches, the medical team might redefine outcomes and treat as priority symptoms and relief suffering. That care encompasses the physical, psychological, social, spiritual, and existential needs of patients and their families. However, symptoms are frequently observed that are intolerable for the patient and which do not respond to usual palliative measures. The intolerable nature and being refractory to treatment indicates to the health-care team, on many occasions, the need for sedation of the patient. The medical team can take comfort in the knowledge that they did their best to provide safe passage to all their patients and that, although they did not always cure them, the patients often were healed.