I-CAN-CARE WP1: use of sedation medication

I-CAN-CARE WP1 centres on the assessment and care of patients (with any diagnosis) receiving sedation medication in the last few days of life.  This work package began with three linked strands: 1.1 systematic reviews of relevant published literature, 1.2 exploring usual care with regard to use of sedative medication - investigating clinicians' views and auditing patient notes in a London teaching hospital and a London hospice, 1.3 examining the acceptability of sedation monitoring through focus groups with clinicians, patients, and patient relatives. 

These three research strands fed into the development of a feasibility study (WP1 strand 1.4), beginning in autumn 2017, to explore objective monitoring of sedation for people receiving specialist palliative care in a London hospice. 

Research background

Sedatives are widely used at the end of life, although the prevalence varies according to country, setting (community, hospice or hospital), and type of sedation administered (light, deep, continuous or intermittent). A recent Cochrane systematic review concluded that future studies should "focus on how sedatives affect a person's quality of life, or peacefulness and comfort during the dying phase, and how well sedation controls the distressing symptoms," and that side effects should be better reported and quantified. Maltoni et al. (2014) recommend that palliative sedation should be "proportionate" and doses of sedatives should be "individually tailored". However, current practice is often based on an informal assessment about whether or not a patient appears to be "settled" or "comfortable", and objective monitoring is rarely used. The result may be either over- or under-sedation, with adverse consequences for patient care and the experience of relatives.

Routine use of objective monitoring (using either observational scales or technical equipment) may have benefits in terms of better titration of medication and ensuring patient comfort.  Bispectral index (BIS) technology is used to monitor depth of sedation in intensive care, and assists in avoiding over- or under-sedation, since this technology provides additional information to clinical assessment to guide the dosage of medication used.

However, the appropriateness or usefulness of BIS technology in a palliative care setting is not yet clear. Some people may perceive this technology as inappropriate, because it increases the medicalisation of death.  This kind of overt and intensive monitoring may also be perceived as excessively intrusive, and uncertainty might be introduced if scores from technical devices differ from results from conventional clinical monitoring. 

Just two studies exploring the use of BIS in palliative care have been conducted to date, in Australia and the Netherlands. These studies suggest that BIS may be useful to monitor the depth of sedation of people receiving palliative care at the end of life. BIS monitoring at the end of life may also reassure families and other carers regarding the safe and appropriate use of sedating medications.  WP1.4 is exploring the feasibility and utility of using BIS technology and other forms of structured observation to monitor the use of sedative medication with palliative care patients.

For more information please contact: Bella Vivat