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were created to combat this obstacle and supply the movement with public funding in order to maintain their services. One of the greatest accomplishments made by the movement was in the inclusion of hospice care in services covered under
Medicare in 1982. This victory prompted the creation of National Hospice Week by President Reagan to take place from November 7–14 as a form of recognition to the vital impact nurses and caregivers have on these individuals and their families. Less than five decades after the first hospice program began, there are now over 4,000 programs in place under the umbrella of a multi-billion dollar industry. The cumulative budget for hospice programs nationwide increased from 10 million in the late 1970s, to 2.8 billion dollars in 1995, and 10 billion in 2008.
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or the treatment period of palliative sedation. In order to make a decision, one must be sufficiently informed of their disease state, the specificities and implications of treatment, and potential risks they may face during the treatment. At the time of consent, the person should fully be aware of and understand all necessary legal and medical consequences of palliative sedation. It is also critical that the individual is making the decision upon their own free will, and not under coercion of any sort. The only exception where the individual's consent is not obtained would be in emergency medical situations where one is incapable of making a decision, in which the individual's family or caregiver must give the consent after adequate education, as one would have been given.
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people who are on end-of-life care. In general, palliative care focuses on managing symptoms, including but not limited to pain, insomnia, mental alterations, fatigue, difficulty breathing, and eating disorders. In order to initiate the care, self-reported information is considered the primary data to assess the symptoms along with other physical examinations and laboratory tests. However, in people at the advanced stage of the disease with potential experience of physical fatigue, mental confusion or delirium which prevent them from fully cooperating with the care team, a comprehensive symptom assessment can be utilized to fully capture all symptoms as well as their severity.
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are no other means of relieving that distress. The intended goal is to provide them some relief of their suffering through the use of benzodiazepines and other agents which inadvertently may increase the risk of death. Studies have been conducted however, showing that the risk of death through palliative sedation is much lower than earlier perceived. This has raised the argument that palliative sedation does not cause or hasten death and that an individual's death following palliative sedation is more likely to be due to their
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individual, not the disease. The
Hospice Care Movement began in the United States during the 1960s and was influenced heavily on the model published by St. Christopher's Hospice of London located in Great Britain. Despite differing setting, services, and staffing, the U.S. hospice care movement still sought to maintain the goals and philosophy of St. Christopher's model which centered on symptom control to allow the person to die with freedom, rather than attempting curative treatment.
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while still relieving the individual of their distress. During intermittent palliative sedation, the person is still able to communicate with their family members. Intermittent sedation is recommended by some authorities for use prior to continuous infusion to provide the person with some relief from distress while still maintaining interactive function.
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team to make sure all other resources and treatment strategies have been exhausted. In the case the person is uncommunicable due to severe suffering, the individual's family member should be consulted, as decreasing the distress of family members is also a key component and goal of palliative care and palliative sedation.
437:
no longer able to decide to stop the sedation or to request food or water, the clinical team can make decisions for the individual. A living will made when competent, can, under UK law, give a directive that the person refuses "Palliative Care" or "Terminal
Sedation", or "any drug likely to suppress my respiration."
600:
The first
Hospice in the United States, Connecticut Hospice, was founded by Florence Wald and opened in 1974. Supporters of the movement faced many challenges early on, the biggest being the lack of insurance coverage for hospice care services. Initiatives to increase public awareness of the movement
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care emphasizes palliative, rather than curative, treatment to support individuals during end-of-life care when all other alternatives have been exhausted. It differs vastly from other forms of healthcare because both the person and the family are included in all decision-making and aims to treat the
436:
People (or their legal representatives) only have the right to refuse treatments in living wills; however the demand of life saving treatments, or any treatments at all is controversial among states and heavily depends on each specific situation. However, once unconsciousness begins, as the person is
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Once assessment is completed and palliative sedation has been decided for the person, a written consent for administration to proceed must be given by the individual. The consent must state their agreement for sedation and lowering their consciousness, regardless of each individual's stage in illness
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In terms of the initiation of palliative sedation, it should be a shared clinical decision initiated preferably between the person receiving treatment and the care team. If severe mental alterations or delirium is the concern for the person to make an informed decision, consent can be obtained in the
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Council on
Ethical and Judicial Affairs approved an ethical policy regarding the practice of palliative sedation. There is no specific law in barring the practice of palliative sedation, and the U.S. Conference of Catholic Bishops is reported to accept the practice of keeping people pain-free at end
170:
Though people may receive palliative care, pharmacologically decreasing one's consciousness may be the only remaining option to help alleviate intolerable disease symptoms and suffering. Prior to receiving palliative sedation, persons should undergo careful consideration along with their health care
398:
The primary difference between palliative sedation, relief of severe pain and symptoms, and euthanasia (the intentional ending of a person's life) is both their intent and their outcome. At the end of life sedation is only used if the individuals perceives their distress to be unbearable, and there
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Palliative sedation can be administered continuously, until the person's death, or intermittently, with the intention to discontinue the sedation at an agreed upon time. Although not as common, intermittent sedation allows family members of the person to gradually come to terms with their grief and
181:
According to a systematic review encompassing over thirty peer-reviewed research studies, 68% of the studies used stated physical symptoms as the primary reason for palliative sedation. The individuals involved in the included studies were terminally ill or suffering from refractory and intolerable
92:
Palliative sedation is legal everywhere and has been administered since the hospice care movement began in the 1960s. The practice of palliative sedation has been a topic of debate and controversy as many view it as a form of slow euthanasia or mercy killing, associated with many ethical questions.
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Palliative sedation can be used for short periods with the plan to awaken the person after a given time period, making terminal sedation a less correct term. The person is sedated while symptom control is attempted, then the person is awakened to see if symptom control is achieved. In some extreme
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medications to relieve refractory symptoms when all other interventions have failed. The phrase "terminal sedation" was initially used to describe the practice of sedation at end of life, but was changed due to ambiguity as to what the word 'terminal' meant. The term "palliative sedation" was then
77:
As of 2013, approximately tens of millions of people a year were unable to resolve their needs of physical, psychological, or spiritual suffering at their time of death. Due to the amount of pain a dying person may face, palliative care is considered important. Proponents claim palliative sedation
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There are reports that after initiation of palliative sedation, 38% of people died within 24 hours and 96% of people died within one week. Other studies report a survival time of < 3 weeks in 94% of people after starting palliative sedation. Some physicians estimate that this practice shortens
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Person is nearing end-of-life: Vitals such as heart rate, blood pressure, and oxygen saturation, are monitored to maintain physiological stability through sedation. Depending on the risk of a person to have respiratory depression or become unstable, the treatment dose may need to be adjusted or a
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There are several states that one may be in that can make palliative sedation the preferred treatment, including but not limited to physical and psychological pain and severe emotional distress. More often than not, refractory or intolerable symptoms give a more sound reason to pursue palliative
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being started as a matter of course rather than to control a specific symptom, there were many reports of patients being left alone for a short-period of time by their families only to find that sedation had been administered leaving them unable to speak to their relatives; relatives and carers
129:
Palliative care is aimed to relieve suffering and improve the quality of life for people with serious and/or life-threatening illness in all stages of disease, as well as for their families. It can be provided either as an add-on therapy to the primary curative treatment or as a monotherapy for
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is the most frequently used medication for palliative sedation for its rapid onset and short duration of action. The main indications for midazolam in palliative sedation are to control delirium and alleviate breathing difficulties so as to minimize distress and prevent exacerbation of these
109:
The term "refractory symptoms" is defined as symptoms that cannot be controlled despite the use of extensive therapeutic resources, with such symptoms having an intolerable effect on the patient's well-being in the final stages of life. The symptoms may be physical, psychological, or both.
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to initially manage the refractory symptoms and relieve suffering, and therapy will continue to maintain adequate effect. Prescribed sedatives can be administered intravenously, rectally, etc. on a continuous and/or intermittent basis. When breakthrough symptoms occur, emergency
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51%. In the home care setting, two
Italian studies reported a prevalence of 25% and 52.5%. Hospital-based palliative support teams vary in prevalence, with reports of 1.33% and also 26%. Different countries also report large differences in prevalence of palliative sedation:
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life by ≤24 hours for 40% of people and > 1 week for 27% of people. Another study reported people receiving sedation in their last week of life survived longer than those who did not receive sedation, or only received sedation during last 48 hours of life.
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There are multiple interventions that can be used to manage the conditions depending on the frequency and severity of the symptoms, including using medications (i.e. opioid in cancer-related pain), physical therapy/modification (i.e. frequent oral hygiene for
352:
As people undergoing terminal sedation are typically in the last hours or days of their lives, they are not usually eating or drinking significant amounts. There have not been any conclusive studies to demonstrate benefit to initiating artificial nutrition
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sedation. Though the interdisciplinary health care team is there to help each person make the most sound medical decision, the individual's judgement is considered to be the most accurate in deciding whether or not their suffering is manageable.
361:). There is also a risk that IV fluids or feedings can worsen symptoms, especially respiratory secretions and pulmonary congestion. If the goal of palliative sedation is comfort, IV fluids and feedings are often not consistent with this goal.
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27% of cases. The prevalence of mild versus deep sedation was also reported: one study reported 51% of cases used mild sedation and 49% deep sedation; a second study reported 80% of cases used mild sedation and 20% deep sedation.
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therapy will be needed to maintain symptom management. Both mild and deep levels of sedation may be used to provide relief from suffering, with deeper levels used when death is imminent and a catastrophic event has occurred.
410:
the measure of success of palliative sedation remains relief of a person's symptoms until their end of life. On the other hand, euthanasia is performed with the intent to permanently relieve the person of their pain through
662:
In
October 2010 Svenska Läkaresällskapet, the Swedish medical association, published guidelines which allowed for palliative sedation to be administered even with the intent of the terminally ill person not to reawaken.
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Suffering managed and symptom controlled: Sedation may be carefully lowered for lucidity. This would provide possibility of reevaluating the person's preferences for care or allow family communication.
146:
Palliative sedation is often the last resort if the person is resistant to other managing therapies or if the therapies fail to provide sufficient relief for their refractory symptoms, including pain,
194:) or respiratory distress were also considered a more urgent reason for pursuing palliative sedation. Other symptoms such as fatigue, nausea, and vomiting were also reasons for palliative sedation.
395:, euthanasia, or killing in the preceding five years with palliative sedation (along with stopping of hydration and nutrition) being the most common act in palliative care interpreted as killing.
311:
Palliative sedation is administered commonly in hospital or inpatient settings, but also reported to be performed in home care settings. The medication prescribed for palliation will need dose
444:. Families of patients in some instances said that they thought the doses of sedatives prevented patients from asking for water leading to death from dehydration, there were many accounts of
2217:
Peruselli C, Di Giulio P, Toscani F, Gallucci M, Brunelli C, Costantini M, et al. (May 1999). "Home palliative care for terminal cancer patients: a survey on the final week of life".
461:, otherwise known as medical aid in dying, is legal in ten jurisdictions (California, Colorado, District of Columbia, Hawaii, Maine, Montana, New Jersey, Oregon, Vermont, and Washington).
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early stage of the disease or upon the admission to the hospice facility. Family members can only participate in the decision-making process if explicitly requested by the person in care.
324:
The person being treated will be monitored during palliative sedation to maintain adequate symptom relief, but the following clinical situations will determine a need for dose titration:
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used to emphasize palliative care. The level of sedation via palliative sedation may be mild, intermediate or deep and the medications may be administered intermittently or continuously.
93:
Discussion of this practice occurs in medical literature, but there is no consensus because of unclear definitions and guidelines, with many differences in practice across the world.
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suppress the activities of nerves in the brain, they also create a sedating effect which is utilized for multiple medical procedures and purposes. Among all benzodiazepine agents,
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Mercadante S, Porzio G, Valle A, Fusco F, Aielli F, Adile C, Casuccio A (June 2012). "Palliative sedation in advanced cancer patients followed at home: a retrospective analysis".
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symptoms. Medical conditions that had the most compelling reasons for palliative sedation were not only limited to intolerable pain, but include psychological symptoms such as
1114:
Erichsén E, Milberg A, Jaarsma T, Friedrichsen MJ (July 2015). "Constipation in
Specialized Palliative Care: Prevalence, Definition, and Patient-Perceived Symptom Distress".
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Williams PD, Graham KM, Storlie DL, Pedace TM, Haeflinger KV, Williams DD, et al. (2013). "Therapy-related symptom checklist use during treatments at a cancer center".
948:"Are there differences in the prevalence of palliative care-related problems in people living with advanced cancer and eight non-cancer conditions? A systematic review"
379:
Before initiating terminal sedation, a discussion about the risks, benefits and goals of nutrition and fluids is encouraged, and is mandatory in the United
Kingdom.
1871:
Maltoni M, Scarpi E, Rosati M, Derni S, Fabbri L, Martini F, et al. (April 2012). "Palliative sedation in end-of-life care and survival: a systematic review".
433:, varied) to keep the individual comfortable without compromising respiration or hastening death. Death typically results from the underlying medical condition.
1601:
Mercadante S, Porzio G, Valle A, Aielli F, Casuccio A (May 2014). "Palliative sedation in patients with advanced cancer followed at home: a prospective study".
2139:
Kohara H, Ueoka H, Takeyama H, Murakami T, Morita T (February 2005). "Sedation for terminally ill patients with cancer with uncontrollable physical distress".
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cases (i.e. for those whose life expectancy is hours or days at the most), palliative sedation is begun with the plan to not attempt to reawaken the person.
223:: These are a drug class that works on the central nervous system to tackle a variety of medical conditions, such as seizures, anxiety, and depression. As
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Cherny NI, Radbruch L (October 2009). "European
Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care".
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Ventafridda V, Ripamonti C, De Conno F, Tamburini M, Cassileth BR (1990). "Symptom prevalence and control during cancer patients' last days of life".
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Palliative sedation is an option of last resort for the people whose symptoms cannot be controlled by any other means. It is not considered a form of
555:
Almost half of the studies reviewed differentiated intermittent versus continuous palliative sedation. The prevalence of intermittent sedation was
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found that while 31% had received low doses of medication to control distress from agitation or restlessness, only 4% had required higher doses.
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can provide an immediate way to administer small volumes of liquids for people in the home setting when the oral route is compromised. Unlike
549:
441:
2850:
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Stone P, Phillips C, Spruyt O, Waight C (March 1997). "A comparison of the use of sedatives in a hospital support team and in a hospice".
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According to 2009 research, 16.5% of all deaths in the United Kingdom during 2007–2008 took place after continuous deep sedation.
1513:"Ethical decision making with end-of-life care: palliative sedation and withholding or withdrawing life-sustaining treatments"
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lines, which usually need to be placed in a hospital environment, the rectal catheter can be placed by a clinician, such as a
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Cherny NI, Portenoy RK (1994). "Sedation in the management of refractory symptoms: guidelines for evaluation and treatment".
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nurse or home health nurse, in the home. This is useful for people who cannot swallow, including those near the end of life.
2463:
Morita T, Tsunoda J, Inoue S, Chihara S (May 1999). "The decision-making process in sedation for symptom control in Japan".
138:/dry mouth treatment), or reversal of precipitating causes (i.e. low fiber diet or dehydration in constipation management).
1647:"National Consensus Project for Quality Palliative Care (NCP) | NCHPC | National Coalition For Hospice and Palliative Care"
2401:
van der Heide A, Onwuteaka-Philipsen BD, Rurup ML, Buiting HM, van Delden JJ, Hanssen-de Wolf JE, et al. (May 2007).
391:. A survey of 663 physicians in the United States, found half had an experience of their treatment being characterised as
478:
of palliative sedation was reported as highly varied. In palliative care units or hospice, the prevalence ranged between
332:. The goal is to achieve comfort, so downward titration of sedation is not recommended due to risk of recurrent distress.
1988:
2885:"Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids"
2346:"Physician reports of terminal sedation without hydration or nutrition for patients nearing death in the Netherlands"
2054:
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Titrated sedation might speed up death, although death is considered a side effect and sedation does not equate with
2751:
2506:
Morita T, Tsunoda J, Inoue S, Chihara S (1999). "Do hospice clinicians sedate patients intending to hasten death?".
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reported instances where they felt that the administration of morphine had directly lead to the death of a patient.
2890:
2775:
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Person is at end-of-life: Vitals are not monitored except for respiratory rate to assess respiratory distress and
2344:
Rietjens JA, van der Heide A, Vrakking AM, Onwuteaka-Philipsen BD, van der Maas PJ, van der Wal G (August 2004).
1562:"Sedation for symptom control in Japan: the importance of intermittent use and communication with family members"
266:
Even though opioids tend to provide a comforting effect for recipients, there exists the risk of drug dependence
263:
also commonly induce sedation or drowsiness. However, they are more frequently used for analgesia than sedation.
1192:
Garetto F, Cancelli F, Rossi R, Maltoni M (October 2018). "Palliative Sedation for the Terminally Ill Patient".
2079:
89:, as the goal of palliative sedation is to control symptoms, rather than to shorten or end the person's life.
2813:
650:
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303:, ongoing monitoring to determine efficacy and any adverse effects, and educating the patient and family.
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from the National Consensus Project recommends a comprehensive assessment of symptoms prior to initiating
174:
The first step in consideration of palliative sedation is assessment of the person seeking the treatment.
2448:
2032:
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The use of sedation for palliative care in the UK was considered as part of an independent review of the
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68% of cases. People starting intermittent sedation may progress to use of continuous sedation in
2303:
Miccinesi G, Rietjens JA, Deliens L, Paci E, Bosshard G, Nilstun T, et al. (February 2006).
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person in the last hours or days of a dying person's life, usually by means of a continuous
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743:"Assisted suicide is controversial, but palliative sedation is legal and offers peace"
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1577:
1536:
1460:
1343:
1333:
1292:
1047:
963:
922:
856:
559:67% of cases and continuous sedation was
2632:
1905:
1723:
830:
802:. Collège des médecins du Québec. 2016.
673:Uniform Rights of the Terminally Ill Act
2444:"National Care of the Dying Audit 2009"
2362:10.7326/0003-4819-141-3-200408030-00006
2055:"Physician-Assisted Suicide Fast Facts"
1029:
429:, the doses of sedatives are titrated (
347:
210:
2915:
2829:
2675:Osterweis M, Champagne DS (May 1979).
2598:Journal of Pain and Symptom Management
2309:Journal of Pain and Symptom Management
2019:A review of the liverpool care pathway
1954:
1668:Journal of Pain and Symptom Management
1603:Journal of Pain and Symptom Management
1566:Journal of Pain and Symptom Management
1449:Journal of Pain and Symptom Management
952:Journal of Pain and Symptom Management
911:Journal of Pain and Symptom Management
800:Palliative sedation at the end of life
766:
760:
740:
697:
141:
2746:
2744:
2591:
2548:
2101:
2099:
2013:
2011:
2009:
1410:
1408:
1406:
583:
459:assisted suicide in the United States
154:, and severe psychological distress.
1726:"Reflections on palliative sedation"
1714:. Lippincott Williams & Wilkins.
833:"Reflections on palliative sedation"
794:
792:
790:
788:
608:
202:Continuous vs. intermittent sedation
50:practice of relieving distress in a
2407:The New England Journal of Medicine
1489:Scottish Palliative Care Guidelines
113:
66:drug, or by means of a specialized
13:
2741:
2096:
2006:
1414:
1403:
215:
118:
101:Palliative sedation is the use of
14:
2944:
2873:
2681:American Journal of Public Health
2655:"History of the Hospice Movement"
2611:10.1016/j.jpainsymman.2009.06.007
2322:10.1016/j.jpainsymman.2005.07.004
2021:. Department of Health Ministers.
1680:10.1016/j.jpainsymman.2011.06.027
1615:10.1016/j.jpainsymman.2013.06.019
1462:10.1016/j.jpainsymman.2007.10.004
965:10.1016/j.jpainsymman.2013.11.009
785:
41:sedation for intractable distress
2849:Ă–sterberg L (October 11, 2010).
2635:"The alternative to euthanasia?"
1989:"Advance decision (living will)"
644:
612:
166:Assessment and obtaining consent
2842:
2823:
2807:
2788:
2768:
2717:
2668:
2647:
2626:
2585:
2542:
2499:
2456:
2435:
2394:
2337:
2296:
2253:
2210:
2167:
2132:
2072:
2047:
2025:
1981:
1948:
1899:
1864:
1815:
1766:
1717:
1704:
1659:
1639:
1594:
1553:
1477:
1360:
1309:
1228:
1185:
1142:
1107:
1064:
1023:
464:
2662:Hospice of the Western Reserve
2141:Journal of Palliative Medicine
1912:Annals of Medicine and Surgery
1828:Journal of Palliative Medicine
1791:10.1002/14651858.CD010206.pub2
1249:10.23736/S0375-9393.17.12091-2
1116:Journal of Palliative Medicine
980:
939:
898:
873:
824:
734:
691:
186:accompanied by uncontrollable
16:Sedation of the terminally ill
1:
2633:Brimelow A (12 August 2009).
2116:10.1007/978-3-540-69960-6_122
1924:10.1016/S2049-0801(12)70013-4
924:10.1016/s0885-3924(02)00440-2
885:Palliative At the End of Life
469:
307:Administration and monitoring
96:
2851:"Sjuka får sövas in i döden"
2814:American Medical Association
1873:Journal of Clinical Oncology
1579:10.1016/0885-3924(96)00046-2
1001:10.1097/NCC.0b013e3182595406
712:10.3109/15360288.2013.848970
651:American Medical Association
190:. Severe trouble breathing (
7:
2449:Royal College of Physicians
2350:Annals of Internal Medicine
666:
604:
571:
10:
2949:
2830:Ollove M (July 30, 2018).
2520:10.1177/082585979901500305
2508:Journal of Palliative Care
2477:10.1177/026921639901300313
2274:10.1177/026921639701100208
2231:10.1191/026921699669863369
2188:10.1177/082585979000600303
2176:Journal of Palliative Care
1163:10.1177/082585979401000207
1151:Journal of Palliative Care
1085:10.1177/104990910001700212
679:Principle of Double Effect
589:U.S. hospice care movement
453:Physician-assisted Suicide
122:
87:physician-assisted suicide
1906:Teoh PJ, Camm CF (2012).
1724:Twycross R (2019-01-27).
1335:10.1186/s12904-018-0288-2
1206:10.1007/s40263-018-0576-7
831:Twycross R (2019-01-01).
657:
2592:Seale C (January 2010).
2563:10.1177/0269216308102042
1885:10.1200/JCO.2011.37.3795
1742:10.1177/1178224218823511
1381:10.1177/0269216309107024
849:10.1177/1178224218823511
767:Ollove M (2 July 2018).
684:
293:diversion of medications
37:continuous deep sedation
1517:Mayo Clinic Proceedings
1237:Minerva Anestesiologica
1030:Quigley C (July 2008).
383:Sedation vs. euthanasia
301:pharmacological therapy
2110:. pp. 2061–2080.
446:subcutaneous infusions
289:substance use disorder
2879:Timothy E. Quill and
2801:American Medical News
2693:10.2105/AJPH.69.5.492
2153:10.1089/jpm.2005.8.20
1840:10.1089/jpm.2011.0234
1529:10.4065/mcp.2010.0201
1417:"Palliative sedation"
1294:10.1093/annonc/mdp048
1128:10.1089/jpm.2014.0414
1036:BMJ Clinical Evidence
364:A specialized rectal
188:psychomotor agitation
2725:"History of Hospice"
2420:10.1056/NEJMsa071143
1736:: 1178224218823511.
843:: 1178224218823511.
348:Nutrition and fluids
340:may be administered.
211:Sedative medications
2909:, December 27, 2009
2891:"Terminal Sedation"
2836:The Washington Post
2794:Kevin B. O'Reilly,
2551:Palliative Medicine
2465:Palliative Medicine
2262:Palliative Medicine
2219:Palliative Medicine
1369:Palliative Medicine
1322:BMC Palliative Care
747:The Washington Post
487:
142:Palliative sedation
29:palliative sedation
2061:. 26 November 2014
1281:Annals of Oncology
624:. You can help by
584:History of hospice
486:
480:3.1 –
359:intravenous fluids
229:midazolam (Versed)
44:of a dying patient
23:, specifically in
2125:978-3-540-69959-0
1965:10.1037/10264-020
1710:Plumer AL. 2007.
1243:(12): 1317–1323.
809:978-2-924674-01-7
741:Ollove M (2018).
642:
641:
565:10 –
561:14 –
557:30 –
546:
545:
295:. Therefore, the
33:terminal sedation
2940:
2897:Discussion Forum
2867:
2866:
2864:
2862:
2846:
2840:
2839:
2827:
2821:
2811:
2805:
2792:
2786:
2785:
2783:
2782:
2772:
2766:
2765:
2763:
2762:
2748:
2739:
2738:
2736:
2735:
2721:
2715:
2714:
2704:
2672:
2666:
2665:
2659:
2651:
2645:
2644:
2630:
2624:
2623:
2613:
2589:
2583:
2582:
2546:
2540:
2539:
2503:
2497:
2496:
2460:
2454:
2453:
2439:
2433:
2432:
2422:
2398:
2392:
2391:
2373:
2341:
2335:
2334:
2324:
2300:
2294:
2293:
2257:
2251:
2250:
2214:
2208:
2207:
2171:
2165:
2164:
2136:
2130:
2129:
2103:
2094:
2093:
2091:
2090:
2076:
2070:
2069:
2067:
2066:
2051:
2045:
2044:
2042:
2040:
2029:
2023:
2022:
2015:
2004:
2003:
2001:
2000:
1985:
1979:
1978:
1952:
1946:
1945:
1935:
1903:
1897:
1896:
1868:
1862:
1861:
1851:
1819:
1813:
1812:
1802:
1770:
1764:
1763:
1753:
1721:
1715:
1708:
1702:
1701:
1691:
1663:
1657:
1656:
1654:
1653:
1643:
1637:
1636:
1626:
1598:
1592:
1591:
1581:
1557:
1551:
1550:
1540:
1508:
1499:
1498:
1496:
1495:
1481:
1475:
1474:
1464:
1440:
1431:
1430:
1428:
1427:
1412:
1401:
1400:
1364:
1358:
1357:
1347:
1337:
1313:
1307:
1306:
1296:
1272:
1261:
1260:
1232:
1226:
1225:
1189:
1183:
1182:
1146:
1140:
1139:
1111:
1105:
1104:
1068:
1062:
1061:
1051:
1027:
1021:
1020:
984:
978:
977:
967:
943:
937:
936:
926:
902:
896:
895:
893:
891:
882:
877:
871:
870:
860:
828:
822:
821:
796:
783:
782:
780:
779:
764:
758:
757:
755:
753:
738:
732:
731:
695:
637:
634:
616:
609:
566:
562:
558:
488:
485:
481:
421:
420:
416:
409:
408:
404:
287:
286:
282:
276:
275:
271:
262:
261:
257:
251:
250:
246:
114:General practice
25:end-of-life care
2948:
2947:
2943:
2942:
2941:
2939:
2938:
2937:
2923:Palliative care
2913:
2912:
2876:
2871:
2870:
2860:
2858:
2847:
2843:
2828:
2824:
2812:
2808:
2804:, July 7, 2008.
2793:
2789:
2780:
2778:
2774:
2773:
2769:
2760:
2758:
2750:
2749:
2742:
2733:
2731:
2723:
2722:
2718:
2673:
2669:
2657:
2653:
2652:
2648:
2631:
2627:
2590:
2586:
2547:
2543:
2504:
2500:
2461:
2457:
2440:
2436:
2413:(19): 1957–65.
2399:
2395:
2342:
2338:
2301:
2297:
2258:
2254:
2215:
2211:
2172:
2168:
2137:
2133:
2126:
2104:
2097:
2088:
2086:
2078:
2077:
2073:
2064:
2062:
2053:
2052:
2048:
2038:
2036:
2031:
2030:
2026:
2017:
2016:
2007:
1998:
1996:
1987:
1986:
1982:
1975:
1953:
1949:
1904:
1900:
1879:(12): 1378–83.
1869:
1865:
1820:
1816:
1785:(1): CD010206.
1771:
1767:
1730:Palliative Care
1722:
1718:
1709:
1705:
1664:
1660:
1651:
1649:
1645:
1644:
1640:
1599:
1595:
1558:
1554:
1509:
1502:
1493:
1491:
1483:
1482:
1478:
1441:
1434:
1425:
1423:
1413:
1404:
1365:
1361:
1314:
1310:
1273:
1264:
1233:
1229:
1200:(10): 951–961.
1190:
1186:
1147:
1143:
1112:
1108:
1069:
1065:
1028:
1024:
985:
981:
944:
940:
903:
899:
889:
887:
880:
879:
878:
874:
837:Palliative Care
829:
825:
810:
798:
797:
786:
777:
775:
765:
761:
751:
749:
739:
735:
696:
692:
687:
675:(United States)
669:
660:
647:
638:
632:
629:
622:needs expansion
607:
591:
586:
574:
564:
560:
556:
479:
472:
467:
455:
427:palliative care
418:
414:
412:
406:
402:
400:
385:
350:
336:benzodiazepine
309:
284:
280:
278:
273:
269:
267:
259:
255:
253:
248:
244:
242:
225:benzodiazepines
221:Benzodiazepines
218:
216:Sedating agents
213:
204:
168:
144:
127:
125:Palliative care
121:
119:Palliative care
116:
99:
31:(also known as
17:
12:
11:
5:
2946:
2936:
2935:
2930:
2925:
2911:
2910:
2907:New York Times
2900:
2894:
2888:
2875:
2874:External links
2872:
2869:
2868:
2855:Dagens Medicin
2841:
2822:
2806:
2787:
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2646:
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2584:
2557:(3): 198–204.
2541:
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2434:
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2166:
2131:
2124:
2095:
2071:
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1980:
1973:
1947:
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1834:(3): 334–339.
1814:
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1703:
1674:(6): 1126–30.
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1523:(10): 949–54.
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989:Cancer Nursing
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123:Main article:
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62:infusion of a
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2256:
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2240:
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2232:
2228:
2225:(3): 233–41.
2224:
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2213:
2205:
2201:
2197:
2193:
2189:
2185:
2181:
2177:
2170:
2162:
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2109:
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2100:
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2075:
2060:
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2050:
2034:
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2020:
2014:
2012:
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1994:
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1984:
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1974:1-55798-369-0
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1522:
1518:
1514:
1507:
1505:
1490:
1486:
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1472:
1468:
1463:
1458:
1455:(3): 310–33.
1454:
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1446:
1439:
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1422:
1418:
1411:
1409:
1407:
1398:
1394:
1390:
1386:
1382:
1378:
1375:(7): 581–93.
1374:
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1351:
1346:
1341:
1336:
1331:
1327:
1323:
1319:
1312:
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1287:(7): 1163–9.
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1122:(7): 585–92.
1121:
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1086:
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1079:(2): 118–24.
1078:
1074:
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1059:
1055:
1050:
1045:
1041:
1037:
1033:
1026:
1018:
1014:
1010:
1006:
1002:
998:
995:(3): 245–54.
994:
990:
983:
975:
971:
966:
961:
958:(4): 660–77.
957:
953:
949:
942:
934:
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916:
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876:
868:
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690:
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677:
674:
671:
670:
664:
655:
652:
649:In 2008, the
645:United States
636:
627:
623:
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