GuidelinesEML (Adult Hospital STG)
Sedation in Palliative Care
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition
Z51.5
- Sedation in palliative care has unique objectives, and tolerance for some adverse effects may be greater than in other situations.
- There is also an emphasis on avoiding parenteral medication.
- Palliative sedation should be undertaken by clinicians experienced in the process and the advice of an expert should be sought where necessary.
- Sedation should only be started after discussion with, and with the consent of, the patient and/or family (when the patient is unable to consent).
- The aim of sedation in palliative care is to ameliorate refractory suffering and not to hasten death.
- Palliative care medication addresses symptoms such as pain, dyspnoea, nausea and depression.
- Managing many of these symptoms involves the use of medications which may have sedative properties.
- Palliative sedation involves the additional use of medication where sedation is the primary objective, and is appropriate only after standard care has proven unsuccessful.
GENERAL MEASURES
- Pain must always be the first symptom to be excluded.
- Always look for reversible causes of symptoms prior to prescribing sedation such as dehydration, hypoxia, concurrent synergistic sedative medicines, hypercalcaemia, renal failure, or infection.
- Caution should be exercised and palliative care prescription examined for possible drug-drug interactions, prior to commencing sedation (or escalating doses of sedative medicines).
- Dose escalation may be considered only if there is evidence of inadequate sedation.
MEDICINE TREATMENT
Dosing in frail, elderly patients should be titrated to effect.
- Lorazepam, oral, 0.5 mg 4 hourly.
- Tablets may be crushed or administered sublingually.
LoE:IVbxxix
OR
If hyperactive delirium or severe agitation
- Olanzapine 2.5–5 mg orodispersible tablet or IM.
- Repeat after 30–60 minutes if needed.
LoE:IVbxxx
Note
Repeated doses may result in excessive sedation
Patient unable to take oral medication or terminal sedation required:
- Midazolam, SC/IV:
- Initial dose: 1–5 mg as needed
- Titrate to effect.
LoE:IIbxxxi
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.0_07 November 2024
Chapter 24: Medicines used in Palliative Care_24.5 Sedation in Palliative Care