Palliative sedation: the hot topics
Main Article Content
Abstract
Palliative Sedation (SP), for the control of symptoms refractory to standard therapy in end of life patients, is a practice inherent pa- lliative care, but many aspects of its application remain the sub- ject of debate and discussion. It's inevitable and proper that the decision to reduce or remove the consciousness of a patient, though very ill and close to death, arouse emotions, clinical and ethical dilemmas. In this paper we have examined and reflected on the main aspects related to the SP and controversial emerging from the literature, a work that formed the basis for outlining a de- cision-making process and internal procedural guidelines to our hospice. Many aspects, from the definition, the indication, the pro- cedures for the SP still have no standard internationally defined and accepted, but there are guidelines and recommendations which, a1though low level of evidence, are indispensable tools that express the reflection and the experience of palliative care physicians trained and experienced. Precisely because of the subtle clinical and ethical boundaries that separate the SP to practice euthanasia, our reflection leads to reiterate the need for the practice of SP should be conducted with rigor, care and skill and to grow more and more trained staff and dedicated who knows the stages of the procedure of SP, in their form and in their content. In ethical terms requires a serious assessment of the re- lationship between the purpose for which it acts and the action taken, so the way in which the aim is reveals the real intentions behind the action. Even in the case of SP to follow a precise and shared mode of procedure is fundamental act that reveals, in cli- nical practice, right intention. It follows that all the reflections in pursuit of a good clinical practice in the SP are essential to ensure hea1thy ethics. With this in mind, the possibility of SP may be «a continuum of good clinical practice» based on a careful and sym- pathetic consideration of the patient and his family whose well-be- ing, from birth to death, is priority and purpose of each medical procedure, particularly in the palliative treatment of end of life.
Downloads
Download data is not yet available.
Article Details
How to Cite
Sangalli, L., & Turriziani, A. (2021). Palliative sedation: the hot topics. Medicina Y Ética, 25(1), 61–104. Retrieved from https://publicaciones.anahuac.mx/index.php/bioetica/article/view/700
Section
Articles
Medicina y Ética is distributed under a Creative Commons License Atribución-NoComercial-CompartirIgual 4.0 Internacional.
The author keeps the property rights with no restriction whatsoever and guarantees the magazine the right to be the first publication of the work. The author is free to deposit the published version in any other medium, such as an institutional archive or on his own website.
References
1 Legge 15 Marzo 2010, n. 38 (G.U. Serie Generale, n. 65 del 19 marzo 2010).
2 SEPÚLVEDA C, MARLIN A, YOSHIDA T et al. Palliative care: the World Health Organization’s global perspective. J Pain Symptom Manage, 2002, 24: 91-96; TURRIZIANI A. Terapie di supporto, cure palliative e oncologia: un contributo alla chiarezza. Rivista Italiana di Cure Palliative, 2012, 14(2): 5-8.
3 DE GRAEFF A, DEAN M. Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. J Pall Med, 2007, 10(1): 67-85; EISENCHLAS JH. Palliative sedation. Curr Opin Support Palliat Care, 2007, 1: 207-212.
4 CARR MF, MOHR GJ. Palliative sedation as part of a continuum of palliative care. J Pall Med, 2008, 11(1): 76-81; CHERNY NI, RADBRUCH L. The board of European Association for Palliative Care Milan Italy: European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med, 2009, 23(7): 581- 593.
5 CLAESSENS P, MENTEN J, SCHOTSMANS P et al. Palliative sedation: a review of the research literature. J Pain Symptom Manage, 2008, 36(3): 310-333; MULLER-BUS- CH HC, ANDRES I, JEHSER T. Sedation in palliative care – a critical analysis of 7 years experience. BMC Palliative Care, 2003, 2: 2; Caraceni A. La sedazione nelle cure palliative: definizione e problematiche cliniche. Neurol Sci, 2004, 25: S435- S437.
6 CHERNY, op. cit., p. 581; SOCIETÀ ITALIANA DI CURE PALLIATLVE (SICP). Racco- mandazioni della Sicp sulla sedazione terminale/sedazione palliativa. A cura del Gruppo di Studio Su etica e cultura al termine della vita. Ottobre 2007.
7 DE GRAEFF, p. 74; CLAESSENS, op. cit., p. 326; DE BENEDICTIS A, VINCENZI B, TAMBONE V. lndagine conoscitiva sull’utilizzo di linee-guida per la sedazione pa- lliativa. Int Nurs Persp., 2008, 8(1): 3-12.
8 ROYAL DUTCH MEDICAL ASSOCIATION (KNMG). Committee on National Guideli- nes for Palliative Sedation. Utrecht, The Netherlands, December 2005; Guideli- nes of the Norwegian Medical Association on Palliative Sedation. Cit. en: MA- TERSTVEDT LJ, BOSSHARD G. Deep and continuous palliative sedation (terminal sedation): clinical-ethical and philosophical aspects. Lancet Oncol., 2009, 10: 622-627; Morita T, Bito S et al. Development of a clinical guideline for palliative sedation therapy using the Delphi method. J Palliat Med., 2005, 8: 716-729.
9 KIRK TW, MAHON MM. National Hospice and Pallaitive Care Organization (NHP- CO) position. Manage, 2010, 39: 914-923; CHERNY, DE GRAEFF, op. cit.;
10 SOCIETÀ ITALIANA DI CURE PALLIATIVE (SICP), op. cit., p. 5.
11 SIAARTI-ITALIAN SOCIETY OF ANAESTHESIA ANALGESIA RESUSCITATION AND INTENSI- VE CARE BIOETHICAL BOARD. End of life care and the intensivist: Siaarti recommen- dations on the management of the dying patient. Minerva Anestesiol., 2006, 72: 927-963.
12 PERUSELLI C. La sedazione profonda nei pazienti oncologici terminali: aspetti cli- nici. Psiconcologia, 2003, Anno II (1).
13 CHERNY, op. cit., p. 581.
14 MERCADANTE S, INTRAVAIA G, VILLARI P et al. Controlled sedation for refractory symptoms in dying patients. J Pain Symptom Manage, 2009, 37(5): 771-779.
15 RYS A, MORTIER F, DELIENS L et al. Continuous sedation until death: moral justifi- cations of physicians and nurses – A content analysis of opinion pieces. Med Health care and Philos, 2012 (Epub ahed of print).
16 Según la duración: sedación ocasional (por el tiempo de efectuar maniobras in- vasivas), sedación intermitente o continua. Según el nivel de inconsciencia: seda- ción profunda (el paciente está consciente y no puede comunicarse en ningún modo), intermedia (el paciente está adormentado pero puede ser despertado para breves comunicaciones) o ligera (el paciente puede comunicarse verbalmente o no verbalmente, es tranquilizado pero mantenido un nivel de consciencia). Según la indicac16 PERUSELLI C. La sedazione profonda nei pazienti oncologici terminali: aspetti clinici. Psiconcologia, 2003, Anno II (1).
16 CHERNY, op.cit., p. 581.
16 MERCADANTE S, INTRAVAIA G, VILLARI P et al. Controlled sedation for refractory symptoms in dying patients. J Pain Symptom Manage, 2009, 37(5): 771-779.
16 RYS A, MORTIER F, DELIENS L et al. Continuous sedation until death: moral justifi- cations of physicians and nurses – A content analysis of opinion pieces. Med Health care and Philos. 2012 (Epub ahed of print).
16 Según la duración: sedación ocasional (por el tiempo de efectuar maniobras in- vasivas), sedación intermitente o continua. Según el nivel de inconsciencia: se- dación profunda (el paciente está consciente y no puede comunicarse en nin- gún modo), intermedia (el paciente está a ión: sedación imprevista/aguda (para eventos catastróficos) o sedación proporcional.
17 LEVY MH, COHEN SD. Sedation for the relief of refractory symptoms in the immi- nently dying: a fine intentional line. Semin Oncol., 2005, 32: 237-246; SYKES N, THORNS A. Sedative use in the last week of life and the implications for end-of-life decision making. Arch Intern Med., 2003, 163: 341-344; Id. The use of opioids and sedatives at the end of life. Lancet Oncol., 2003, 4:312-18; Claessens, op.cit.; CARACENI, op. cit.; DE BENEDICTIS, VINCENZI, TAMBONE. Indagine co- noscitiva.
18 MALTONI M, SCARPI E, ROSATI M. Palliative sedation in end-of-life care and sur- vival. A systematic review. J Clin Oncol., 2012, 30: 1378-1383.
19 PITTURERI C, TURCI P, TORRONI M et al. Sedazione palliativa nel paziente onco- logico: dati di uno studio retrospettivo in hospice. Rivista italiana di Cure Palliati- ve, 2005, 4: 11-16.
20 MERCADANTE, op. cit., p. 773.
21 BULLI F, MICCINESI G, BIANCALANI E et al. Continuos deep sedation in home pa- lliative care units: case studies in the Florence area in 2000 and in 2003-2004. Minerva Anestesiol., 2007, 73(5): 291-298.
22 SOCIETÁ ITALIANA DI CURE PALLIATIVE (SICP). op. cit.
23 CHERNY NI, PORTENOY RK. Sedation in the management of refractory symptoms: guide lines for evaluation and treatment. J Pall Care, 1994, 10: 31-38.
24 Se define síntoma refractario “un síntoma para el cual los posibles tratamien- tos han fallado, o se considera que no existan otros métodos disponibles para la paliación actuables en tiempos útiles y con una proporción riesgos/benefi- cios aceptables para el paciente”.
25 BRINKKEMPER T, VAN NOREL AM, SZADEK KM et al. The use of observational scales to monitor symptom control and depth of sedation in patients requiring palliative sedation: A systematic review. Palliat Med, 2013, 27(1): 54-67.
26 SWART SJ, RLETJENS JA, VAN ZUYLEN L et al. Continuous palliative sedation for cancer and noncancer patients. J Pain Symptom Manage, 2012, 43(2): 172-181. 27 CHERNY, op. cit., p. 584; DE GRAEFF, op. cit. p. 70; SICP. op. cit., p. 8; SIAARTI- ITALLAN SOCIETY OF ANAESTHESIA ANALGESIA RESUSCITATION AND INTENSIVE CARE BIOETHICAL BOARD. End of life care.
28 CLAESSENS, op. cit.; PITTURERI, op. cit,
29 MALTONI M, PITTURERI C, SCARPI et al. Palliative sedation therapy does not hasten death results from a prospective multicenter study. Ann Onc., 2009, 20: 1163-1169.
30 MULLER-BUSCH, ANDRES, JEHSER, op. cit., p. 6.
31 MORITA T. Differences in physician-reported practice in palliative sedation the- rapy. Support Care Cancer, 2004, 12: 584-592.
32 CHERNY, op. cit., p. 582.
33 SICP. p. 43.
34 BUCKMAN R. La comunicazione delta diagnosi in caso di malattie gravi. Milán: Raffaello Cortina Editore, 2003.
35 SOCIETA ITALIANA DI CURE PALLIATIVE (SICP), op. cit., p. 24: Variantes relativas al enfermo/familia: el grado de autonomía decisional, el deseo de ser informa- dos, el modelo antropológico, presencia de conflictos, presencia de personas significativas para el enfermo que fungen de referencia y apoyo, el grado de consciencia de los familiares, el grado de comprensión y tolerancia emotiva, la capacidad del equipo de ofrecer todas las informaciones y el apoyo necesarios. Variables relativas a sistemas comunicativos externos: el nivel de comunicación del equipo, el apoyo psicológico a los operadores y familiares, las diferencias profesionales o culturales con personas que giran en torno al paciente.
36 LO B, RUBENFELD G. Palliative sedation in dying patients «We turn to it when everything else hasn’t worked»: Jama, 2005, 294(14): 1810-1816; CHERNY, op. cit., p. 585; DE GRAEFF, op. cit., p. 72; SICP. op. cit., p. 26: SIAARTI-ITALLAN SOCIETY OF ANAESTHESLA ANALGESIA RESUSCITATION AND INTENSIVE CARE BIOETHICAL BOARD, op. cit.
37 MERCADANTE. op. cit.
38 LEVY MH, COHEN SD. Sedation for the relief of refractory symptoms in the immi- nently dying: afine intentional line. Semin Oncol., 2005, 32: 237-246.
39 CHERNY, op. cit., p. 588.
40 SICP, op. cit., p. 43.
41 DE GRAEFF, op. cit., p. 73.
42 CHERNY, op. cit., p. 588; SICP, op. cit.
43 SICP, op. cit. p. 18.
44 MORITA T, INOUE S, CHIHARA S. Sedation for symptom control in Japan: the im- portance of intermittent use and communication with family members. J Pain Symptom Manage, 1996, 12: 32-38; CHERNY. The board of European Association- for Palliative Care...; MULLER-BUSCH, LEVY, op. cit.;
45 Las escalas de valoración referidas para esta finalidad son múltiples: La Ram- sey Sedation, Scale, Motor Activity Assesment Scale (MAAS), Comunication Capa- city Scale, Richmond Agitation Sedation. Estos instrumentos son intercambiados por la experiencia mejor codificada de las secciones de terapia intensiva, y su adecuación en cuidados paliativos no ha sido probada.
46 Escala Rudkin: Grado l) paciente despierto y orientado; Grado 2) somnoliento pero despertable; Grado 3) ojos cerrados pero despertable a la llamada; Grado 4) ojos cerrados pero despertable con estímulo táctil (no doloroso); Grado 5) ojos cerrados no respondiente a estímulo táctil.
47 CHERNY, op. cit., SICP, op. cit., p. 45.
48 BRUINSMA SM, RIETJENS JA, SEYMOUR JE et al. The experiences of relatives with the practice of palliative sedation: a systematic review. J Pain Symptom Manage, 201, 44(3): 431-445; Claessens. Palliative sedation: a review..., p. 326.
49 DE GRAEFF, op. cit.; CHERNY, op. cit.; SICP, op. cit., p. 18.
50 DE GRAEFF, op. cit.; DE BENEDICTIS, op. cit., p. 8.
51 Claessens, op. cit.
52 DE GRAEFF, op. cit.
53 NATIONAL ETHICS COMMITTEE, VETERANS HEALTH ADMINISTRATION. The ethics of palliative sedation as a therapy of last resort. Am J Hosp Palliat Care, 2006; 23 (6): 483-491.
54 “Es lícito suprimir el dolor por medio de narcóticos, aún con la consecuencia de limitar la conciencia y abreviar la vida, ‘si no existen otros medios y si, en esas determinadas circunstancias, eso no impide el cumplimiento de otros de- beres religiosos y morales’. En este caso de hecho la muerte no es querida o buscada no obstante que por motivos razonables, se cubra su riesgo. Sin em- bargo no se debe privar al moribundo de la consciencia de sí sin grave motivo: acercándose la muerte, los hombres deben ser capaces de poder satisfacer sus obligaciones morales y familiares y sobre todo deben poderse preparar con plena consciencia al encuentro definitivo con Dios”. JUAN PABLO II. Carta Encícli- ca “Evangelium Vitae”, n. 65.
55 THORNS A. A review of the doctrine of double effect. Eur J Pall Careo, 1998, 5 (4): 117-120; Rys. Continuous sedation until death...
56 Cfr.: VIRDIS A. Il principio morale dell’atto a duplice effetto e il suo uso in bioeti- ca. Medicina e Morale, 2006, 5: 951-979.
57 MORITA T, TSUNODA J, INOUE S et al., Effects of high dose opioids and sedatives on survival in terminal ill cancer patients. J Pain Symptom Manage, 2001, 21(4): 283-289; DE GRAEFF, op. cit.; CLAESSENS, op. cit.; MULLER-BUSCH, op. cit.; PERU- SELLI, op. cit.; PITTURERI, op. cit., MALTONI, PITTURERI, SCARPI et al., op. cit.
58 LEHEUP BF, PIOT E, DUCROCQ X et al. Principle of double effect and sedation for intractabile distress: reflexion on survival in sedated patients. Press Med, 2012, 41 (10): 927-932.
59 SICP, op. cit., p. 36.
60 SCHILDMANN E, VOLLMANN J, SCHILDMANN J. Palliative sedation: further evidence needs to be accompanied by ethical guidance to ensure professional practice at the end-of-life. J Clin Oncol, 2012, 30(33): 4176.
61 JANSSENS R, VAN DELDEN JJM, WIDDERSHOVEN GAM. Palliative sedation: not just normal medical practice . Ethical reflections on the Royal Dutch medical Association’s guidelines on palliative sedation. J Med Ethics, 2012, 38(11): 664- 668.
62 MATERSTVEDT LJ, BOSSHARD G. Deep and continuous palliative sedation (termi- nal sedation): clinical-ethical and philosophical aspects. Lancet Oncol, 2009, 10: 622-627.
63 NATIONAL ETHICS COMMITTEE, VETERANS HEALTH ADMINISTRATION, op. cit.
64 MATERSTVEDT LJ, CLARK D, ELLERSHAW J, et al. Euthanasia and physician-assis- ted suicide: a view from an Eapc Ethics Task Force. Palliat Med, 2003, 17(2): 97- 101.
65 DE GRAEFF, op. cit.; p. 75; CHERNY, op. cit.; CLAESSENS, op. cit.; SICP. op. cit., p. 38; SIAARTI-ITALIAN SOCIETY OF ANAESTHESIA ANALGESIA RESUSCITATION AND IN- TENSIVE CARE BIOETHICAL BOARD, NATIONAL ETHICS COMMITTEE, VETERANS HEALTH ADMINISTRATION, op. cit.
66 CLAESSENS, op. cit.; MULLER-BUSCH, MALTONI, op. cit. 67 CARACENI, op. cit., p. S436; MATERSTVEDT, op. cit.
68 SICP, op. cit., p. 12.
69 NATIONAL ETHICS COMMITIEE, VETERANS HEALTH ADMINISTRATION, op. cit.
70 DE GRAEFF, op. cit.; SICP, op. cit., p. 13.
71 CHERNY, op. cit.
72 FAISINGER RL, WALZER A, BERCOVICI M et al. A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients. Palliat Med, 2000, 14: 257-265.
73 SYKES, op. cit.
74 MALTONI, op. cit.
75 MORITA, op. cit., p. 763.
76 FURSTENBERG C. The key of the relational care: the care along the way in the place of residence. Rech Soins Infirm, 2011, (l07): 76-81.
77 CHOCHINOV HM, HACK T, HASSARD T et al. Dignity therapy: a novel psychothera- peutic intervention for patients near the end of life. J Clin Oncol, 2005, 23: 5520- 5525.
78 NATIONAL ETHICS COMMITTEE, VETERANS HEALTH ADMINISTRATION, op. cit., p. 488. 79 COMITATO NAZIONALE PER LA BIOETICA. Rifiuto e rinuncia consapevole al tratta- mento sanitario nella relazione paziente-medico (24 Ottobre 2008) Roma: Presi- denza del Consiglio dei Ministri, Dipartimento per l’Informazione e l’Editoria, 2008: 3, paragrafo l.
80 Ibid., p. 6, paragrafo 2.
81 CLAESSENS, op. cit.
82 CHIU TY, SCI MH, HU WY et al. Sedation for refractory symptoms of terminal cancer patients in Taiwan. J Pain Symptom Manage, 2001, 21: 467-472; BULLI F, MICCINESI G, BIANCALANI E et al. Continuos deep sedation in home palliative care units: case studies in the Florence area in 2000 and in 2003-2004. Minerva Anes- tesiol, 2007, 73(5): 291-298; RIETJENS J, VAN DELDEN J, ONWUTEAKA-PHILIPSEN et al. Continuous deep sedation for patients nearing death in the Netherlands: descriptive study. BMJ, 2008, 336: 810-813.
83 CHERNY, op. cit.; De Graeff, op. cit., p. 72; SICP, op. cit., p. 38.
84 Procedimiento decisional en el cual se anima a los familiares y a las seres que- ridos del enfermo a expresar su testimonio acerca de la decisión que el enfermo habría probablemente tomado en aquella circunstancia clínica.
85 Ley 09.01.2004 n. 6. Gazzetta Ufficiale del 19.01.2004; Código Civil Libro 1, Tí- tulo XII, Sección 1.
86 FNOMCEO. Codice di Deontologia Medica 1998; CONSIGLIO EUROPEO. Convenzio- ne sui Diritti Umani e la Biomedicina (Oviedo, 4 de abril de 1997, ratificada por el Parlamento Italiano el 14 de marzo de 2001).
87 SICP, op. cit., p. 39.
88 LO, RUBENFELD, op. cit.
89 LEVY, COHEN, op. cit.
90 MATERSTVEDT, op. cit.
2 SEPÚLVEDA C, MARLIN A, YOSHIDA T et al. Palliative care: the World Health Organization’s global perspective. J Pain Symptom Manage, 2002, 24: 91-96; TURRIZIANI A. Terapie di supporto, cure palliative e oncologia: un contributo alla chiarezza. Rivista Italiana di Cure Palliative, 2012, 14(2): 5-8.
3 DE GRAEFF A, DEAN M. Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. J Pall Med, 2007, 10(1): 67-85; EISENCHLAS JH. Palliative sedation. Curr Opin Support Palliat Care, 2007, 1: 207-212.
4 CARR MF, MOHR GJ. Palliative sedation as part of a continuum of palliative care. J Pall Med, 2008, 11(1): 76-81; CHERNY NI, RADBRUCH L. The board of European Association for Palliative Care Milan Italy: European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med, 2009, 23(7): 581- 593.
5 CLAESSENS P, MENTEN J, SCHOTSMANS P et al. Palliative sedation: a review of the research literature. J Pain Symptom Manage, 2008, 36(3): 310-333; MULLER-BUS- CH HC, ANDRES I, JEHSER T. Sedation in palliative care – a critical analysis of 7 years experience. BMC Palliative Care, 2003, 2: 2; Caraceni A. La sedazione nelle cure palliative: definizione e problematiche cliniche. Neurol Sci, 2004, 25: S435- S437.
6 CHERNY, op. cit., p. 581; SOCIETÀ ITALIANA DI CURE PALLIATLVE (SICP). Racco- mandazioni della Sicp sulla sedazione terminale/sedazione palliativa. A cura del Gruppo di Studio Su etica e cultura al termine della vita. Ottobre 2007.
7 DE GRAEFF, p. 74; CLAESSENS, op. cit., p. 326; DE BENEDICTIS A, VINCENZI B, TAMBONE V. lndagine conoscitiva sull’utilizzo di linee-guida per la sedazione pa- lliativa. Int Nurs Persp., 2008, 8(1): 3-12.
8 ROYAL DUTCH MEDICAL ASSOCIATION (KNMG). Committee on National Guideli- nes for Palliative Sedation. Utrecht, The Netherlands, December 2005; Guideli- nes of the Norwegian Medical Association on Palliative Sedation. Cit. en: MA- TERSTVEDT LJ, BOSSHARD G. Deep and continuous palliative sedation (terminal sedation): clinical-ethical and philosophical aspects. Lancet Oncol., 2009, 10: 622-627; Morita T, Bito S et al. Development of a clinical guideline for palliative sedation therapy using the Delphi method. J Palliat Med., 2005, 8: 716-729.
9 KIRK TW, MAHON MM. National Hospice and Pallaitive Care Organization (NHP- CO) position. Manage, 2010, 39: 914-923; CHERNY, DE GRAEFF, op. cit.;
10 SOCIETÀ ITALIANA DI CURE PALLIATIVE (SICP), op. cit., p. 5.
11 SIAARTI-ITALIAN SOCIETY OF ANAESTHESIA ANALGESIA RESUSCITATION AND INTENSI- VE CARE BIOETHICAL BOARD. End of life care and the intensivist: Siaarti recommen- dations on the management of the dying patient. Minerva Anestesiol., 2006, 72: 927-963.
12 PERUSELLI C. La sedazione profonda nei pazienti oncologici terminali: aspetti cli- nici. Psiconcologia, 2003, Anno II (1).
13 CHERNY, op. cit., p. 581.
14 MERCADANTE S, INTRAVAIA G, VILLARI P et al. Controlled sedation for refractory symptoms in dying patients. J Pain Symptom Manage, 2009, 37(5): 771-779.
15 RYS A, MORTIER F, DELIENS L et al. Continuous sedation until death: moral justifi- cations of physicians and nurses – A content analysis of opinion pieces. Med Health care and Philos, 2012 (Epub ahed of print).
16 Según la duración: sedación ocasional (por el tiempo de efectuar maniobras in- vasivas), sedación intermitente o continua. Según el nivel de inconsciencia: seda- ción profunda (el paciente está consciente y no puede comunicarse en ningún modo), intermedia (el paciente está adormentado pero puede ser despertado para breves comunicaciones) o ligera (el paciente puede comunicarse verbalmente o no verbalmente, es tranquilizado pero mantenido un nivel de consciencia). Según la indicac16 PERUSELLI C. La sedazione profonda nei pazienti oncologici terminali: aspetti clinici. Psiconcologia, 2003, Anno II (1).
16 CHERNY, op.cit., p. 581.
16 MERCADANTE S, INTRAVAIA G, VILLARI P et al. Controlled sedation for refractory symptoms in dying patients. J Pain Symptom Manage, 2009, 37(5): 771-779.
16 RYS A, MORTIER F, DELIENS L et al. Continuous sedation until death: moral justifi- cations of physicians and nurses – A content analysis of opinion pieces. Med Health care and Philos. 2012 (Epub ahed of print).
16 Según la duración: sedación ocasional (por el tiempo de efectuar maniobras in- vasivas), sedación intermitente o continua. Según el nivel de inconsciencia: se- dación profunda (el paciente está consciente y no puede comunicarse en nin- gún modo), intermedia (el paciente está a ión: sedación imprevista/aguda (para eventos catastróficos) o sedación proporcional.
17 LEVY MH, COHEN SD. Sedation for the relief of refractory symptoms in the immi- nently dying: a fine intentional line. Semin Oncol., 2005, 32: 237-246; SYKES N, THORNS A. Sedative use in the last week of life and the implications for end-of-life decision making. Arch Intern Med., 2003, 163: 341-344; Id. The use of opioids and sedatives at the end of life. Lancet Oncol., 2003, 4:312-18; Claessens, op.cit.; CARACENI, op. cit.; DE BENEDICTIS, VINCENZI, TAMBONE. Indagine co- noscitiva.
18 MALTONI M, SCARPI E, ROSATI M. Palliative sedation in end-of-life care and sur- vival. A systematic review. J Clin Oncol., 2012, 30: 1378-1383.
19 PITTURERI C, TURCI P, TORRONI M et al. Sedazione palliativa nel paziente onco- logico: dati di uno studio retrospettivo in hospice. Rivista italiana di Cure Palliati- ve, 2005, 4: 11-16.
20 MERCADANTE, op. cit., p. 773.
21 BULLI F, MICCINESI G, BIANCALANI E et al. Continuos deep sedation in home pa- lliative care units: case studies in the Florence area in 2000 and in 2003-2004. Minerva Anestesiol., 2007, 73(5): 291-298.
22 SOCIETÁ ITALIANA DI CURE PALLIATIVE (SICP). op. cit.
23 CHERNY NI, PORTENOY RK. Sedation in the management of refractory symptoms: guide lines for evaluation and treatment. J Pall Care, 1994, 10: 31-38.
24 Se define síntoma refractario “un síntoma para el cual los posibles tratamien- tos han fallado, o se considera que no existan otros métodos disponibles para la paliación actuables en tiempos útiles y con una proporción riesgos/benefi- cios aceptables para el paciente”.
25 BRINKKEMPER T, VAN NOREL AM, SZADEK KM et al. The use of observational scales to monitor symptom control and depth of sedation in patients requiring palliative sedation: A systematic review. Palliat Med, 2013, 27(1): 54-67.
26 SWART SJ, RLETJENS JA, VAN ZUYLEN L et al. Continuous palliative sedation for cancer and noncancer patients. J Pain Symptom Manage, 2012, 43(2): 172-181. 27 CHERNY, op. cit., p. 584; DE GRAEFF, op. cit. p. 70; SICP. op. cit., p. 8; SIAARTI- ITALLAN SOCIETY OF ANAESTHESIA ANALGESIA RESUSCITATION AND INTENSIVE CARE BIOETHICAL BOARD. End of life care.
28 CLAESSENS, op. cit.; PITTURERI, op. cit,
29 MALTONI M, PITTURERI C, SCARPI et al. Palliative sedation therapy does not hasten death results from a prospective multicenter study. Ann Onc., 2009, 20: 1163-1169.
30 MULLER-BUSCH, ANDRES, JEHSER, op. cit., p. 6.
31 MORITA T. Differences in physician-reported practice in palliative sedation the- rapy. Support Care Cancer, 2004, 12: 584-592.
32 CHERNY, op. cit., p. 582.
33 SICP. p. 43.
34 BUCKMAN R. La comunicazione delta diagnosi in caso di malattie gravi. Milán: Raffaello Cortina Editore, 2003.
35 SOCIETA ITALIANA DI CURE PALLIATIVE (SICP), op. cit., p. 24: Variantes relativas al enfermo/familia: el grado de autonomía decisional, el deseo de ser informa- dos, el modelo antropológico, presencia de conflictos, presencia de personas significativas para el enfermo que fungen de referencia y apoyo, el grado de consciencia de los familiares, el grado de comprensión y tolerancia emotiva, la capacidad del equipo de ofrecer todas las informaciones y el apoyo necesarios. Variables relativas a sistemas comunicativos externos: el nivel de comunicación del equipo, el apoyo psicológico a los operadores y familiares, las diferencias profesionales o culturales con personas que giran en torno al paciente.
36 LO B, RUBENFELD G. Palliative sedation in dying patients «We turn to it when everything else hasn’t worked»: Jama, 2005, 294(14): 1810-1816; CHERNY, op. cit., p. 585; DE GRAEFF, op. cit., p. 72; SICP. op. cit., p. 26: SIAARTI-ITALLAN SOCIETY OF ANAESTHESLA ANALGESIA RESUSCITATION AND INTENSIVE CARE BIOETHICAL BOARD, op. cit.
37 MERCADANTE. op. cit.
38 LEVY MH, COHEN SD. Sedation for the relief of refractory symptoms in the immi- nently dying: afine intentional line. Semin Oncol., 2005, 32: 237-246.
39 CHERNY, op. cit., p. 588.
40 SICP, op. cit., p. 43.
41 DE GRAEFF, op. cit., p. 73.
42 CHERNY, op. cit., p. 588; SICP, op. cit.
43 SICP, op. cit. p. 18.
44 MORITA T, INOUE S, CHIHARA S. Sedation for symptom control in Japan: the im- portance of intermittent use and communication with family members. J Pain Symptom Manage, 1996, 12: 32-38; CHERNY. The board of European Association- for Palliative Care...; MULLER-BUSCH, LEVY, op. cit.;
45 Las escalas de valoración referidas para esta finalidad son múltiples: La Ram- sey Sedation, Scale, Motor Activity Assesment Scale (MAAS), Comunication Capa- city Scale, Richmond Agitation Sedation. Estos instrumentos son intercambiados por la experiencia mejor codificada de las secciones de terapia intensiva, y su adecuación en cuidados paliativos no ha sido probada.
46 Escala Rudkin: Grado l) paciente despierto y orientado; Grado 2) somnoliento pero despertable; Grado 3) ojos cerrados pero despertable a la llamada; Grado 4) ojos cerrados pero despertable con estímulo táctil (no doloroso); Grado 5) ojos cerrados no respondiente a estímulo táctil.
47 CHERNY, op. cit., SICP, op. cit., p. 45.
48 BRUINSMA SM, RIETJENS JA, SEYMOUR JE et al. The experiences of relatives with the practice of palliative sedation: a systematic review. J Pain Symptom Manage, 201, 44(3): 431-445; Claessens. Palliative sedation: a review..., p. 326.
49 DE GRAEFF, op. cit.; CHERNY, op. cit.; SICP, op. cit., p. 18.
50 DE GRAEFF, op. cit.; DE BENEDICTIS, op. cit., p. 8.
51 Claessens, op. cit.
52 DE GRAEFF, op. cit.
53 NATIONAL ETHICS COMMITTEE, VETERANS HEALTH ADMINISTRATION. The ethics of palliative sedation as a therapy of last resort. Am J Hosp Palliat Care, 2006; 23 (6): 483-491.
54 “Es lícito suprimir el dolor por medio de narcóticos, aún con la consecuencia de limitar la conciencia y abreviar la vida, ‘si no existen otros medios y si, en esas determinadas circunstancias, eso no impide el cumplimiento de otros de- beres religiosos y morales’. En este caso de hecho la muerte no es querida o buscada no obstante que por motivos razonables, se cubra su riesgo. Sin em- bargo no se debe privar al moribundo de la consciencia de sí sin grave motivo: acercándose la muerte, los hombres deben ser capaces de poder satisfacer sus obligaciones morales y familiares y sobre todo deben poderse preparar con plena consciencia al encuentro definitivo con Dios”. JUAN PABLO II. Carta Encícli- ca “Evangelium Vitae”, n. 65.
55 THORNS A. A review of the doctrine of double effect. Eur J Pall Careo, 1998, 5 (4): 117-120; Rys. Continuous sedation until death...
56 Cfr.: VIRDIS A. Il principio morale dell’atto a duplice effetto e il suo uso in bioeti- ca. Medicina e Morale, 2006, 5: 951-979.
57 MORITA T, TSUNODA J, INOUE S et al., Effects of high dose opioids and sedatives on survival in terminal ill cancer patients. J Pain Symptom Manage, 2001, 21(4): 283-289; DE GRAEFF, op. cit.; CLAESSENS, op. cit.; MULLER-BUSCH, op. cit.; PERU- SELLI, op. cit.; PITTURERI, op. cit., MALTONI, PITTURERI, SCARPI et al., op. cit.
58 LEHEUP BF, PIOT E, DUCROCQ X et al. Principle of double effect and sedation for intractabile distress: reflexion on survival in sedated patients. Press Med, 2012, 41 (10): 927-932.
59 SICP, op. cit., p. 36.
60 SCHILDMANN E, VOLLMANN J, SCHILDMANN J. Palliative sedation: further evidence needs to be accompanied by ethical guidance to ensure professional practice at the end-of-life. J Clin Oncol, 2012, 30(33): 4176.
61 JANSSENS R, VAN DELDEN JJM, WIDDERSHOVEN GAM. Palliative sedation: not just normal medical practice . Ethical reflections on the Royal Dutch medical Association’s guidelines on palliative sedation. J Med Ethics, 2012, 38(11): 664- 668.
62 MATERSTVEDT LJ, BOSSHARD G. Deep and continuous palliative sedation (termi- nal sedation): clinical-ethical and philosophical aspects. Lancet Oncol, 2009, 10: 622-627.
63 NATIONAL ETHICS COMMITTEE, VETERANS HEALTH ADMINISTRATION, op. cit.
64 MATERSTVEDT LJ, CLARK D, ELLERSHAW J, et al. Euthanasia and physician-assis- ted suicide: a view from an Eapc Ethics Task Force. Palliat Med, 2003, 17(2): 97- 101.
65 DE GRAEFF, op. cit.; p. 75; CHERNY, op. cit.; CLAESSENS, op. cit.; SICP. op. cit., p. 38; SIAARTI-ITALIAN SOCIETY OF ANAESTHESIA ANALGESIA RESUSCITATION AND IN- TENSIVE CARE BIOETHICAL BOARD, NATIONAL ETHICS COMMITTEE, VETERANS HEALTH ADMINISTRATION, op. cit.
66 CLAESSENS, op. cit.; MULLER-BUSCH, MALTONI, op. cit. 67 CARACENI, op. cit., p. S436; MATERSTVEDT, op. cit.
68 SICP, op. cit., p. 12.
69 NATIONAL ETHICS COMMITIEE, VETERANS HEALTH ADMINISTRATION, op. cit.
70 DE GRAEFF, op. cit.; SICP, op. cit., p. 13.
71 CHERNY, op. cit.
72 FAISINGER RL, WALZER A, BERCOVICI M et al. A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients. Palliat Med, 2000, 14: 257-265.
73 SYKES, op. cit.
74 MALTONI, op. cit.
75 MORITA, op. cit., p. 763.
76 FURSTENBERG C. The key of the relational care: the care along the way in the place of residence. Rech Soins Infirm, 2011, (l07): 76-81.
77 CHOCHINOV HM, HACK T, HASSARD T et al. Dignity therapy: a novel psychothera- peutic intervention for patients near the end of life. J Clin Oncol, 2005, 23: 5520- 5525.
78 NATIONAL ETHICS COMMITTEE, VETERANS HEALTH ADMINISTRATION, op. cit., p. 488. 79 COMITATO NAZIONALE PER LA BIOETICA. Rifiuto e rinuncia consapevole al tratta- mento sanitario nella relazione paziente-medico (24 Ottobre 2008) Roma: Presi- denza del Consiglio dei Ministri, Dipartimento per l’Informazione e l’Editoria, 2008: 3, paragrafo l.
80 Ibid., p. 6, paragrafo 2.
81 CLAESSENS, op. cit.
82 CHIU TY, SCI MH, HU WY et al. Sedation for refractory symptoms of terminal cancer patients in Taiwan. J Pain Symptom Manage, 2001, 21: 467-472; BULLI F, MICCINESI G, BIANCALANI E et al. Continuos deep sedation in home palliative care units: case studies in the Florence area in 2000 and in 2003-2004. Minerva Anes- tesiol, 2007, 73(5): 291-298; RIETJENS J, VAN DELDEN J, ONWUTEAKA-PHILIPSEN et al. Continuous deep sedation for patients nearing death in the Netherlands: descriptive study. BMJ, 2008, 336: 810-813.
83 CHERNY, op. cit.; De Graeff, op. cit., p. 72; SICP, op. cit., p. 38.
84 Procedimiento decisional en el cual se anima a los familiares y a las seres que- ridos del enfermo a expresar su testimonio acerca de la decisión que el enfermo habría probablemente tomado en aquella circunstancia clínica.
85 Ley 09.01.2004 n. 6. Gazzetta Ufficiale del 19.01.2004; Código Civil Libro 1, Tí- tulo XII, Sección 1.
86 FNOMCEO. Codice di Deontologia Medica 1998; CONSIGLIO EUROPEO. Convenzio- ne sui Diritti Umani e la Biomedicina (Oviedo, 4 de abril de 1997, ratificada por el Parlamento Italiano el 14 de marzo de 2001).
87 SICP, op. cit., p. 39.
88 LO, RUBENFELD, op. cit.
89 LEVY, COHEN, op. cit.
90 MATERSTVEDT, op. cit.