To Create or Not to Create: How to Establish a System-Wide Proportionate Palliative Sedation Guideline Through Comprehensive Interdisciplinary Collaboration (TH108A)

Document Type

Conference Proceeding

Publication Date


Publication Title

J Pain Symptom Manage


Outcomes: 1. Assess the need to create a proportionate palliative sedation (PPS) guideline for one's clinical setting 2. Describe one health system's process of designing and establishing a PPS guideline across its multiple institutions Proportionate palliative sedation (PPS) for the terminally ill involves the use of sedating medications to treat distressing, refractory symptoms as a “last resort” intervention for patients pursuing comfort-focused care. This intervention has moral, ethical, spiritual, regulatory, and operational implications. Studies and several palliative organizations advocate the need for institutional PPS guidelines; however, there is a lack of recommendations on the process for establishing them. We present a clinical case, which served as a catalyst for an interdisciplinary collaboration of designing and establishing a PPS guideline for a healthcare system. A 70-year-old male with metastatic lung cancer was admitted with uncontrolled, cancer-related pain. Palliative care was consulted and his regimen was escalated and optimized, but his pain persisted. He requested to be sedated, even to the point of unconsciousness if necessary, and the family agreed. An interdisciplinary consensus was reached to proceed with PPS while addressing significant distress among providers for various reasons—no institutional guideline, uncertainty of patient's prognosis, providers’ inexperience, etc. The patient passed comfortably 5 days after initiation of PPS. This case highlighted the need to establish a system-wide guideline that is culturally sensitive, inclusive, and equitable for this vulnerable patient population. Key stakeholders were recruited from palliative care, interventional pain, ethics, psychiatry, pharmacy, nursing, social work, chaplaincy, and regulatory. Sensitive issues such as defining terminal illness, differentiating physical versus existential distress, and addressing different regulations among institutions created challenges. Reflective and active listening skills were utilized to address these concerns. Small workgroups were designated to reconcile multiple perspectives and draft a cohesive guideline. This process aligns with the Responsible, Accountable, Consulted, Informed (RACI) model, an organizational tool widely used in project management. We plan to share additional challenges and lessons learned during the subsequent implementation and re-evaluation phases.





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