A multicentre international study of sedation for uncontrolled symptoms interminally ill patients

The issue of symptom management at the end of life and the need to use seda tion has become a controversial topic. This debate has been intensified by the suggestion that sedation may correlate with 'slow euthanasia'. The need to have more facts and less anecdote was a motivating factor in this multi centre study. Four palliative care programmes in Israel, South Africa, and Spain agreed t o participate. The target population was palliative care patients in an inp atient setting. Information was collected on demographics, major symptom di stress, and intent and need to use sedatives in the last week of life. Furt her data on level of consciousness, adequacy of symptom control, and opioid s and psychotropic agents used during the final week of life was recorded. As the final week of life can be difficult to predict, treating physicians were asked to complete the data at the time of death. The data available for analysis included 100 patients each from Israel and Madrid, 94 patients from Durban, and 93 patients from Cape Town. More than 90% of patients required medical management for pain, dyspnoea, delirium an d/or nausea in the final week of life. The intent to sedate varied from 15% to 36%, with delirium being the most common problem requiring sedation. Th ere were variations in the need to sedate patients for dyspnoea, and existe ntial and family distress. Midazolam was the most common medication prescri bed to achieve sedation. The diversity in symptom distress, intent to sedate and use of sedatives, p rovides further knowledge in characterizing and describing the use of delib erate pharmacological sedation for problematic symptoms at the end of life. The international nature of the patient population studied enhances our un derstanding of potential differences in definition of symptom issues, varia tion of clinical practice, and cultural and psychosocial influences.