An (In)appropriate Case of Palliative Sedation

Palliative sedation is the use of medical therapy to induce decreased awareness to relieve severe and refractory symptoms (1). A recent case I had involved the use of antipsychotics to the point of palliative sedation for refractory symptoms in a non terminally ill patient.

The patient is a 64 year old female with a history of progressive supranuclear palsy, major depressive disorder, who had progressive decline over the last 3 years. She stopped eating and was admitted for grave disability, hypernatremia. During her hospitalization, the patient was exhibiting signs of emotional distress, anguish, and was trialed on half a dozen different regimens to control her symptoms. At one point electroconvulsive therapy was considered as treatment but the patient ultimately responded to a regimen that kept her asleep for 20-22 hours a day. 

When my attending and I met the patient and her husband (and durable power of attorney) for a home visit she had been home for 3 months sleeping 20-22 hours and awake but minimally interactive for the remainder of the day. She would track movement but not respond to attempts at communication. We discussed with the patient's husband what we thought, and Psychiatry consultants agreed, that this level of sedation was extreme and recommended weaning Seroquel. We also shared that our Neurology consultants gave her a prognosis of years and this level of sedation that is typically reserved for those with a prognosis of much shorter duration of hours to days. While my attending and I were uncomfortable with this level of sedation, the patient's husband had a different perspective. He shared the story of her emotional suffering, prolonged hospitalization for months, and that he felt she had too many “experimental trials” of medications to control her symptoms. To him, this was the only regimen that alleviated her emotional suffering. Patient’s husband agreed to discuss the prospects of weaning Seroquel with his family.

We presented this patient’s case during a Bioethics Committee meeting. The Bioethics Committee had different suggestions and considerations from legal (concerns for malpractice) to ethical (issue of use of antipsychotics to the point of palliative sedation for refractory symptoms in a non terminally ill patient) to medical considerations (not standard of care for use of palliative sedation in a patient receiving artificial nutrition from a gastrostomy tube). All members agreed that this was a challenging situation without a clear cut answer. We ultimately agreed that the best approach at the time was to continue with goals of care discussion with the patient's husband, specifically clarifying a clearer picture of the patient's ideal quality of life.

On follow-up with this patient and her husband, the patient's husband had already accidentally missed a few doses of medications and noted her alertness had improved with more awake hours during the day. Patient was able to have limited interactions with family, something she had not been able to do previously. We are continuing to build a therapeutic partnership with her husband to come up with a therapeutic regimen that enables the patient to have meaningful interactions and that limits her emotional turmoil.

by Dong M .Tran, MD
Geriatric Medicine Fellow at Kaiser Permanente ( Fontana) SBC program


1.     Cherny NI, Portenoy RK. Sedation in the management of refractory symptoms: guidelines for evaluation and treatment. J Palliat Care (1994)

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