Menezes Miriam S, Figueiredo Maria das Graças Mota da Cruz de Assis
Universidade Federal de Santa Maria (UFSM), Santa Maria, RS, Brasil.
Faculdade de Medicina de Itajubá, Itajubá, MG, Brasil.
Braz J Anesthesiol. 2019 Jan-Feb;69(1):72-77. doi: 10.1016/j.bjan.2018.03.002. Epub 2018 Aug 1.
Palliative sedation is a medical procedure that has been used for more than 25 years to relieve refractory symptoms not responsive to any previous treatment in patients with no possibility of cure and near the end of life. Many uncertainties persist on the theme regarding definition, indications, decision making, most appropriate place to perform the procedure, most used drugs, need for monitoring, fluids and nutritional support, and possible ethical dilemmas. The objective of this review was to seek a probable consensus among the authors regarding these topics not yet fully defined.
An exploratory search was made in secondary sources, from 1990 to 2016, regarding palliative sedation and its clinical and bioethical implications.
Palliative sedation is an alternative to alleviate end-of-life patient suffering due to refractory symptoms, particularly dyspnea and delirium, after all other treatment options have been exhausted. Decision making involves prior explanations, discussions and agreement of the team, patient, and/or family members. It can be performed in general hospital units, hospices and even at home. Midazolam is the most indicated drug, and neuroleptics may also be required in the presence of delirium. These patients’ monitoring is limited to comfort observation, relief of symptoms, and presence of adverse effects. There is no consensus on whether or not to suspend fluid and nutritional support, and the decision must be made with family members. From the bioethical standpoint, the great majority of authors are based on intention and proportionality to distinguish between palliative sedation, euthanasia, or assisted suicide.
姑息性镇静是一种已应用超过25年的医疗手段，用于缓解那些无法治愈且临近生命末期的患者对先前任何治疗均无反应的难治性症状。关于其定义、适应症、决策制定、实施该操作的最合适场所、最常用药物、监测需求、液体和营养支持以及可能存在的伦理困境等主题，仍存在诸多不确定性。本综述的目的是就这些尚未完全明确的主题在作者之间寻求可能的共识。
对1990年至2016年的二手资料进行了关于姑息性镇静及其临床和生物伦理意义的探索性检索。
姑息性镇静是在所有其他治疗选择均已用尽后，缓解临终患者因难治性症状（尤其是呼吸困难和谵妄）而痛苦的一种选择。决策制定涉及团队、患者和/或家庭成员事先的解释、讨论和同意。该操作可在综合医院病房、临终关怀机构甚至家中进行。咪达唑仑是最适用的药物，在存在谵妄时可能还需要使用抗精神病药物。对这些患者的监测仅限于舒适度观察、症状缓解以及不良反应的出现情况。对于是否暂停液体和营养支持尚无共识，必须与家庭成员共同做出决定。从生物伦理角度来看，绝大多数作者基于意图和相称性来区分姑息性镇静、安乐死或协助自杀。
