Palliative Sedation Therapy: A Systematic Literature Review and Critical Appraisal of Available Guidance on Indication and Decision Making

Background: Palliative sedation therapy (PST) is increasingly used in end-of-life care. However, consensus about definitions, indications, and treatment decision making is lacking. Objective: The objective is to review and critically appraise published guidelines on indication and decision making for PST. Methods: Data sources are CINAHL, Cochrane Library, EMBASE, PsycINFO, PubMed, and references of included papers through February 2013. Selection criteria were that papers included a PST guideline and were written in English or German. The term guideline was defined according to MEDLINE. Two investigators extracted information on the guidelines' recommendations on indication and decision making. Results: The nine eligible guidelines differ in their definitions of PST. In addition key terms such as refractory symptom or intolerable suffering are used differently. These criteria are also weighed differently in their relevance for indication and decision making. PST for psychological distress is regarded as exceptional by eight guidelines, but only two guidelines provide reasons for this exceptionalism in comparison with PST for somatic suffering. In the majority of guidelines the role of different stakeholders involved in decision making is not specified. With regards to the limitation of life-sustaining measures, e.g., intravenous hydration, in the context of PST the analyzed guidelines differ in their recommendations. Conclusions: PST guidelines differ considerably on aspects of indication and decision making about PST which are relevant from a clinical as well as ethical perspective. The comparison and critical appraisal can serve as a starting point for the improvement of future PST policies.