"Can't You Just Make Him Sleep?" The Trials and Tribulations of Pediatric Palliative Sedation

Key Message: Pediatric palliative care is fraught with complexities that are unique to its population and arguably the biggest challenge in the field is palliative sedation. In this sessions, we hope to pull back the veil on the lack of evidence base for indications, medical management and communication surrounding its use.

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Abstract: Palliative sedation, as defined in the AAHPM statement, is defined as "the intentional lowering of awareness towards, and including, unconsciousness for patients with severe and refractory symptoms", typically those that are nearing end-of-life. In the rare frequency of indication for palliative sedation in the pediatric population, this procedure is complicated by ethical dilemmas and moral distress that necessitate the highest levels of clear communication and highest risk pharmaceutical interventions. Without clear evidence-based guidelines for palliative sedation, it is often at the discretion of those with the most experience and/or comfort with both the clinical scenario and pharmaceutical management.

In a case-based approach, the goal of this session is to discuss a multi-pronged approach to the management of palliative sedation. First, we would like to describe and review. the definition of palliative sedation and its indications in the pediatric population. Thereafter, we would like to discuss optimal pharmaceutical management for physical symptoms including, but not limited to drugs of choice, dosing, dose escalation and alternative drug classes for extreme refractory symptoms. This discussion would come from the small evidence base that exists in the literature as well as anecdotal experience from two of the largest pediatric centers in the country. We will not only discuss our successes, but lessons learned from our experiences.

Lastly, while palliative sedation does lack an evidence-base and is a rare clinical occurrence in pediatric palliative care, it often creates moral distress and questions about ethical dilemmas. At the end of the session, we will discuss obtaining parental consent, communication tools for talking to families and to providers as well as how to mitigate challenging scenarios regarding clinical staff.

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