Topic: 4.5 Palliative Care

SUCCESSFUL USE OF CONSCIOUS SEDATION WITH DEXMEDETOMIDINE TO EASE TOTAL PAIN IN END OF LIFE CARE.

W. Freiherr von Hornstein 1), S. Hoey 1), M. Wilson 1), P. Pinheiro 2)
1) HSE, Specialist Palliative Care Service Cavan & Monaghan, Cavan, Ireland, HSE, Cavan
2) General Hospital, General Internal Medicine, Cavan, Ireland

Background and aims
A 63 years old lady was discharged from a tertiary hospital.  She had received intensive treatment with complications for two malignant conditions over the last year, and developed brain metastases.  Twelve days before her death she attended a specialist palliative care outpatient clinic in rural Ireland.  Her main symptoms were: anxiety, panic attacks, pain, nausea, decreased appetite, weight loss, confusion, and cognitive impairment.
This palliative care service had previously accompanied her sister who died in complete denial of her condition leaving her entire family in total distress.

Methods
This case report describes how palliative care can be provided in a life limiting condition with total pain.  It reveals how unexpected healing occurred in the patient and her family.

Results
As her symptoms escalated she was admitted to her local hospital three days later.  Psychiatry diagnosed a delirium and advised to use neuroleptics and avoid benzodiazepines for their risk of causing a paradoxical reaction.  However after successful treatment of the undiagnosed seizure activity with appropriate anticonvulsive medication and stopping the neuroleptics, her condition stabilized.  Her pain could be settled with Fentanyl 200 μg/24h continuous subcutaneous infusion (CSCI). Her anxiety, agitation, confusion and cognitive impairment subsided with dexmedetomidine CSCI for her last four days at a dose ranging from 0.13 to 0.19 μg/kg/h.

Conclusions
Two days before she died a dramatic transformation happened.  Via conscious sedation she could face her own dying and create a healing space for her family to deal with their own distress.