The importance of defining a refractory symptom is central in utilizing palliative
sedation in a safe, efficacious, and ethical manner.
A refractory symptom is one that cannot be adequately controlled
despite aggressive efforts to identify a tolerable therapy that does not
compromise consciousness (Cherny
A refractory symptom may be subjective and, at times, nonspecific.
It is 2007-12-07ot;difficult" symptoms,
since many symptoms considered refractory are at times successfully managed
by specialized hospice and palliative care programs (Broeckaert
The malignant tumors most often associated with refractory symptoms include
those in the lungs, gastrointestinal tract, head and neck, colon, rectum,
and breasts, though certainly any malignancy can cause refractory symptoms.
Pain, dyspnea, persistent emesis, and agitated delirium are the symptoms
most commonly requiring sedation (Rousseau
1999, Braun 2000).
Nonmalignant disorders may exhibit refractory symptoms,
including congestive heart failure (dyspnea etc), chronic obstructive pulmonary
disease, and debilitating neurological ailments, such as dementia and amyotrophic
Most patients requiring palliative sedation demonstrate
more than one refractory symptom (Cowan
2002; Cowan 2001).
Palliative medicine experts reported that 34% of
their patients received sedation for nonphysical symptoms (Charter
1994). In patients sedated for nonphysical symptoms, 60% were for neuropsychiatric
symptoms, whereas 6% were for "anguish".
In deciding when a symptom
is refractory, the clinician must perceive that further invasive and non-invasive
interventions are :
incapable of providing adequate relief,
are associated with excessive and
intolerable acute or chronic morbidity, or
are unlikely to provide relief
within a tolerable time frame.
Interestingly, in a study by Braun and associates (Braun
2000), 50% of patients receiving palliative sedation at the beginning
of the study were sedated in response to symptoms that were not considered
refractory. Moreover, after the implementation of clinical practice guidelines
for palliative sedation, the incidence of palliative sedation was reported
to be significantly reduced. Consequently, the importance of defining a refractory
symptom is central in utilizing palliative sedation in a safe, efficacious,
and ethical manner.