Medication and monitoring in palliative sedation therapy: a systematic review and quality assessment of published guidelines

J Pain Symptom Manage. 2015 Apr;49(4):734-46. doi: 10.1016/j.jpainsymman.2014.08.013. Epub 2014 Sep 19.


Context: Palliative sedation therapy (PST) is increasingly used in patients at the end of life. However, consensus about medications and monitoring is lacking.

Objectives: To assess published PST guidelines with regard to quality and recommendations on drugs and monitoring.

Methods: We searched CINAHL, the Cochrane Library, Embase, PsycINFO, PubMed, and references of included articles until July 2014. Search terms included "palliative sedation" or "sedation" and "guideline" or "policy" or "framework." Guideline selection was based on English or German publications that included a PST guideline. Two investigators independently assessed the quality of the guidelines according to the Appraisal of Guidelines for Research and Evaluation II instrument (AGREE II) and extracted information on drug selection and monitoring.

Results: Nine guidelines were eligible. Eight guidelines received high quality scores for the domain "scope and purpose" (median 69%, range 28-83%), whereas in the other domains the guidelines' quality differed considerably. The majority of guidelines suggest midazolam as drug of first choice. Recommendations on dosage and alternatives vary. The guidelines' recommendations regarding monitoring of PST show wide variation in the number and details of outcome parameters and methods of assessment.

Conclusion: The published guidelines on PST vary considerably regarding their quality and content on drugs and monitoring. Given the need for clear guidance regarding PST in patients at the end of life, this comparative analysis may serve as a starting point for further improvement.

Keywords: Palliative sedation; drug monitoring; practice guidelines; quality assurance.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Guidelines as Topic*
  • Humans
  • Hypnotics and Sedatives / therapeutic use*
  • Monitoring, Physiologic / methods*
  • Palliative Care / methods*
  • Quality Assurance, Health Care


  • Hypnotics and Sedatives