Refractory symptoms and end of life midazolam use in cancer patients, a single center experience

Cancer patients often suffer from refractory symptoms near death. The use of sedatives aims to relieve suffering caused by these symptoms. The practice varies broadly. The aim of this study was to evaluate the role and trends of midazolam use in cancer patients dying in a university hospital oncology ward.

The study population of this retrospective registry-based study consists of patients who died in a university hospital oncology ward in Eastern Finland in 2010-2018 (n = 639). Information about treatment decisions, midazolam use, and background factors were gathered.

During the study period, 14.7 % of the patients dying in the ward received midazolam with sedative intent prior to death. 4.7 % (n = 30) of the whole study population had continuous infusion and the rest of the midazolam use was one or multiple single doses. Documented discussion of possible palliative sedation (PS) use was found in almost one third of all patients. Out of those, eventually receiving midazolam with sedative intent, two thirds had had this discussion. The most common symptoms leading to midazolam were dyspnea, pain, and delirium. In continuous use the median midazolam infusion rate was 4.0 mg/h. The continuous infusion started median of 23.25 h and multiple single doses 19 h before death. If only one dose of midazolam was needed, it was given median of 30 minutes prior to death and the most common symptom was dyspnea. Those who received midazolam were more likely to be younger (p = 0.003) and had had a palliative outpatient clinic visit (p = 0.045).

This is the first study to report the trends and practices of midazolam use for refractory symptoms in Finland. Midazolam was used for approximately every 7^th dying cancer patient. Applying midazolam was supported by a history of palliative clinic visits and younger age.