Pediatric Palliative Sedation Practices in the Intensive Care Unit

Palliative sedation therapy (PST) is a tool that can mitigate suffering for dying patients. However, it is infrequently utilized, and little is known about the practice of PST in the intensive care unit (ICU).

To explore PST practices in pediatric ICU settings.

We distributed an IRB-exempt anonymous electronic survey to American pediatric pain, palliative, and ICU providers. Survey responses were collated and descriptively reported.

Of 74 responses, many participants (62%, n = 46) were early-career physicians (≤10 years in practice) and represented the pediatric, neonatal, and cardiac ICU (34%, n = 25; 30%, n = 22; and 15%, n = 11), respectively. Most reported an institutional guideline for PST (55%, n = 41), no ethics involvement (86%, n = 64), and were unsure if a Do Not Resuscitate order was required prior to PST (55%, n = 40). Intractable pain (47%, n = 35) and refractory respiratory distress (38%, n = 28) were the most common symptoms requiring PST. For medication selection in PST initiation, opioids (78%, n = 58) and benzodiazepines (12%, n = 9) were selected as the primary drug of choice. The second most common medications chosen included benzodiazepines (63%, n = 47), opioids (12%, n = 9), dexmedetomidine (11%, n = 8), ketamine (7%, n = 5), barbiturates (4%, n = 3), and propofol (3%, n = 2). Participants reported an average comfort level of 6.4 on a Likert scale in providing PST. Overall, increased education on PST (81%, n = 60), and development of guidelines (76%, n = 56) and order sets (62%, n = 46) for PST implementation were reported as beneficial.

PST practices in the ICU are varied, necessitating increased education and standardization of clinical practice.