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subcutaneous route is theoretically preferable, but many EOL patients are lacking viable subcutaneous tissue due to cachexia and frailty.
Benzodiazepines are a first line medication for PST and produce effective sedation in individuals that are largely naïve to this class of drugs. However, as benzodiazepines are effective for a myriad of palliative issues, many people at the end of a long course of illness have previously utilized this class of drugs on a regular basis for anxiety, sleep and other symptoms. As a result, benzodiazepine tolerance can be a potential barrier to successful PST at EOL.
In cases where sedation appears to have been achieved, some individuals continue to have intermittent break-through symptoms such as twitching, myoclonic jerks, and hiccups. A study by Claessens et al. (2008) report a PST effectiveness rate of 74%-91%, as measured by perception of clinicians and family members. A study of 1181 home deaths by Pype et al. (2017) reports 63 palliative sedations, with 11 of these resulting in a sub-optimal outcome.
This article seeks to contribute to discussions of how to increase the numbers of people who experience an unperturbed dying process. Toward that aim, a more specific definition of the “usual road” is needed. Individuals that experience the “usual road” are able to tolerate a dismantling of homeostatic control systems without experiencing a triggering of symptomatic events.
This group maintains a death associated dynamic equilibrium in the context of expected physiological insults such as drug toxicities, sepsis, tissue-trauma, hypoxia, and intracranial pressure. Individuals with conditions associated with long-term dysregulation, such as cancer and AIDS, come to the dying process with a disadvantage. For this group, homeostatic regulation has already broken down to some extent as a result of disease process and treatment.
New medicines targeting persistent EOL symptom-management problems are urgently needed. In their article entitled “Repurposing Medications for Hospice/Palliative Care Symptom Control Is No Longer Sufficient: A Manifesto for Change”, Currow et. al. (2017:533) call for an inquiry into new interventions that are hospice-specific, and based upon evidence gathered within an EOL context: