Sedative drugs were used to treat a variety of symptoms in the hospice, from breathlessness to seizures. The process of symptom control using sedative drugs appeared to be similar to that described above for pain. For example, Simon was a 44 year old man with an aggressive lung cancer. He was very breathless, and became anxious as a result of his breathlessness. He was given a variety of different treatments
99 to help his symptoms, including benzodiazepines3. A typical night for him was
described during a nursing handover as this extract from field notes shows.
4:2 Simon was 44 and had a pulmonary adenocarcinoma. He had been admitted because of panic attacks and anxiety, with increasing breathlessness. He had a ‘usual night’, and had required Oramorph and midazolam4
, lorazepam5 and paracetamol, at different stages through the night, for anxiety, headaches and breathlessness.
[FN 16/02/10 line 39] I observed one of the nurses, Jane, as she went in to see him after he had pressed his buzzer. I stood just inside the doorway as she went in.
4:3 He was sitting up in a wheelchair with an oxygen mask on, breathing very quickly. He couldn’t speak in sentences, only managing to get one or two words out at a time between each breath. He said he couldn’t breathe. Jane crouched beside him and asked if he had any pain or if anything else was going on. Simon shook his head and said no, he just couldn’t breathe. Jane said she’d get him ‘something’ and be back soon. Simon looked straight ahead the whole time and didn’t turn at all to look at Jane. He looked very anxious and frightened with his eyes wide open and just staring ahead. Jane looked at his chart as we walked back up the corridor – she said it was horrible, wasn’t it? She said she would try some lorazepam - the girls6 at handover had said it worked better than the
Oramorph.
[FN 17/02/10 line 23] The lorazepam which Jane was planning to give to Simon for agitation was considered in a similar way to the use of oramorph for Paula’s pain in the first extract. Indeed, it appeared that having first tried oramorph to treat Simon’s breathlessness, the lorazepam was considered to be more effective. These symptoms were assessed on the basis of
3
Sedative group of drugs
4
Injectable benzodiazepine
5 Oral benzodiazepine
100 what the patient volunteered to the nurse. A further ‘routine’ use of sedation for
symptom control was the use of sedation for behaviours which appeared to be indictors of distress. Staff in the hospice regularly used the terms ‘unsettled’, ‘restless’ or
‘agitated’ to describe a patient’s behaviour in situations in which a patient was unable to communicate their symptoms. These behaviours conveyed a sense that a patient was in some way distressed, and these behaviours were manifestations of this distress. The treatment of these behaviours could also be regarded as a form of routine symptom control, it appeared. On a daily basis in the nursing handover meetings a description of which drugs a patient had ‘needed’ during the previous shift was provided. Almost invariably this included a patient who had received a sedative drug for one of these ‘distress-behaviours’. For example, during a handover meeting one of the nurses described giving some midazolam to a patient:
4:4 He was a bit agitated so I gave him some midazolam and it settled him lovely
[FN 16/10/09 line 12] Similarly, another nurse, in the same meeting described a different patient who had been restless and had ‘needed a couple of extras but settled in the end’ [FN 16/10/09 line 20]. The ‘extras’ were injections of midazolam, I realised later, after going with one of the nurses to give out the regular drugs later in the day. The fact that the sedative drugs were simply referred to as ‘extras’, enhanced an impression that this form of sedation was routine and a formed a normal part of work in the hospice. Handovers of this nature occurred every day without question or challenge.
Assessments of these distress-behaviours were carried out by both doctors and nurses. A further example of the routine use of sedation to treat distress behaviour was for Charlie. He was a patient who was 76 years old and had a form of lung cancer. He had been admitted to the hospice for symptom control of pain. He had rapidly deteriorated and was described in the handover as being very ‘agitated’ overnight. One of the registrars, Gillian, had been to review him and came to talk to one of the senior doctors, Julia, about him in the MDT office. She told Julia about the change in his condition and her assessment of him.
101
4:5 Overnight he had had nearly 20 mg of extra midazolam and so they had increased the syringe driver7 this morning to 20 mg of midazolam over 24 hours. She had been back in to see him and he was still not settled. He had been moving about the bed and looked ‘unsettled’. His arms were constantly moving and fidgeting, she said. He was on some levomepromazine8 6.25 mg for nausea but she had just asked Lisa [staff nurse] to give him 12.5 mg for his agitation. She was wondering about adding levomepromazine into the syringe driver now for
agitation.
[FN 11/02/10 line 43]
Gillian’s description of the patient’s agitation was typical of this type of ‘distress- behaviour’ which I observed in the fieldwork. The use of sedative drugs to cause cessation of the behaviour described was part of everyday practice. If a patient was breathless, a nurse would make an assessment, look at what had worked before and treat with whatever had been given before or was prescribed to be given as a ‘first line’ treatment. In the same way if a patient looked restless, the nurse made an assessment, looked at what had been given before and treated the restlessness with whatever had worked in the past or was prescribed as first line. These were described as part of normal practice in the handover meetings as simply the ‘extras’ which had been required overnight or since the previous shift. Thus sedation used in this way, it appeared, was considered as simply a matter of symptom control. A difference
however, emerged when observing the treatment of breathlessness with lorazepam and the treatment of distress with midazolam; a difference which did not appear to be explicitly acknowledged by staff in the hospice. It appeared that a reduction in consciousness was acceptable when restlessness and other distress-behaviours were treated, but this was not acceptable at the point at which lorazepam was given for breathlessness. The patients were at different stages, it seemed, in their dying processes. Lisa, one of the staff nurses, expressly stated the staff’s aims of avoiding drowsiness with Simon’s use of lorazepam in an MDT meeting.
7 A small machine frequently used in palliative care to deliver a set dose of an injectable drug, normally
over 24 hours, into the subcutaneous tissue
8
An antipsychotic drug used for control of nausea in low doses and agitation in higher doses as its sedative properties increase
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4:6 Lisa said, as a positive statement, he was having less lorazepam and
Oramorph now that he was on MST9, and he was managing his panic attacks a bit better. The lorazepam had been making him a bit drowsy so they were avoiding it as far as they could and trying to engage him with complementary therapies.
[FN 17/02/10 line 96]
An alternative to the lorazepam was sought in order to reduce his drowsiness, it seemed. In contrast, the doctors who discussed the use of sedation for Charlie appeared to accept that it would make him sleep, although were still concerned they didn’t give ‘too much’.
4:7 Julia [senior doctor] then asked what Gillian [registrar] was worried about in adding the levomepromazine into the driver now. Gillian wasn’t sure what she meant. Julia then asked whether part of the reason she was hesitating was that she was worried that if the levomepromazine which he had just had worked, and made him more relaxed and made him sleep, that in adding 50 mg to the driver, it would perhaps be more than he needed. In other words, was it that she wanted to give him the lowest dose possible of a drug which was effective, and not give too much and over sedate him? Gillian agreed that that was what she wanted.
[FN 11/02/10 line 84]
It seemed that both Julia and Gillian accepted that they wanted to give the drugs to make Charlie ‘more relaxed’ and ‘sleep’; this would be the measure of whether or not the drugs had ‘worked’. Simon was not acknowledged to be dying; from the hospice perspective he was still expected to improve and be discharged. Charlie was thought to be dying; as Gillian said later in the conversation to Julia, she didn’t think; ‘it would be
long’ [FN 11/02/10 line 61]. Both practices of giving sedation, for breathlessness and
for agitation, appeared to be routine, but were very different in consequence. The routine nature of giving sedation for agitation, with a reduction in consciousness, appeared to occur as a patient progressed towards imminent dying. That which was acceptable as a patient was dying was unacceptable, it seemed, when they were not thought to be actively dying. This relied implicitly upon the interpretation of the dying process; this process has been explored and delineated perhaps most clearly by Glaser and Strauss in their original work on the ‘transitional statuses of dying’. An
103 understanding of the changing nature of sedation in relation to the ‘transitional statuses of dying’ is explored next, relying, I suggest, upon an acceptance of a reduction in consciousness as a patient comes closer to death.