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Palliative sedation has become a standard practice to treat refractory symptoms at end-of-life. Dyspnea and delirium are the two most commonly treated symptoms. The medications used in palliative sedation are usually benzodiazepines, barbiturates, antipsychotics, and/or anesthetics. Some ethical considerations remain, especially surrounding the use of palliative sedation in psychological distress and existential suffering.

Pain management in a hospital setting remains a challenge today. Many health care providers remain anxious and uninformed regarding analgesic titration within a hospital setting. Overcoming the potential risks to obtain the benefits of opiate titration is a challenge within any health care setting. Virginia Commonwealth University, a tertiary medical center which houses schools of medicine, nursing, and pharmacy, evaluated the use of algorithms for managing acute pain. This article describes the Pain Committee's efforts and offers one potential intervention for safe analgesic opioid titration, an algorithm for acute pain management.

Ms. G is a 71-year-old woman with metastatic gastric adenocarcinoma recently diagnosed after an extensive surgical resection for a small bowel obstruction (SBO). She was admitted from the surgery clinic with intractable nausea and vomiting. An abdominal computerized tomographic (CT) scan revealed a partial SBO and peritoneal carcinomatosis. Given her recent surgery, the extent of her disease, and high likelihood of recurrent SBO, the surgical team decided that Ms. G was no longer a surgical candidate. When her symptoms did not improve with conservative measures, both oncology and palliative medicine were consulted to assist with symptom management and goals of care. The oncology team stated that Ms. G was still a chemotherapy candidate and suggested that she attend her new patient evaluation in oncology clinic the following week. The palliative medicine team then met with the patient to discuss management options and her preferences for care. The palliative care team explained ways to control her nausea and vomiting without using a nasogastric tube, and the patient agreed to transfer to their service for symptom management. The palliative team explained that her cancer was incurable but that chemotherapy options existed to help control her disease and possibly prolong her life. They also explained that the chemotherapy has side effects and that the patient would need to decide if she wanted to undergo treatment and accept potential side effects for the possibility of prolonging her life by weeks to months and improving her symptoms. As an alternative, she was told that she could focus solely on symptom control with medications and allow her disease to take its natural course. Ms. G was asked to think about how she wanted to spend the time she had left. Prior to discharge, as her symptoms improved, Ms. G was evaluated by another oncologist, who, after consulting the expert gastrointestinal cancer team, explained to her that the current chemotherapy options available for metastatic gastric cancer were rarely, if ever, successful at reversing malignant obstruction. With this information, the patient decided to be discharged home with hospice and spend time with her family. She died peacefully at her home approximately two weeks later.