Palliative Care Guidelines
Jimmy S Bilimoria Foundation



Good symptom control remains the central goal of palliative care in patients with incurable illness. In some patients as they approach the end of life, physical, psycho-social and existential/spiritual problems may not be adequately controlled despite adequate titration of medications in combination with non-pharmacological measures. In such situations sedation may need to be considered as a therapeutic intervention to relieve distress and suffering.

Therapeutic palliative sedation is defined as monitored continued or intermittent administration of medications intended to induce a state of decreased or absent awareness (unconsciousness) to relieve the burden of otherwise intractable suffering refractory to other therapies or interventions.

The common situations requiring therapeutic palliative sedation are:

  • Refractory physical symptoms
    • Pain
    • Breathlessness
    • Vomiting
    • Bleeding
    • Fatigue
  • Psychological
    • Depression
    • Anxiety
    • Delirium
  • Existential distress
    • Feeling of hopelessness/helplessness/worthlessness/meaninglessness/dependency and isolation
    • Fear or panic of impending death
    • Spiritual issues


  • Assess the physical symptoms psycho-social and existential/spiritual issues and the adequacy of the therapeutic interventions to manage the same
  • Assess the mental capacity of the patient to make his/her own decisions
  • Assess for alcohol, benzodiazepine and nicotine withdrawal


  • Therapeutic palliative sedation should be considered at the end of life, only after all other available treatment options have been exhausted
  • Therapeutic palliative sedation should be used  with the intent of relieving distress and suffering
  • Continue to administer medications such as opioids, psychotropic, anti-secretory and anti-emetics for adequate control of symptoms
  • At least one other palliative care physician should be consulted by the treating physician to agree before considering therapeutic palliative sedation
  • Patient, family and health care providers should agree before initiating therapeutic palliative sedation
  • Minimum quantity of medications should be used to achieve adequate relief of suffering
  • Midazolam is the most commonly used medication for therapeutic palliative sedation
  • Use Richmond Agitation-Sedation Scale (RASS) as a guide for increasing or decreasing sedation – 


  • Correct the correctable
    • Treat the underlying cause
    • If urinary retention, consider catheterization
    • If any biochemical imbalance, consider correction
    • If nicotine withdrawal, use TD nicotine patches
    • If alcohol or benzodiazepine withdrawal, then consider benzodiazepine
  • Non-pharmacological measures
    • Use a multi-disciplinary approach
    • Assess and record the wishes of patient and family
    • Adequate communication between the doctor, patient, and family on physical, psychological, social and existential/ spiritual issues and the pros and cons of therapeutic palliative sedation should be done in advance, if palliative sedation is considered a possible intervention necessary in the future
    • Clearly document in detail the communication with patient/family
  • Pharmacological measures
    • Start with Midazolam
    • Intermittent sedation
      • Inj. Midazolam 2.5-5mg (max 10mg) S/C stat and q1h prn
    • Continuous sedation
      • Inj. Midazolam 10-60mg/24 hours CSCI
      • Reported upper dose for agitation is 60mg/24 hours
      If Midazolam alone is not effective at doses above 60mg/24 hours (terminal agitation), then add
    • Haloperidol 5mg S/C stat, and 10-30mg/24 hours CSCI
    • If above is not effective, then consider phenobarbital
    • Start with loading dose of 200mg (1mL ampoule) as:
      • undiluted intramuscular injection or
      • diluted intravenous bolus given over 2min (1mL ampoule diluted to 10mL with water for injection)
    • If agitation persists, give 1 or 2 further doses of 200mg IM/IV prn 30 minutes apart
    • If agitation persists or recurs, give further doses of 200mg IM/IV q1h prn
    • Maintain with 800mg/24 hours CSCI; or more if total initial dose necessary to control was ≥600mg
    • If necessary, increase the dose progressively to 1,600mg/24 hours, i.e. 800mg→1,200mg→1,600mg
    • A typical dose is 800–1,200mg/24 hours but can range 200–1,600mg/24 hours
    • Alternatively
    • Consider Chlorpromazine 25mg q4h escalating to 200mg/24 hours PR or S/L


  • Adam, J. (2006). The last 48 hours. ABC of Palliative Care (pp. 44-47)
  • Krakauer, E.L. (2015). Sedation at the end of life. Oxford Textbook of Palliative Medicine (pp. 1134-1142)
  • Nogueira, F.L. and Sakata, R.K. Palliative Sedation of Terminally Ill Patients. Brazilian Journal of Anaesthesiology.(2012); 62(4): 580-592
  • Olsen, M.L., Swetz, K.M., Mueller, P.S. Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatment. Mayo Clinic Proceedings. (2010); 85(10):949-954
  • Twycross, R., Wilcock, A., Howard, P. (2014). Drug treatment in the imminently dying. Palliative Care Formulary 5. (pp. 822-823)
  • Twycross, R., Wilcock, A., Howard, P. (2014). Central nervous system – Benzodiazepines. Palliative Care Formulary 5. (pp. 214-215)
  • Twycross, R., Wilcock, A., Howard, P. (2014). Central nervous system – Phenobarbital. Palliative Care Formulary 5. (pp. 383)

Palliative Care Guidelines