# Palliative sedation for refractory suffering at the end of life

Source: https://onco.cc/protocols/palliative-sedation-for-refractory-suffering/  
OnCo record `palliative-sedation-for-refractory-suffering` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Very occasionally, near the end of life, suffering cannot be relieved by any other treatment. Palliative sedation uses medicines to make the person sleepy, only as deeply as needed to relieve the suffering. It is decided together with the person and their family, after specialist advice, and checked often.

## Summary

The revised EAPC framework (2024; 42 statements, all with high or very high Delphi consensus) defines palliative sedation as the proportionate, monitored lowering of consciousness for refractory suffering, refractory meaning that the professionals can no longer relieve it by other means and the patient finds it intolerable. Suffering includes physical and psychological symptoms and existential suffering. Consultation with palliative care or other experts to confirm refractoriness is strongly recommended before sedation. Proportionality governs both depth (titrate to the lowest dose that relieves suffering, keeping interaction where possible, rather than aiming straight at unconsciousness) and timing (intermittent, transient or respite sedation earlier in the illness; deep continuous sedation generally in the final stages). No life-expectancy threshold is set, and hydration is decided separately. Apart from emergencies, a planned interruption to reassess is recommended. The framework's stepwise drugs: midazolam first (deep sedation bolus 5 to 10 mg SC or 2.5 to 5 mg IV, then about 1 mg/h, titrated; halved with risk factors), lorazepam as an alternative, levomepromazine (or chlorpromazine) added at step 2, and propofol at step 3 under an anaesthetist's supervision. The Korean guideline (2020) grades palliative sedation for severe symptoms unresponsive to available treatments D IIb.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: terminal sedation; continuous deep sedation; proportional sedation; respite sedation; sedation for refractory symptoms; midazolam infusion at the end of life

## Connected records

- protocols: [Care in the last days of life: recognising dying, hydration, symptom control and anticipatory medicines](https://onco.cc/protocols/care-in-the-last-days-of-life/)
- technologies: [Early integrated palliative care](https://onco.cc/technologies/palliative-care/), [Syringe pumps and subcutaneous syringe drivers](https://onco.cc/technologies/syringe-drivers/)
- terms: [Care of dying adults in the last days of life](https://onco.cc/terms/last-days-of-life-care/), [Palliative sedation](https://onco.cc/terms/palliative-sedation/)

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