Symptom burden profiles and applied medication strategies in the days before and after initiation of palliative sedation in advanced cancer patients: an international prospective multicentre observational study (PALSED)

BACKGROUND: Advanced cancer patients may experience refractory suffering at the end of life despite optimal symptom management. When symptoms can no longer be controlled, or not within an acceptable timeframe, palliative sedation may be indicated. However, evidence on symptom severity and pharmacological strategies before sedation remains limited. This study aimed to characterize symptom burden and medication use in the 24 h before and after initiation of palliative sedation. METHODS: In this prospective observational study, data were collected from adult cancer patients receiving palliative sedation at seven European care settings (hospital wards, hospices, and PCUs). Healthcare professionals documented symptoms, pharmacological management, and sedation characteristics. Symptom prevalence and severity was assessed by patients or proxies using the Edmonton Symptom Assessment System (ESAS). RESULTS: Among 80 patients with palliative sedation, multiple refractory symptoms were common at initiation; 81% had two or more symptoms. Dyspnoea (23%), delirium (18%), and exhaustion (16%) were the primary symptoms prompting sedation. ESAS data (n = 66) showed high prevalence of drowsiness, appetite loss, tiredness, and reduced wellbeing (73-91%), with severe burden scores (≥ 7) in 63-78%. Prior palliative sedation, patients with fewer symptoms (1-2) received a wider range of medications, including corticosteroids, cardiovascular agents, and anti-infectives, while those with ≥ 3 symptoms more often received anxiolytics, hypnotics, and sedatives. After initiation, most medications were discontinued; opioids were continued, and midazolam was the predominant continuously administered sedative. CONCLUSION: Refractory suffering often reflected overall clinical decline rather than isolated symptoms. While pre-sedation medication use varied, post-initiation strategies were consistent across patients.