COSMIN database

The use of observational scales to monitor symptom control and depth of sedation in patients requiring palliative sedation: A systematic review

Brinkkemper, T., van Norel, A. M., Szadek, K. M., Loer, S. A., Zuurmond, W. W., and Perez, R. S.
BACKGROUND: Palliative sedation is the intentional lowering of consciousness of a patient in the last phase of life to relieve suffering from refractory symptoms such as pain, delirium and dyspnoea.

AIM: In this systematic review, we evaluated the use of monitoring scales to assess the degree of control of refractory symptoms and/or the depth of the sedation.

DESIGN: A database search of PubMed and Embase was performed up to January 2010 using the search terms 'palliative sedation' OR 'terminal sedation'. Data sources: Retro- and prospective studies as well as reviews and guidelines containing information about monitoring of palliative sedation, written in the English, German or Dutch language were included.

RESULTS: The search yielded 264 articles of which 30 were considered relevant. Most studies focused on monitoring refractory symptoms (pain, fatigue or delirium) or the level of awareness to control the level of sedation. Four prospective and one retrospective study used scales validated in other settings: the Numeric Pain Rating Scale, the Visual Analogue Scale, the Memorial Delirium Assessment Scale, the Communication Capacity Scale and Agitation Distress Scale. Only the Community Capacity Scale was partially validated for use in a palliative sedation setting. One guideline described the use of a scale validated in another setting.

CONCLUSIONS: A minority of studies reported the use of observational scales to monitor the effect of palliative sedation. Future studies should be focused on establishing proper instruments, most adequate frequency and timing of assessment, and interdisciplinary evaluation of sedation depth and symptom control for palliative sedation
Publication year:
Symptom status:
Physical state
Adults (18-65)
Seniors (65+)
Certain infections and parasitic diseases and related symptoms
Diseases of and symptoms related to the blood and blood-forming organs and certain disorders involving the immune mechanism
Diseases of and symptoms related to the circulatory system
Diseases of and symptoms related to the digestive system
Diseases of and symptoms related to the genitourinary system
Diseases of and symptoms related to the nervous system
Diseases of and symptoms related to the respiratory system
Endocrine, nutritional and metabolic diseases and related symptoms
External causes of morbidity and mortality
Injury, poisoning and certain other consequences of external causes
Neoplasms and related symptoms
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
PRO / non-PRO:
Non-patient Reported Outcome
Patient Reported Outcome
Type of measurement instrument:
1 - Questionnaires
6 - Clinical rating scales
7 - Observations
Agitation Distress Scale
CCPOT - Critical-Care Pain Observation Tool
CCS - Communication Capacity Scale
ESAS - Edmonton Symptom Assessment System (versions: ESAS-PD - ESAS-Parkinson's Disease)
MDAS - Memorial Delirium Assessment Scale
RASS - Richmond Agitation Sedation Scale
RSS - Ramsay Sedation Scale
VAS - Visual Analogue Scale (versions: vertical; horizontal)