alliative sedation is used in the field of hospice and palliative medicine for the management of refractory symptoms; however, common mis- conceptions persist in the medical community and general public regarding its use. Palliative sedation can be an effective tool for controlling symptoms unre- sponsive to multiple forms of aggressive palliative in- terventions. Yet, without clear guidelines and proper informed consent, palliative sedation may cross some important ethical boundaries in medical practice. A lack of unifying terminology and clear indications to define the process has complicated clinical use and research. This article reviews definitions and clarifies important concepts underlying the practice of pallia- tive sedation so that it can be implemented in an ethi- cal, legal, and medically safe manner as needed. TERMINOLOGY AND DEFINITIONS One of the most prominent early terms for the use of medicines to sedate a dying patient was “terminal sedation,” and this term is still commonly used to refer to this practice. 1 Because of the word “terminal” and its obvious negative connotations, some believe this term implies that the goal of sedation is death instead of a means to control difficult symptoms; thus, this termi- nology has fallen out of favor in the palliative medicine literature. “Total sedation” has also been used, 2 but as the procedure becomes more refined, some have called for describing varying levels of sedation (eg, deep or total sedation versus light or intermittent seda- tion). 3 The emerging unifying term has become pallia- tive sedation. 4,5 The word “palliative” originates from the Latin word palliatus, meaning “to be cloaked or shielded.” This helps to reinforce that the goal of pal- liative sedation is to relieve symptoms through seda- tion. Palliative sedation can be defined as a procedure to provide relief of intractable symptoms (ie, physical, psychologic, spiritual) by inducing an intentional state of decreased consciousness without intending death. 6 Additional terms that have been used for palliative sedation are listed in Table 1. Chater et al 6 chose the term “sedation for the in- tractable distress in the dying” to describe palliative seda- tion and defined the procedure as deliberately inducing and maintaining deep sleep but not deliberately causing death in very specific circumstances: (1) for the relief of 1 or more intractable symptoms when all other possible interventions have failed and the patient is perceived to Dr. Sinclair is associate medical director and palliative medicine fellowship director, Kansas City Hospice and Palliative Care, Kansas City, MO. Dr. Stephenson is a clinical assistant professor, Wake Forest University School of Medicine, and medical director, Hospice and Palliative Care Center, Winston- Salem, NC. www.turner-white.com Hospital Physician March 2006 33 Clinical Review Article Palliative Sedation: Assessment, Management, and Ethics Christian T. Sinclair, MD Richard C. Stephenson, MD P TAKE HOME POINTS • Palliative sedation can be defined as a procedure to provide relief of intractable symptoms (ie, physical, psychological, or spiritual) by inducing an inten- tional state of decreased consciousness without in- tending death. • Palliative sedation should be considered only after all other interventions have failed for 1 or more in- tractable symptoms. • A palliative medicine physician and practitioners from other health care disciplines should be in- volved to assure that all possible interventions have been utilized. • Informed consent should be obtained from the patient, or if the patient lacks decision-making capacity, a surrogate decision maker. • Consider a trial of sedation for 24 to 48 hours to determine if sedation provides the symptom relief the patient desires. • Good documentation and communication are essential to avoid misunderstanding of the intent of palliative sedation.