Sintomas refratários e o manejo farmacológico na sedação paliativa: uma revisão narrativa

Abstract

This work synthesizes, through a narrative review, the scientific knowledge on palliative sedation in patients with advanced diseases, focusing on its indications, pharmacological therapy, and monitoring. It is ethically distinguished from euthanasia by aiming to relieve suffering, previously considered intractable, and not to shorten life. The study identifies the main refractory symptoms, such as delirium, dyspnea, and psycho-existential suffering, which justify the intervention. The analysis of pharmacological management shows that, despite the heterogeneity in clinical practice, midazolam is consolidated as a first-line drug, while options such as levomepromazine, phenobarbital, propofol, and dexmedetomidine constitute second and third-line alternatives, reserved for more complex cases, following the principle of proportionality to titrate the lowest effective dose. The monitoring of sedation depth and symptomatic relief relies predominantly on observational clinical scales, such as the Richmond Agitation-Sedation Scale and the Ramsay Sedation Scale, which highlights the lack of validated tools for the palliative care context. It is concluded that palliative sedation is an indispensable practice; however, it is based more on consensus and observational studies than on robust evidence, which makes future research, such as randomized clinical trials and scale validation studies, urgent to improve and standardize protocols and ensure safe and dignified care at the end of life.