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Revised European Association for Palliative Care (EAPC) recommended framework on palliative sedation: An international Delphi study

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posted on 2023-05-26, 16:07 authored by Severine Marie SurgesSeverine Marie Surges, Holger Brunsch, Birgit Jaspers, Kathi Apostolidis, Antonella Cardone, Carlos Centeno, Nathan Cherny, Agnes Csikos, Robin Fainsinger, Eduardo Garralda, Julie Ling, Johan Menten, Sebastiano Mercadante, Daniela Mosoiu, Sheila Payne, Nancy Preston, Lieve Van den Block, Jeroen Hasselaar, Lukas Radbruch


As part of the Palliative Sedation project funded by the European Union’s Horizon 2020 programme (grant no. 825700) entitled Palliative Sedation (SC1-BHC-23-2018 A) (, the aim of our study was to revise and update the 2009 European Association for Palliative Care (EAPC) framework on palliative sedation. For this framework as for other guidelines on palliative sedation the general weakness of its methodological development and the lack of consensus on terminology and concepts has been criticized, and issues such as the complexity of assessing refractory symptoms or the differentiation between somatic, psychological and existential suffering have remained under controversial debate. 

For the new framework a rigid consensus methodology with a four-step Delphi procedure involving international experts and a European cancer patient organisation has been used. The development of the recommendations addressed all relevant methodological and content aspects of the Appraisal Guideline Research and Evaluation II (AGREE II), and the reporting was based on the standards for Conducting and Reporting Delphi Studies (CREDES).

To our knowledge, this is the first evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in the care of adult patients with life-limiting disease in all settings. It is structured into 42 statements and explanatory texts, for which a high or very high level of consensus has been reached among experts from 28 different countries with a broad range of professions, and a European patient organisation. It has been endorsed in January 2023 by the EAPC board of directors. The importance of patient autonomy is emphasised in all phases of the process. It provides guidance on the decision-making process and on the way palliative sedation should be administered, monitoring tools as well as a step-by-step pharmacological approach with a detailed description of recommended medications and a more detailed guide to hydration decision-making based on the recent literature.


European Union´s Horizon 2020 research and innovation programme under grant agree-ment No. 825700


Declaration of conflicts of interest

The authors declare that there is no conflict of interest.

Corresponding author email

Lead author country

  • Germany

Lead author job role

  • Higher Education Researcher

Lead author institution

Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany

Human Participants

  • No

Ethics statement

The study was approved by the Ethics Commission, University of Bonn, No. 268/20 (19 June 2020).

Terms agreed

  • Yes, I agree to Advance terms


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