Best Practice: Standardized Monitoring in Palliative Sedation Therapy

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Richmond Agitation-Sedation Scale – Palliative Version (RASS-PAL)

The Richmond Agitation-Sedation Scale (RASS) is a simple observational instrument which was developed and validated for the intensive care setting.

RASS is commonly used and recommended in palliative care settings to assess sedation and distress levels in palliative care patients with lowered consciousness.

The RASS was adapted to the palliative care context in a recent study, which confirmed the validity and feasibility of the RASS-PAL.

Unlike the original RASS, the RASS-PAL does not require eliciting a patient’s response using painful or startling stimuli, in keeping with the aim of palliative sedation therapy: to administer the lightest sedation necessary for symptom relief.

Score Term Description
+4 Combative Overtly combative, violent, immediate danger to staff (e.g. throwing items); +/- attempting to get out of bed or chair
+3 Very agitated Pulls or removes lines (e.g. IV/SQ/Oxygen tubing) or catheter(s); aggressive, +/- attempting to get out of bed or chair
+2 Agitated Frequent non-purposeful movement, +/- attempting to get out of bed or chair
+1 Restless Occasional non-purposeful movement, but movements not aggressive or vigorous
0 Alert and calm
-1 Drowsy Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (10 seconds or longer)
-2 Light sedation Briefly awakens with eye contact to voice (less than 10 seconds)
-3 Moderate sedation Any movement (eye or body) or eye opening to voice (but no eye contact)
-4 Deep sedation No response to voice, but any movement (eye or body) or eye opening to stimulation by light touch
-5 Not rousable No response to voice or stimulation by light touch

Procedure for RASS-PAL

Observe patient for 20 seconds.

  • Patient is alert, restless, or agitated for more than 10 seconds. Note: If patient is alert, restless, or agitated for less than 10 seconds and is otherwise drowsy, then score patient according to your assessment for the majority of the observation period.
  

Score
0 to +4
If not alert, greet patient, call by name and say “open your eyes and look at me”.

  • Patient awakens with sustained eye opening and eye contact (10 seconds or longer).
  • Patient awakens with eye opening and eye contact, but not sustained (less than 10 seconds).
  • Patient has any eye or body movement in response to voice but no eye contact.
  

Score -1

Score -2

Score -3
When no response to verbal stimulation, physically stimulate patient by light touch e.g. gently shake shoulder.

  • Patient has any eye or body movement to gentle physical stimulation.
  • Patient has no response to any stimulation.
  

 

Score -4
Score -5
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PDF – Best Practice: Standardized Monitoring in Palliative Sedation Therapy

Sources:

Bush SH, Grassau PA, Yarmo MN, Zhang T, Zinkie SJ, Pereira JL: The Richmond Agitation-Sedation Scale modified for palliative care inpatients (RASS-PAL): a pilot study exploring validity and feasibility in clinical practice. BMC Palliative Care 2014, 13:17. 10.1186/1472-684X-13-17

Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, Tesoro EP, Elswick RK: The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002, 166: 1338-1344. 10.1164/rccm.2107138

Waterloo Wellington Interdisciplinary HPC Education Committee; PST Task Force (2015). The Waterloo Wellington Palliative Sedation Therapy Protocol. Canada: Author. Available at https://hpcconnection.ca/wp-content/uploads/2016/10/22916_palliativesedation_protocol_w.pdf