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The Richmond Agitation-Sedation Scale modified for palliative care inpatients (RASS-PAL): a pilot study exploring validity and feasibility in clinical practice

Shirley H Bush123*, Pamela A Grassau2, Michelle N Yarmo2, Tinghua Zhang4, Samantha J Zinkie2 and José L Pereira123

Author Affiliations

1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada

2 Bruyère Research Institute, Ottawa, Canada

3 Department of Palliative Care, Bruyère Continuing Care, 43 Bruyère Street, K1N 5C8 Ottawa, Ontario, Canada

4 Ottawa Hospital Research Institute, Methods Centre, Ottawa, OT, Canada

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BMC Palliative Care 2014, 13:17  doi:10.1186/1472-684X-13-17

Published: 31 March 2014



The Richmond Agitation-Sedation Scale (RASS), which assesses level of sedation and agitation, is a simple observational instrument which was developed and validated for the intensive care setting. Although used and recommended in palliative care settings, further validation is required in this patient population. The aim of this study was to explore the validity and feasibility of a version of the RASS modified for palliative care populations (RASS-PAL).


A prospective study, using a mixed methods approach, was conducted. Thirteen health care professionals (physicians and nurses) working in an acute palliative care unit assessed ten consecutive patients with an agitated delirium or receiving palliative sedation. Patients were assessed at five designated time points using the RASS-PAL. Health care professionals completed a short survey and data from semi-structured interviews was analyzed using thematic analysis.


The inter-rater intraclass correlation coefficient range of the RASS-PAL was 0.84 to 0.98 for the five time points. Professionals agreed that the tool was useful for assessing sedation and was easy to use. Its role in monitoring delirium however was deemed problematic. Professionals felt that it may assist interprofessional communication. The need for formal education on why and how to use the instrument was highlighted.


This study provides preliminary validity evidence for the use of the RASS-PAL by physicians and nurses working in a palliative care unit, specifically for assessing sedation and agitation levels in the management of palliative sedation. Further validity evidence should be sought, particularly in the context of assessing delirium.

Palliative care; Richmond Agitation-Sedation Scale (RASS); Palliative sedation; Agitation; Delirium