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The term" refractory" can be applied when a symptom cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness. For patients with advanced cancer, the designation of a symptom as refractory has profound implications, suggesting that suffering will not be relieved with routine measures. In deciding that a symptom is refractory, the clinician must perceive that further invasive and noninvasive interventions are either (a) incapable of providing adequate relief,(b) associated with excessive and intolerable acute or chronic morbidity, or (c) unlikely to provide relief within a tolerable time frame. Controlled sedation is routinely used to manage the severe pain and anxiety associated with noxious procedures, to enable patients to endure interventions that would otherwise be intolerable. The depth of sedation required is influenced by the nature of the …