Tension between continuous and deep sedation and assistance in dying: a national survey of intensive care professionals' perceptions

Deep Continuous Sedation Until Death and Experience of Relatives and Healthcare Providers: A Systematic Review

BACKGROUND

Continuous deep sedation until death (CDS) is a procedure commonly used in palliative care to alleviate refractory symptoms in terminally ill patients. This systematic review aims to explore the experiences of both healthcare providers (HCPs) and relatives regarding the use of CDS, highlighting emotional, ethical, and practical implications.

METHODS

A systematic search was conducted in six electronic databases (Embase, PsycINFO, PubMed, Scopus, Web of Science, Cairn). Studies were included if they focused on the experiences of HCPs and/or relatives related to CDS in terminally ill adults. The Crowe Critical Appraisal Tool (CCAT) was used to assess the quality in the included studies.

RESULTS

A total of 40 studies were included, comprising 9260 HCPs and 1062 relatives. The review identified four main themes: decision-making processes, emotional and psychological adjustment, ethical concerns regarding the distinction between CDS and medical assistance in dying and communication challenges. CDS was found to contribute to a "good death" from the perspective of many relatives, though concerns about hastening death were noted. Healthcare providers reported mixed emotions, including ethical dilemmas and emotional burden when administering CDS. Communication issues between families and healthcare teams were highlighted as key challenges.

CONCLUSIONS

CDS can alleviate suffering but raises ethical and communication challenges for both families and healthcare providers. Clearer guidelines, enhanced support systems, and improved communication strategies are essential for better CDS practices.

The experience of nurses when providing care across acts that may be perceived as death hastening: A qualitative evidence synthesis

BACKGROUND

Nurses can be involved in interventions that they perceive as hastening death. These interventions may intentionally cause death, as in the case of assisted dying or result in death as an unintended consequence, such as when life-sustaining treatment is withdrawn. There is increasing evidence regarding nurses' experiences of providing care in these separate contexts. However, it remains less clear whether parallels exist in experiences across various acts that nurses might consider death hastening.

AIM

To synthesise qualitative research findings on the lived experiences of nurses when involved with acts that may be perceived as death hastening.

DESIGN

A qualitative evidence synthesis utilising thematic synthesis.

DATA SOURCES

An initial search of CINHAL, PsychInfo and Medline was undertaken in December 2022 and updated in August 2024. Papers were quality assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research.

RESULTS

Twenty-three papers were included in the review. An overarching theme linked to the emotional labour required to provide care was developed. Three sub-themes influence emotional labour: (1) experiencing personal and professional conflicts, (2) the provision of 'normal(ised)' care and (3) perceptions of palliative care as a proxy for hastening death.

CONCLUSIONS

This synthesis demonstrates that nurses experience significant emotional labour across acts that may be perceived as death hastening. The level of emotional labour is influenced by nurses' uncertainty of the ethical and moral status of these interventions and navigating these uncertainties alongside colleagues, patients and those important to them during care delivery.

An easier way to die?-A qualitative interview study on specialist palliative care team members' views on dying under sedation

BACKGROUND

Professionals' personal perceptions of sedated patients in the context of palliative care may influence their opinion on sedation as treatment option. However, little is known of palliative care professionals' perception of patients dying under sedation.

AIM

To explore German specialist palliative care team members' views on and perception of the dying process under sedation.

DESIGN

Qualitative phenomenological study using semi-structured interviews (n = 59). Interviews took place in-person after recruitment via a contact person and were transcribed verbatim. Framework Analysis was used for analysis.

SETTING/PARTICIPANTS

Physicians, nurses, psychologists, physical therapists, chaplains, and social workers from 10 palliative care units and 7 specialist palliative homecare teams across 12 German cities.

RESULTS

Participants' views on patients dying under sedation can be grouped into: (i) those who perceived an influence of sedation on the dying process with and without positive and/or negative connotations and (ii) those who saw no difference between dying with or without sedation. Positive connotations referred to the perception of sedation providing an easier path. Concerns were mainly related to the deprivation of patients regarding a conscious dying. The metaphorical description of sedation as "sleep" was common among participants.

CONCLUSIONS

The wide range of perceptions of patients dying under sedation may be rooted in different judgements regarding aspects of a good death. Clarifying ideals of a good death with professionals, patients, and relatives before sedation may support transparent decision-making and help avoid conflicts or moral distress.

"How to navigate this new area": Intensive care clinicians' perceptions of voluntary assisted dying in the intensive care unit: A multisite exploratory study

BACKGROUND

There is growing momentum worldwide for assisted dying. In Australia, voluntary assisted dying may occur in any setting, including an intensive care unit (ICU). As the subject of much debate worldwide, exploring ICU clinicians' perceptions of assisted dying is essential.

AIM

The aim of this study was to explore clinicians' perceptions of and preparedness for voluntary assisted dying in the ICU.

METHOD

An exploratory qualitative descriptive design using individual interviews was used. Medical, nursing, and allied health clinicians from three ICUs were recruited. Interviews were conducted between Nov 2022 and Jan 2023, with a hypothetical scenario about voluntary assisted dying used to prompt discussion. Interviews were recorded, professionally transcribed, and analysed using inductive content analysis.

FINDINGS

ICU registered nurses (n = 20), physicians (n = 2), and allied health clinicians (n = 4) participated with interviews lasting 18-45 min (mean: 28 min). Analysis revealed four themes: (i) purpose of ICU reflected that ICU care was not all about saving lives, yet recognising dying and changing priorities was challenging; (ii) dying in the ICU is complex due to difficulties in talking about dying, accepting death as the outcome and evaluating care efficacy; (iii) voluntary assisted dying is a lot of grey because of perceived clinical and ethicolegal challenges; and finally, (iv) respecting choice was about respecting patients' values, beliefs, and autonomy, as well as clinicians' beliefs and right to exercise autonomy through conscientious objection.

CONCLUSION

Dying and death are inevitable, and views and perspectives about assisted dying will continue to evolve. Respecting patient choice is at the core of assisted dying, but respecting clinicians' perspectives and choice is equally important. With voluntary assisted dying now legal in all Australian states, ensuring ICU team and individual clinician preparedness through access to education, resources, and specialist support services is key to raising awareness and easing uncertainty about deaths through voluntary assisted dying.