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Surges SM, Brunsch H, Jaspers B, Apostolidis K, Cardone A, Centeno C, Cherny N, Csikós À, Fainsinger R, Garralda E, Ling J, Menten J, Mercadante S, Mosoiu D, Payne S, Preston N, Van den Block L, Hasselaar J, Radbruch L. Revised European Association for Palliative Care (EAPC) recommended framework on palliative sedation: An international Delphi study. Palliat Med 2024; 38:213-228. [PMID: 38297460 PMCID: PMC10865771 DOI: 10.1177/02692163231220225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability. AIM To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers. DESIGN Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure. SETTING European. PARTICIPANTS International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation. RESULTS A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms suffering used to encompass distressing physical and psychological symptoms as well as existential suffering and refractory to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided. CONCLUSIONS This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals.
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Affiliation(s)
- Séverine M Surges
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Holger Brunsch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Birgit Jaspers
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Department of Palliative Medicine, University Medicine Goettingen, Goettingen, Germany
| | | | - Antonella Cardone
- Cancer Patients Europe, Brussels, Belgium
- Pancreatic Cancer Europe, Brussels, Belgium
| | - Carlos Centeno
- ATLANTES Global Observatory of Palliative Care, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Nathan Cherny
- Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Àgnes Csikós
- Department of Primary Health Care, Department of Hospice-Palliative Care, University of Pecs Medical School, Pecs, Hungary
| | | | - Eduardo Garralda
- ATLANTES Global Observatory of Palliative Care, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Julie Ling
- European Association for Palliative Care, Vilvoorde, Belgium
| | - Johan Menten
- Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Sebastiano Mercadante
- Main Regional Centre for Pain Relief and Palliative/Supportive Care, La Maddalena Cancer Centre, Palermo, Italy
| | - Daniela Mosoiu
- Medical Faculty, Transilvania University, Brasov, Romania
- Education and National Development Department, Hospice Casa Sperantei, Brasov, Romania
| | - Sheila Payne
- International Observatory on End-of-Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Nancy Preston
- International Observatory on End-of-Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Lieve Van den Block
- VUB-UGhent End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jeroen Hasselaar
- Department of Primary Care, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
- Task Force on Palliative Sedation of the European Association for Palliative Care, Brussels, Belgium
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Task Force on Palliative Sedation of the European Association for Palliative Care, Brussels, Belgium
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Tan F, Li N, Wu Y, Zhang C. Palliative sedation determinants: systematic review and meta-analysis in palliative medicine. BMJ Support Palliat Care 2024; 13:e664-e675. [PMID: 37553203 PMCID: PMC10850834 DOI: 10.1136/spcare-2022-004085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 07/25/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The utilisation of palliative sedation is often favoured by patients approaching end of life due to the presence of multiple difficult-to-manage symptoms during the terminal stage. This study aimed to identify the determinants of the use of palliative sedation. METHODS To identify pertinent observational studies, a comprehensive search was performed in PubMed, Embase, Cochrane Library, and PsycINFO databases from their inception until March 2022. The methodological quality of the chosen prospective and retrospective cohort studies was assessed using the Newcastle Ottawa Scale, while the Agency for Healthcare Research and Quality was used to evaluate the methodological quality of the selected cross-sectional studies. For each potential determinant of interest, the collected data were synthesised and analysed, and in cases where data could not be combined, a narrative synthesis approach was adopted. RESULTS A total of 21 studies were analysed in this research, consisting of 4 prospective cohort studies, 7 retrospective cohort studies, and 10 cross-sectional studies. The findings indicated that several determinants were significantly associated with palliative sedation. These determinants included younger age, male gender, presence of tumours, dyspnoea, pain, delirium, making advanced medical end-of-life decisions, and dying in a hospital setting. CONCLUSIONS The findings of our review could help physicians identify patients who may need palliative sedation in advance and implement targeted interventions to reverse refractory symptoms, develop personalized palliative sedation programs, and ultimately improve the quality of palliative care services. TRIAL REGISTRATION PROSPERO registration number CRD42022324720.
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Affiliation(s)
- Fang Tan
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- Medicine Research Center, West China-PUMC C.C. Chen Institute of Health, West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Na Li
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- Medicine Research Center, West China-PUMC C.C. Chen Institute of Health, West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Wu
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- Medicine Research Center, West China-PUMC C.C. Chen Institute of Health, West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chuan Zhang
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- Medicine Research Center, West China-PUMC C.C. Chen Institute of Health, West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
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Tan F, Chen S, Huang L, Chen Y, Wu Y. Continuous palliative sedation in terminally ill patients with cancer: a retrospective observational cohort study from a Chinese palliative care unit. BMJ Open 2023; 13:e071859. [PMID: 37230518 DOI: 10.1136/bmjopen-2023-071859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE This study aimed to describe a 4-year practice of continuous palliative sedation (CPS) in a palliative medicine ward of an academic hospital in China. To compare the survival time of patients with cancer with and without CPS during end-of-life care, we used the propensity score matching method and explored potential patient-related factors. DESIGN A retrospective observational cohort study. SETTING The palliative ward at a tertiary teaching hospital between January 2018 and 10 May 2022, in Chengdu, Sichuan, China. PARTICIPANTS The palliative care unit had 1445 deaths. We excluded 283 patients who were sedated on admission due to mechanical ventilation or non-invasive ventilators, 122 patients who were sedated due to epilepsy and sleep disorders, 69 patients without cancer, 26 patients who were younger than 18 years, 435 patients with end-of-life intervention when the patients' vital signs were unstable and 5 patients with unavailable medical records. Finally, we included 505 patients with cancer who met our requirements. MAIN OUTCOME MEASURES The survival time and analysis of sedation potential factors between the two groups were compared. RESULTS The total prevalence of CPS was 39.7%. Patients who were sedated more commonly experienced delirium, dyspnoea, refractory existential or psychological distress, and pain. After propensity score matching, the median survival was 10 (IQR: 5-17.75) and 9 days (IQR: 4-16) with and without CPS, respectively. After matching, the two survival curves of the sedated and non-sedated groups were no different (HR 0.82; 95% CI 0.64 to 0.84; log-rank p=0.10). CONCLUSIONS Developing countries also practise palliative sedation. Median survival was not different between patients who were and were not sedated.
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Affiliation(s)
- Fang Tan
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shan Chen
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lan Huang
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yang Chen
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Wu
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
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Ridley A, Vial-Cholley E, Robert G, Jounis-Jahan F, Lervat C, Betremieux P, Viallard ML, Frache S, Cojean N. Nationwide Study of Continuous Deep Sedation Practices Among Pediatric Palliative Care Teams. J Pain Symptom Manage 2023; 65:308-317. [PMID: 36528187 DOI: 10.1016/j.jpainsymman.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/16/2022]
Abstract
CONTEXT Palliative sedation practices evolved in France when the Claeys-Leonetti law passed in 2016 authorized patient-requested continuous deep sedation (CDS) until death. Its implementation in the pediatric setting is less frequently encountered and can pose several clinical and ethical challenges for health care teams and families. OBJECTIVES Our study aimed to describe CDS requests and practices of patients receiving specialized pediatric palliative care in France since its legalization in 2016. METHODS We conducted a nationwide multicentric, descriptive, retrospective study using a self-report questionnaire completed by all Pediatric Palliative Care (PPC) Teams that were involved in a CDS case between January 2017 and December 2019. RESULTS Six PPC teams had cared for six patients that had requested CDS, predominantly male adolescents/young adults diagnosed with a solid tumour. The refractory symptoms were diverse (pain, bleeding, and sensory loss) and always coupled with psycho-existential suffering. Each request was analyzed in multidisciplinary collegial meetings. Parental consent was always obtained regardless of age. Sedation typically required the use of multiple drugs including Midazolam (n = 5 cases), Chlorpromazine (n = 3), Ketamine (n = 2), and Propofol (n = 2). Despite close monitoring, achieving a satisfactory level of deep sedation was challenging and most patients unexpectedly awoke during CDS. Death occurred between 27 and 96 hours after induction. CONCLUSION Managing patient-requested CDS in pediatrics is challenging due to its rarity, multi-factorial refractory symptoms and drug tolerance despite polytherapy. Few recommendations exist to guide CDS practice for pediatricians. Further studies investigating pediatric CDS practices across various cultural and legal settings, refractory symptom management and specific pharmacology are warranted.
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Affiliation(s)
- Ashley Ridley
- Necker Enfants Malades Children's Hospital, Pediatric Palliative Care Team (A.R., M.L.V.), Paris, France.
| | | | - Guillaume Robert
- Pediatric Palliative Care Team Bretagne (G.R.), Rennes, France; University of Rennes 1 (G.R.), Rennes, France
| | | | - Cyril Lervat
- Pediatric Palliative Care Team Hauts de France (C.L.), Lille, France; Pediatric, Adolescent and Young Adult Oncology Unit (C.L.), Oscar Lambret Centre, Lille, France
| | - Pierre Betremieux
- French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
| | - Marcel-Louis Viallard
- Necker Enfants Malades Children's Hospital, Pediatric Palliative Care Team (A.R., M.L.V.), Paris, France
| | - Sandra Frache
- Pediatric Palliative Care Team Franche-Comté (S.F.), Besançon, France; French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
| | - Nadine Cojean
- Pediatric Palliative Care Team Alsace (N.C.), Strasbourg, France; French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
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Vivat B, Twycross R. CSD Continuous Sedation Until Death; A Response to Changing Practices in the Use of Continuous Sedation at the End of Life: A Systematic Review of the Literature (Heijltjes et al., 2020). J Pain Symptom Manage 2022; 63:e139-e141. [PMID: 34562594 DOI: 10.1016/j.jpainsymman.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry (B.V.), University College London, London, UK.
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Heijltjes MT, Morita T, Mori M, Heckel M, Klein C, Stiel S, Miccinesi G, Deliens L, Robijn L, Stone P, Sykes N, Hui D, Krishna L, van Delden JJM, van der Heide A, Rietjens JAC. Physicians' Opinion and Practice With the Continuous Use of Sedatives in the Last Days of Life. J Pain Symptom Manage 2022; 63:78-87. [PMID: 34333097 DOI: 10.1016/j.jpainsymman.2021.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 11/18/2022]
Abstract
CONTEXT There are few international studies about the continuous use of sedatives (CUS) in the last days of life. OBJECTIVES We aim to describe the experiences and opinions regarding CUS of physicians caring for terminally ill patients in seven countries. METHODS Questionnaire study about practices and experiences with CUS in the last days of life among physicians caring for terminally ill patients in Belgium (n = 175), Germany (n = 546), Italy (n = 214), Japan (n = 513), the Netherlands (n = 829), United Kingdom (n = 114) and Singapore (n = 21). RESULTS The overall response rate was 22%. Of the respondents, 88-99% reported that they had clinical experience of CUS in the last 12 months. More than 90% of respondents indicated that they mostly used midazolam for sedation. The use of sedatives to relieve suffering in the last days of life was considered acceptable in cases of physical suffering (87%-99%). This percentage was lower but still substantial in cases of psycho-existential suffering in the absence of physical symptoms (45%-88%). These percentages were lower when the prognosis was at least several weeks (22%-66% for physical suffering and 5%-42% for psycho-existential suffering). Of the respondents, 10% or less agreed with the statement that CUS is unnecessary because suffering can be alleviated with other measures. A substantial proportion (41%-95%) agreed with the statement that a competent patient with severe suffering has the right to demand the use of sedatives in the last days of life. CONCLUSION Many respondents in our study considered CUS acceptable for the relief of physical and psycho-existential suffering in the last days of life. The acceptability was lower regarding CUS for psycho-existential suffering and regarding CUS for patients with a longer life expectancy.
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Affiliation(s)
- Madelon T Heijltjes
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care (M.T.H., J.J.M.V.D.), UMC Utrecht, Utrecht, The Netherlands.
| | - Tatsuya Morita
- Palliative and Supportive Care Division (T.M., M.M.), Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Masanori Mori
- Palliative and Supportive Care Division (T.M., M.M.), Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Maria Heckel
- Department of Palliative Medicine (M.H., C.K.), CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine (M.H., C.K.), CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stephanie Stiel
- Hannover Medical School (S.S.), Institute for General Practice and Palliative Care, Düsseldorf, Germany
| | - Guido Miccinesi
- Oncological network (G.M.), Prevention and Research Institute-ISPRO, Firenze, Italy
| | - Luc Deliens
- Vrije Universiteit Brussel (L.D.), Ixelles, Belgium
| | - Lenzo Robijn
- Department of Public Health and Primary Care (L.R.), Ghent University, Ghent, Belgium
| | - Patrick Stone
- Marie Curie Palliative Care Research Department (P.S., N.S.), University College London, London, United Kingdom
| | - Nigel Sykes
- Marie Curie Palliative Care Research Department (P.S., N.S.), University College London, London, United Kingdom
| | - David Hui
- MD Anderson Cancer Center (D.H.), University of Texas, Texas, USA
| | | | - Johannes J M van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care (M.T.H., J.J.M.V.D.), UMC Utrecht, Utrecht, The Netherlands
| | - Agnes van der Heide
- Erasmus MC (A.V.D.H., J.A.C.R.), University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Judith A C Rietjens
- Erasmus MC (A.V.D.H., J.A.C.R.), University Medical Center Rotterdam, Rotterdam, The Netherlands
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Refractory psycho-existential distress and continuous deep sedation until death in palliative care: The French perspective. Palliat Support Care 2021; 18:486-494. [PMID: 31551106 DOI: 10.1017/s1478951519000816] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Since February 2016, French Claeys-Leonetti law has recognized patients' right to confront incurable diseases with short-term prognosis and refractory physical or psychological or existential symptoms by requesting continuous deep sedation until death (CDSUD). Determining when psychological or existential distress is refractory and unbearable remains complex and controversial.This review provides a comprehensive thought on CDSUD for advanced incurable patients with refractory psychological and/or existential distress in palliative care settings. It offers guidance on psychiatric or psychological diagnosis for explaining patients' requests for CDSUD. METHOD A narrative literature review (2000-2019) was conducted on the MedLine search about the use of palliative sedation in cases of refractory psychological and/or existential distress. RESULTS (1) Definitions of "refractory symptom," "refractory psychological distress," and "refractory existential distress" are inconsistent; (2) alternative diagnoses might obscure or be obscured by psycho-existential distress; and (3) criteria on meanings, reasons for requests, decision-making processes, and functions are evolving in practice. SIGNIFICANCE OF RESULTS Before implementing CDSUD, palliative healthcare professionals should seek input from psycho-oncologists in palliative care. Mental health professionals should analyze and assess the reasons for psychological and/or existential distress, consider the intentionality processes of requests, and explore alternative diagnoses, such as depressive or adjustment disorders, demoralization syndrome, desire to hasten death, and desire for euthanasia. Therapeutic responses (e.g., pharmacological and psychotherapeutic) should be implemented before deciding that psycho-existential distress is refractory.
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Takla A, Savulescu J, Kappes A, Wilkinson DJC. British laypeople's attitudes towards gradual sedation, sedation to unconsciousness and euthanasia at the end of life. PLoS One 2021; 16:e0247193. [PMID: 33770083 PMCID: PMC7997648 DOI: 10.1371/journal.pone.0247193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/02/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Many patients at the end of life require analgesia to relieve pain. Additionally, up to 1/5 of patients in the UK receive sedation for refractory symptoms at the end of life. The use of sedation in end-of-life care (EOLC) remains controversial. While gradual sedation to alleviate intractable suffering is generally accepted, there is more opposition towards deliberate and rapid sedation to unconsciousness (so-called "terminal anaesthesia", TA). However, the general public's views about sedation in EOLC are not known. We sought to investigate the general public's views to inform policy and practice in the UK. METHODS We performed two anonymous online surveys of members of the UK public, sampled to be representative for key demographic characteristics (n = 509). Participants were given a scenario of a hypothetical terminally ill patient with one week of life left. We sought views on the acceptability of providing titrated analgesia, gradual sedation, terminal anaesthesia, and euthanasia. We asked participants about the intentions of doctors, what risks of sedation would be acceptable, and the equivalence of terminal anaesthesia and euthanasia. FINDINGS Of the 509 total participants, 84% and 72% indicated that it is permissible to offer titrated analgesia and gradual sedation (respectively); 75% believed it is ethical to offer TA. Eighty-eight percent of participants indicated that they would like to have the option of TA available in their EOLC (compared with 79% for euthanasia); 64% indicated that they would potentially wish for TA at the end of life (52% for euthanasia). Two-thirds indicated that doctors should be allowed to make a dying patient completely unconscious. More than 50% of participants believed that TA and euthanasia were non-equivalent; a third believed they were. INTERPRETATION These novel findings demonstrate substantial support from the UK general public for the use of sedation and TA in EOLC. More discussion is needed about the range of options that should be offered for dying patients.
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Affiliation(s)
- Antony Takla
- Faculty of Medicine, Nursing and Health Science, Monash University, Clayton, Victoria, Australia
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, United Kingdom
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, United Kingdom
- Murdoch Children’s Research Institute, Melbourne, Australia
| | - Andreas Kappes
- School of Arts and Social Sciences, Department of Psychology, City University of London, London, United Kingdom
| | - Dominic J. C. Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, United Kingdom
- Murdoch Children’s Research Institute, Melbourne, Australia
- John Radcliffe Hospital, Oxford, United Kingdom
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Heino L, Stolt M, Haavisto E. The practices and attitudes of nurses regarding palliative sedation: A scoping review. Int J Nurs Stud 2020; 117:103859. [PMID: 33545642 DOI: 10.1016/j.ijnurstu.2020.103859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/12/2020] [Accepted: 12/20/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Palliative sedation is used as a last-resort option to treat refractory symptoms of dying patients. Nurses are important participants in the process of sedation. However, little is known about palliative sedation from a nursing perspective. OBJECTIVES To analyze the practices and attitudes of nurses concerning palliative sedation. DATA SOURCES AND REVIEW METHODS A scoping review guided by Arksey and O`Malley`s methodological framework was used to analyze existing peer-reviewed empirical research on the topic of the practices and attitudes of nurses related to the palliative sedation of patients aged 18 years and older. Of the 316 publications identified from the PubMed, CINAHL and Cochrane Library, 17 full-text articles were included in this review. The data of the included articles were charted (author(s), year of publication, country, objectives, study design, data collection, setting, respondents, definition of palliative sedation, focus of the study and key findings), and the results were summarized with inductive content analysis. The PRISMA-ScR checklist was used as a guideline for the reporting in this review. RESULTS During the decision-making concerning the start of palliative sedation, nurses usually have an advocatory and supportive role, although the role varies between different countries. This role then changes to a relatively independent performance of sedation; including administration of the medication, monitoring the effectiveness of sedation, and in some cases taking decisions concerning the medication and dosage policy. Further, nurses provide information and compassionate care to both the patient and the family during the process of palliative sedation. Most nurses view palliative sedation as a positive and sometimes necessary last resort therapy to relieve refractory suffering of dying patients. However, sedation poses ethical problems for many nurses. These problems especially concern the essential elements of deciding to use palliative sedation, the depth of sedation, the potential for shortening life, and the loss of social interaction. CONCLUSIONS Nurses play a key role in palliative sedation, as they often perform sedation independently and have important information about the needs and wishes of both patients and their families due to their unique position at the bedside of the patient. Although nurses generally see palliative sedation as a positive practice for selected patients, many of them feel it is ethically controversial. This scoping review reveals a great need for further research and discussion on the practices and attitudes of nurses regarding palliative sedation.
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Affiliation(s)
- Linda Heino
- Bachelor of Health Sciences, Department of Nursing Science, University of Turku, Turku, Finland.
| | - Minna Stolt
- Department of Nursing Science, University of Turku, Turku and Turku University Hospital, Turku, Finland
| | - Elina Haavisto
- Department of Nursing Science, University of Turku, Turku and Satakunta Central Hospital, Pori, Finland
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Robijn L, Deliens L, Rietjens J, Pype P, Chambaere K. Barriers in the Decision Making About and Performance of Continuous Sedation Until Death in Nursing Homes. THE GERONTOLOGIST 2020; 60:916-925. [PMID: 31850500 DOI: 10.1093/geront/gnz165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES While decision making about and performance of continuous sedation involve many challenges, they appear to be particularly pervasive in nursing homes. This study aims to identify barriers to the decision making and performance of continuous sedation until death in Flemish nursing homes as experienced by the health care professionals involved. RESEARCH DESIGN AND METHODS Ten focus groups were held with 71 health care professionals including 16 palliative care physicians, 42 general practitioners, and 13 nursing home staff. Discussions were transcribed verbatim and analyzed using a constant comparative approach. RESULTS Perceived barriers concerned factors prior to and during sedation and were classified according to three types: (a) personal barriers related to knowledge and skills including the lack of clarity on what continuous sedation should be used for (linguistic ambiguity) and when and how it should be used (practical ambiguity); (b) relational barriers concerning communication and collaboration both between health care professionals and with family; (c) organizational barriers related to the organization of care in nursing homes where, for example, there is no on-site physician, or where the recommended medication is not always available. DISCUSSION AND IMPLICATIONS The findings suggest there are considerable challenges for sound decision making about and performance of continuous sedation until death in nursing homes. There is a need for multicomponent initiatives that provide guidance in the context of the complexity of a resident's medical situation, the family, and the specific organization of care, which would have the potential to facilitate and improve the decision-making process and performance of continuous sedation in nursing homes.
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Affiliation(s)
- Lenzo Robijn
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Judith Rietjens
- Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, the Netherlands
| | - Peter Pype
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
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Heijltjes MT, van Thiel GJMW, Rietjens JAC, van der Heide A, de Graeff A, van Delden JJM. Changing Practices in the Use of Continuous Sedation at the End of Life: A Systematic Review of the Literature. J Pain Symptom Manage 2020; 60:828-846.e3. [PMID: 32599152 DOI: 10.1016/j.jpainsymman.2020.06.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/14/2020] [Indexed: 01/10/2023]
Abstract
CONTEXT The use of continuous sedation until death (CSD) has been highly debated for many years. It is unknown how the use of CSD evolves over time. Reports suggest that there is an international increase in the use of CSD for terminally ill patients. OBJECTIVE To gain insight in developments in the use of CSD in various countries and subpopulations. METHODS We performed a search of the literature published between January 2000 and April 2020, in PubMed, Embase, CINAHL, PsycInfo, and the Cochrane Library by using the Preferred reporting items for systematic review and meta-analysis protocols guidelines. The search contained the following terms: continuous sedation, terminal sedation, palliative sedation, deep sedation, end-of-life sedation, sedation practice, and sedation until death. RESULTS We found 23 articles on 16 nationwide studies and 38 articles on 37 subpopulation studies. In nationwide studies on frequencies of CSD in deceased persons varied from 3% in Denmark in 2001 to 18% in The Netherlands in 2015. Nationwide studies indicate an increase in the use of CSD. Frequencies of CSD in the different subpopulations varied too widely to observe time trends. Over the years, more studies reported on the use of CSD for nonphysical symptoms including fear, anxiety, and psycho-existential distress. In some studies, there was an increase in requests for sedation of patients from their families. CONCLUSIONS The frequency of CSD seems to increase over time, possibly partly because of an extension of indications for sedation, from mainly physical symptoms to also nonphysical symptoms.
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Affiliation(s)
- Madelon T Heijltjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Ghislaine J M W van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alexander de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, The Netherlands and Academic Hospice Demeter, De Bilt, The Netherlands
| | - Johannes J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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12
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Benítez-Rosario MA, Ascanio-León B. Palliative sedation: beliefs and decision-making among Spanish palliative care physicians. Support Care Cancer 2020; 28:2651-2658. [PMID: 31637516 DOI: 10.1007/s00520-019-05086-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/16/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe physician attitudes to deep palliative sedation. METHODS A nationwide e-survey of Spanish palliative care specialists was performed using vignettes which described patients close to death with intractable symptoms. Sedation levels were defined according to the Richmond Agitation-Sedation Scale. Multivariate analyses were performed to assess the explanatory factors involved in decision-making. RESULTS Responses of 292 palliative care specialists were analyzed (response rate 40%). Ninety-four percent, 87%, and 81% of the respondents supported the use of palliative sedation in cases of irreversible refractory symptoms as hyperactive delirium and dyspnea at rest secondary to lung cancer and GOLD stage IV COPD; 60% agreed with the use of palliative sedation in cases of existential suffering. Logistic regression analysis found as the explanatory factor in not performing palliative sedation the physicians' belief that sedation therapy constitutes undercover euthanasia (OR = 12, p < 0.01). Around 80% of physicians who decided on palliative sedation chose deep/complete sedation for every vignette; there were no common explanatory factors for decision-making for every vignette. The belief that sedation therapy equates to undercover euthanasia justifies not performing deep sedation in cases of irreversible refractory agitated delirium (OR = 7) and irreversible intractable dyspnea (OR = 6). Physician background in palliative care and sedation were associated with the selection of deep/complete sedation in cases of refractory delirium and cancer-associated dyspnea. CONCLUSIONS Spanish palliative physicians generally agree with the use of deep sedation as a proportionate treatment in dying patients with refractory symptoms. Decision-making is associated with physician beliefs regarding euthanasia and with the physician's background in palliative care and sedation.
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Affiliation(s)
- Miguel Angel Benítez-Rosario
- Palliative Care Unit, La Candelaria Hospital, Canary Health Service, Facultad de Medicina, Universidad de La Laguna, Crtra del Rosario 145, 38010, Santa Cruz de Tenerife, Spain.
| | - Belén Ascanio-León
- Palliative Care Unit, La Candelaria Hospital, Canary Health Service, Facultad de Medicina, Universidad de La Laguna, Crtra del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
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13
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Ziegler S, Schmid M, Bopp M, Bosshard G, Puhan MA. Using sedative substances until death: A mortality follow-back study on the role of healthcare settings. Palliat Med 2019; 33:213-220. [PMID: 30516090 DOI: 10.1177/0269216318815799] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: In the last decade, the use of sedative substances to keep a patient in deep sedation until death increased fourfold in German-speaking Switzerland, where every third patient admitted to hospital, palliative care unit or hospice died continuously deeply sedated. Aim: To investigate sedation practices across healthcare settings and to identify their associations with conventional symptom control. Design: National mortality follow-back study in Switzerland between 2013 and 2014. Questionnaires on medical end-of-life decisions were sent to attending physicians of a continuous random sample of all registered deaths aged 1 year or older. Setting/participants: Of all sampled deaths, 3678 individuals who died non-suddenly and not through an external cause were included. Results: Across settings, continuous deep sedation appeared more likely in patients aged younger than 65 years (odds ratio range: 1.53–2.34) and as part of or after intensified alleviation of pain and symptoms (odds ratio range: 1.90–10.27). In hospitals, sedation was less likely for cancer patients (odds ratio: 0.7, 95% confidence interval: 0.5–1.0, p = 0.022). In nursing homes, sedation was more likely for people who were married (odds ratio: 1.8, 95% confidence interval 1.3–2.5, p = 0.001). Conclusion: In all settings, sedated patients have significantly more pain problems compared to patients not receiving sedation. Large differences between settings seem to indicate different patient populations, different levels of professionals’ palliative care experience and different availability of treatment options. Our study suggests that certain patient groups who may be as vulnerable to refractory pain and symptoms as others are less likely to receive continuous deep sedation until death when warranted.
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Affiliation(s)
- Sarah Ziegler
- 1 Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Margareta Schmid
- 1 Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Matthias Bopp
- 1 Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Georg Bosshard
- 2 Clinic for Geriatric Medicine, University Hospital Zurich and Centre on Aging and Mobility, University of Zurich and City Hospital Waid, Zurich, Switzerland
| | - Milo Alan Puhan
- 1 Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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14
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Abstract
'Palliation sedation' is a widely used term to describe the intentional administration of sedatives to reduce a dying person's consciousness to relieve intolerable suffering from refractory symptoms. Research studies generally focus on either 'continuous sedation until death' or 'continuous deep sedation'. It is not always clear whether instances of secondary sedation (i.e. caused by specific symptom management) have been excluded. Continuous deep sedation is controversial because it ends a person's 'biographical life' (the ability to interact meaningfully with other people) and shortens 'biological life'. Ethically, continuous deep sedation is an exceptional last resort measure. Studies suggest that continuous deep sedation has become 'normalized' in some countries and some palliative care services. Of concern is the dissonance between guidelines and practice. At the extreme, there are reports of continuous deep sedation which are best described as non-voluntary (unrequested) euthanasia. Other major concerns relate to its use for solely non-physical (existential) reasons, the under-diagnosis of delirium and its mistreatment, and not appreciating that unresponsiveness is not the same as unconsciousness (unawareness). Ideally, a multiprofessional palliative care team should be involved before proceeding to continuous deep sedation. Good palliative care greatly reduces the need for continuous deep sedation.
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15
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Badarau DO, De Clercq E, Elger BS. Continuous Deep Sedation and Euthanasia in Pediatrics: Does One Really Exclude the Other for Terminally Ill Patients? THE JOURNAL OF MEDICINE AND PHILOSOPHY 2019; 44:50-70. [PMID: 30649451 DOI: 10.1093/jmp/jhy033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Debates on morally acceptable and lawful end-of-life (EOL) practices in pediatrics were reignited by the recent amendment in Belgian law to allow euthanasia for minors of any age who meet the criteria for capacity. Euthanasia and its legalization in pediatrics are often opposed based on the availability of aggressive palliative sedation. For terminally ill patients, this type of sedation is often identified as continuous and deep sedation until death (CDS). We demonstrate that this reasoning is based on flawed assumptions: (1) CDS is a morally preferable alternative to euthanasia; (2) CDS can meet the same patient needs as euthanasia; (3) children lack the capacity and experience to make EOL decisions; (4) unlike euthanasia, CDS does not raise capacity issues. Our aim is not to reject CDS as a valid option at the EOL, nor to offer a clear-cut defense of euthanasia for minors, but to emphasize the ethical issues with both practices.
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16
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Ziegler S, Schmid M, Bopp M, Bosshard G, Puhan MA. Continuous Deep Sedation Until Death-a Swiss Death Certificate Study. J Gen Intern Med 2018; 33:1052-1059. [PMID: 29560568 PMCID: PMC6025678 DOI: 10.1007/s11606-018-4401-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/14/2017] [Accepted: 03/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND In the last decade, the number of patients continuously deeply sedated until death increased up to fourfold. The reasons for this increase remain unclear. OBJECTIVE To identify socio-demographic and clinical characteristics of sedated patients, and concurrent possibly life-shortening medical end-of-life decisions. DESIGN Cross-sectional death certificate study in German-speaking Switzerland in 2001 and 2013. PARTICIPANTS Non-sudden and expected deaths (2001: N = 2281, 2013: N = 2256) based on a random sample of death certificates and followed by an anonymous survey on end-of-life practices among attending physicians. MAIN MEASURES Physicians' reported proportion of patients continuously deeply sedated until death, socio-demographic and clinical characteristics, and possibly life-shortening medical end-of life decisions. KEY RESULTS In 2013, physicians sedated four times more patients continuously until death (6.7% in 2001; 24.5.5% in 2013). Four out of five sedated patients died in hospitals, outside specialized palliative care units, or in nursing homes. Sedation was more likely among patients younger than 65 (odds ratio 2.24, 95% CI 1.6 to 3.2) and those dying in specialized palliative care (OR 2.2, 95% CI 1.3 to 3.8) or in hospitals (1.7, 95% CI 1.3 to 2.3). Forgoing life-prolonging treatment with the explicit intention to hasten or not to postpone death combined with intensified alleviation of symptoms was very strongly associated with continuous deep sedation (OR 6.8, 95% CI 4.7 to 9.8). CONCLUSIONS In Swiss clinical practice, continuously deeply sedated patients predominantly died outside specialized palliative care. The increasing trend over time appears to be related to changes in medical end-of-life practice rather than to patient's clinical characteristics.
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Affiliation(s)
- Sarah Ziegler
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
| | - Margareta Schmid
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Georg Bosshard
- Clinic for Geriatric Medicine, Zurich University Hospital, Zurich, Switzerland
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
- City Hospital Waid, Zurich, Switzerland
| | - Milo Alan Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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17
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Lokker ME, Swart SJ, Rietjens JAC, van Zuylen L, Perez RSGM, van der Heide A. Palliative sedation and moral distress: A qualitative study of nurses. Appl Nurs Res 2018; 40:157-161. [PMID: 29579492 DOI: 10.1016/j.apnr.2018.02.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/06/2018] [Accepted: 02/12/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clinical nursing practice may involve moral distress, which has been reported to occur frequently when nurses care for dying patients. Palliative sedation is a practice that is used to alleviate unbearable and refractory suffering in the last phase of life and has been linked to distress in nurses. AIM The aim of this study was to explore nurses' reports on the practice of palliative sedation focusing on their experiences with pressure, dilemmas and morally distressing situations. METHODS In-depth interviews with 36 nurses working in hospital, nursing home or primary care. RESULTS Several nurses described situations in which they felt that administration of palliative sedation was in the patient's best interest, but where they were constrained from taking action. Nurses also reported on situations where they experienced pressure to be actively involved in the provision of palliative sedation, while they felt this was not in the patient's best interest. The latter situation related to (1) starting palliative sedation when the nurse felt not all options to relieve suffering had been explored yet; (2) family requesting an increase of the sedation level where the nurse felt that this may involve unjustified hastening of death; (3) a decision by the physician to start palliative sedation where the patient had previously expressed an explicit wish for euthanasia. CONCLUSIONS Nurses experienced moral distress in situations where they were not able to act in what they believed is the patient's best interest. Situations involving moral distress require nurses to be well informed and able to adequately communicate with suffering patients, distressed family and physicians.
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Affiliation(s)
- M E Lokker
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands; Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands.
| | - S J Swart
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - J A C Rietjens
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - L van Zuylen
- Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands
| | - R S G M Perez
- Department of Anesthesiology, VUmc, Amsterdam, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
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19
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Ziegler S, Merker H, Schmid M, Puhan MA. The impact of the inpatient practice of continuous deep sedation until death on healthcare professionals' emotional well-being: a systematic review. BMC Palliat Care 2017; 16:30. [PMID: 28482856 PMCID: PMC5422916 DOI: 10.1186/s12904-017-0205-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 04/26/2017] [Indexed: 12/01/2022] Open
Abstract
Background The practice of continuous deep sedation is a challenging clinical intervention with demanding clinical and ethical decision-making. Though current research indicates that healthcare professionals’ involvement in such decisions is associated with emotional stress, little is known about sedation-related emotional burden. This study aims to systematically review the evidence on the impact of the inpatient practice of continuous deep sedation until death on healthcare professionals’ emotional well-being. Methods A systematic review of literature published between January 1990 and October 2016 was performed following a predefined protocol. MEDLINE, EMBASE, PubMed, Cochrane Library, CINAHL, Scopus, and PsycINFO were searched using search terms within “end-of-life care”, “sedation”, and “emotional well-being”. Dissertations and reference lists were screened by hand. Two independent reviewers conducted study selection, data extraction and quality assessment. We abstracted measures of psychological outcomes, which were related to the practice of continuous deep sedation until death, including emotional well-being, stress and exhaustion. We used the GRADE approach to rate the quality of evidence. Results Three studies remained out of 528 publications identified. A total of 3′900 healthcare professionals (82% nurses, 18% physicians) from Japan (n = 3384) and the Netherlands (n = 16) were included. The prevalence of sedation-related burden in nurses varied from 11 to 26%, depending on outcome measure. Physicians showed medium levels of emotional exhaustion and low levels of depersonalization. Common clinical concerns contributing to professionals’ burden were diagnosing refractory symptoms and sedation in the context of possibly life-shortening decisions. Non-clinical challenges included conflicting wishes between patients and families, disagreements within the care team, and insufficient professionals’ skills and coping. Due to the limited results and heterogeneity in outcome measure, the GRADE ratings for the quality of evidence were low. Conclusions Current evidence does not suggest that practicing continuous deep sedation is generally associated with lower emotional well-being of healthcare professionals. Higher emotional burden seems more likely when professionals struggled with clinical and ethical justifications for continuous deep sedation. This appeared to be in part a function of clinical experience. Further research is needed to strengthen this evidence, as it is likely that additional studies will change the current evidence base.
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Affiliation(s)
- Sarah Ziegler
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland.
| | - Hannes Merker
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland
| | - Margareta Schmid
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland
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20
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Abarshi E, Rietjens J, Robijn L, Caraceni A, Payne S, Deliens L, Van den Block L. International variations in clinical practice guidelines for palliative sedation: a systematic review. BMJ Support Palliat Care 2017; 7:223-229. [PMID: 28432090 DOI: 10.1136/bmjspcare-2016-001159] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 01/09/2017] [Accepted: 04/01/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Palliative sedation is a highly debated medical practice, particularly regarding its proper use in end-of-life care. Worldwide, guidelines are used to standardise care and regulate this practice. In this review, we identify and compare national/regional clinical practice guidelines on palliative sedation against the European Association for Palliative Care (EAPC) palliative sedation Framework and assess the developmental quality of these guidelines using the Appraisal Guideline Research and Evaluation (AGREE II) instrument. METHODS Using the PRISMA criteria, we searched multiple databases (PubMed, CancerLit, CINAHL, Cochrane Library, NHS Evidence and Google Scholar) for relevant guidelines, and selected those written in English, Dutch and Italian; published between January 2000 and March 2016. RESULTS Of 264 hits, 13 guidelines-Belgium, Canada (3), Ireland, Italy, Japan, the Netherlands, Norway, Spain, Europe, and USA (2) were selected. 8 contained at least 9/10 recommendations published in the EAPC Framework; 9 recommended 'pre-emptive discussion of the potential role of sedation in end-of-life care'; 9 recommended 'nutrition/hydration while performing sedation' and 8 acknowledged the need to 'care for the medical team'. There were striking differences in terminologies used and in life expectancy preceding the practice. Selected guidelines were conceptually similar, comparing closely to the EAPC Framework recommendations, albeit with notable variations. CONCLUSIONS Based on AGREE II, 3 guidelines achieved top scores and could therefore be recommended for use in this context. Also, domains 'scope and purpose' and 'editorial independence' ranked highest and lowest, respectively-underscoring the importance of good reportage at the developmental stage.
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Affiliation(s)
- Ebun Abarshi
- International Observatory on End-of-Life Care, Lancaster, United Kingdom
| | - Judith Rietjens
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands.,End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Lenzo Robijn
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Augusto Caraceni
- Fondazione IRCCS Instituto Nazionale dei Tumori, Milan, Italy.,European Palliative Care Research Center, Norwegian University of Science and Technology Trondheim Norway, EAPC Research Network
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster, United Kingdom
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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21
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A systematic literature review on the ethics of palliative sedation: an update (2016). Curr Opin Support Palliat Care 2016; 10:201-7. [DOI: 10.1097/spc.0000000000000224] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Cripe LD, Perkins SM, Cottingham A, Tong Y, Kozak MA, Mehta R. Physicians in Postgraduate Training Characteristics and Support of Palliative Sedation for Existential Distress. Am J Hosp Palliat Care 2016; 34:697-703. [PMID: 27432319 DOI: 10.1177/1049909116660516] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Palliative sedation for refractory existential distress (PS-ED) is ethically troubling but potentially critical to quality end-of-life (EOL) care. Physicians' in postgraduate training support toward PS-ED is unknown nor is it known how empathy, hope, optimism, or intrinsic religious motivation (IRM) affect their support. These knowledge gaps hinder efforts to support physicians who struggle with patients' EOL care preferences. METHODS One hundred thirty-four postgraduate physicians rated their support of PS for refractory physical pain (PS-PP) or PS-ED, ranked the importance of patient preferences in ethically challenging situations, and completed measures of empathy, hope, optimism, and IRM. Predictors of PS-ED and PS-PP support were examined using binary and multinomial logistic regression. RESULTS Only 22.7% of residents were very supportive of PS-ED, and 82.0% were very supportive of PS-PP. Support for PS-PP or PS-ED did not correlate with levels of empathy, hope, optimism, or IRM; however, for residents with lower IRM, greater optimism was associated with greater PS-ED support. In contrast, among residents with higher IRM, optimism was not associated with PS-ED support. CONCLUSIONS Comparing current results to published surveys, a similar proportion of residents and practicing physicians support PS-ED and PS-PP. In contrast to practicing physicians, however, IRM does not directly influence residents' supportiveness. The interaction between optimism and IRM suggests residents' beliefs and characteristics are salient to their EOL decisions. End-of-life curricula should provide physicians opportunities to reflect on the personal and ethical factors that influence their support for PS-ED.
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Affiliation(s)
- Larry D Cripe
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA.,2 IU Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | - Susan M Perkins
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA.,2 IU Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | - Ann Cottingham
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA
| | - Yan Tong
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA
| | - Mary Ann Kozak
- 3 Purdue University School of Pharmacy, West Lafayette, IN, USA
| | - Rakesh Mehta
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA.,2 IU Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
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23
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Robijn L, Cohen J, Rietjens J, Deliens L, Chambaere K. Trends in Continuous Deep Sedation until Death between 2007 and 2013: A Repeated Nationwide Survey. PLoS One 2016; 11:e0158188. [PMID: 27337064 PMCID: PMC4918927 DOI: 10.1371/journal.pone.0158188] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 06/10/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuous deep sedation until death is a highly debated medical practice, particularly regarding its potential to hasten death and its proper use in end-of-life care. A thorough analysis of important trends in this practice is needed to identify potentially problematic developments. This study aims to examine trends in the prevalence and practice characteristics of continuous deep sedation until death in Flanders, Belgium between 2007 and 2013, and to study variation on physicians' degree of palliative training. METHODS Population-based death certificate study in 2007 and 2013 in Flanders, Belgium. Reporting physicians received questionnaires about medical practices preceding the patient's death. Patient characteristics, clinical characteristics (drugs used, duration, artificial nutrition/hydration, intention and consent), and palliative care training of attending physician were recorded. We posed the following question regarding continuous deep sedation: 'Was the patient continuously and deeply sedated or kept in a coma until death by the use of one or more drugs'. RESULTS After the initial rise of continuous deep sedation to 14.5% in 2007 (95%CI 13.1%-15.9%), its use decreased to 12.0% in 2013 (95%CI 10.9%-13.2%). Compared with 2007, in 2013 opioids were less often used as sole drug and the decision to use continuous deep sedation was more often preceded by patient request. Compared to non-experts, palliative care experts more often used benzodiazepines and less often opioids, withheld artificial nutrition/hydration more often and performed sedation more often after a request from or with the consent of the patient or family. CONCLUSION Worldwide, this study is the first to show a decrease in the prevalence of continuous deep sedation. Despite positive changes in performance and decision-making towards more compliance with due care requirements, there is still room for improvement in the use of recommended drugs and in the involvement of patients and relatives in the decision-making process.
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Affiliation(s)
- Lenzo Robijn
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Judith Rietjens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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Ethical dilemmas faced by hospice nurses when administering palliative sedation to patients with terminal cancer. Palliat Support Care 2016; 15:148-157. [PMID: 27323872 DOI: 10.1017/s1478951516000419] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Palliative sedation is a method of symptom management frequently used in hospices to treat uncontrolled symptoms at the end of life. There is a substantial body of literature on this subject; however, there has been little research into the experiences of hospice nurses when administering palliative sedation in an attempt to manage the terminal restlessness experienced by cancer patients. METHOD Semistructured interviews were conducted with a purposive sample of seven hospice nurses who had cared for at least one patient who had undergone palliative sedation within the past year in a hospice in the south of England in the United Kingdom. A phenomenological approach and Colaizzi's stages of analysis were employed to develop themes from the data. RESULTS Facilitating a "peaceful death" was the primary goal of the nurses, where through the administration of palliative sedation they sought to enable and support patients to be "comfortable," "relaxed," and "calm" at the terminal stage of their illness. Ethical dilemmas related to decision making were a factor in achieving this. These were: medication decisions, "juggling the drugs," "causing the death," sedating young people, the family "requesting" sedation, and believing that hospice is a place where death is hastened. SIGNIFICANCE OF RESULTS Hospice nurses in the U.K. frequently encounter ethical and emotional dilemmas when administering palliative sedation. Making such decisions about using palliative sedation causes general discomfort for them. Undertaking this aspect of care requires confidence and competence on the part of nurses, and working within a supportive hospice team is of fundamental importance in supporting this practice.
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den Hartogh G. Continuous deep sedation and homicide: an unsolved problem in law and professional morality. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2016; 19:285-97. [PMID: 26715284 PMCID: PMC4880626 DOI: 10.1007/s11019-015-9680-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
When a severely suffering dying patient is deeply sedated, and this sedated condition is meant to continue until his death, the doctor involved often decides to abstain from artificially administering fluids. For this dual procedure almost all guidelines require that the patient should not have a life expectancy beyond a stipulated maximum of days (4-14). The reason obviously is that in case of a longer life-expectancy the patient may die from dehydration rather than from his lethal illness. But no guideline tells us how we should describe the dual procedure in case of a longer life-expectancy. Many arguments have been advanced why we should not consider it to be a form of homicide, that is, ending the life of the patient (with or without his request). I argue that none of these arguments, taken separately or jointly, is persuasive. When a commission, even one that is not itself life-shortening, foreseeably renders a person unable to undo the life-shortening effects of another, simultaneous omission, the commission and the omission together should be acknowledged to kill her. I discuss the legal and ethical implications of this conclusion.
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Affiliation(s)
- Govert den Hartogh
- Department of Philosophy, University of Amsterdam, Staten Bolwerk 16, 2011 ML, Haarlem, The Netherlands.
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van Deijck RHPD, Hasselaar JGJ, Verhagen SCAHHVM, Vissers KCP, Koopmans RTCM. Patient-Related Determinants of the Administration of Continuous Palliative Sedation in Hospices and Palliative Care Units: A Prospective, Multicenter, Observational Study. J Pain Symptom Manage 2016; 51:882-9. [PMID: 26921495 DOI: 10.1016/j.jpainsymman.2015.12.327] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/16/2015] [Accepted: 12/23/2015] [Indexed: 11/25/2022]
Abstract
CONTEXT Knowledge of determinants that are associated with the administration of continuous palliative sedation (CPS) helps physicians identify patients who are at risk of developing refractory symptoms, thereby enabling proactive care planning. OBJECTIVES This study aims to explore which patient-related factors at admission are associated with receiving CPS later in the terminal phase of life. METHODS A prospective multicenter observational study was performed in six Dutch hospices and three nursing home-based palliative care units. The association between patient-related variables at admission (age, gender, diagnosis, use of opioids or psycholeptics, number of medications, Karnofsky Performance Status scale score, Edmonton Symptom Assessment System distress score, and Glasgow Coma Scale score) and the administration of CPS at the end of life was analyzed. RESULTS A total of 467 patients died during the study period, of whom 130 received CPS. In univariate analysis, statistically significant differences were noted between the sedated and nonsedated patients with respect to younger age (P = 0.009), malignancy as a diagnosis (P = 0.05), higher Karnofsky Performance Status score (P = 0.03), the use of opioids (P < 0.001), the use of psycholeptics (P = 0.003), and higher Edmonton Symptom Assessment System distress score (P = 0.05). Multivariate logistic regression analysis showed that only the use of opioids at admission (odds ratio 1.90; 95% confidence interval 1.18-3.05) was significantly associated with the administration of CPS. CONCLUSION Physicians should be aware that patients who use opioids at admission have an increased risk for the administration of CPS at the end of life. In this group of patients, a comprehensive personalized care plan starting at admission is mandatory to try to prevent the development of refractory symptoms. Further research is recommended, to identify other determinants of the administration of CPS and to investigate which early interventions will be effective to prevent the need for CPS in patients at high risk.
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Affiliation(s)
| | - Jeroen G J Hasselaar
- Department of Anesthesiology, Pain and Palliative Medicine, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Stans C A H H V M Verhagen
- Department of Anesthesiology, Pain and Palliative Medicine, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; De Waalboog "Joachim en Anna", Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
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No Negative Impact of Palliative Sedation on Relatives' Experience of the Dying Phase and Their Wellbeing after the Patient's Death: An Observational Study. PLoS One 2016; 11:e0149250. [PMID: 26871717 PMCID: PMC4752210 DOI: 10.1371/journal.pone.0149250] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 01/28/2016] [Indexed: 11/19/2022] Open
Abstract
Background Palliative sedation is the widely-used intervention of administering sedating agents to induce a state of unconsciousness to take away a dying patient’s perception of otherwise irrelievable symptoms. However, it remains questionable whether this ethically complex intervention is beneficial for patients and whether the associated lack of communication in the last phase of life has a negative impact on relatives’ wellbeing. Methods An observational questionnaire study was conducted among relatives of a consecutive sample of patients who died a non-sudden death in the Erasmus MC Cancer Institute or in the hospice ‘Laurens Cadenza’ (both in Rotterdam) between 2010 and 2013. Results Relatives filled in questionnaires regarding 151 patients who had been sedated and 90 patients who had not been sedated. The median time since all patients had passed away was 21 (IQR 14–32) months. No significant differences were found in relatives´ assessments of the quality of end-of-life care, patients´ quality of life in the last week before death and their quality of dying, between patients who did and did not receive sedation, or in relatives’ satisfaction with their own life, their general health and their mental wellbeing after the patient’s death. Conclusions The use of sedation in these patients appears to have no negative effect on bereaved relatives’ evaluation of the patient’s dying phase, or on their own wellbeing after the patient’s death.
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Robijn L, Chambaere K, Raus K, Rietjens J, Deliens L. Reasons for continuous sedation until death in cancer patients: a qualitative interview study. Eur J Cancer Care (Engl) 2015; 26. [PMID: 26515814 DOI: 10.1111/ecc.12405] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 11/28/2022]
Abstract
End-of-life sedation, though increasingly prevalent and widespread, remains a highly debated medical practice in the context of palliative medicine. This qualitative study aims to look more specifically at how health care workers justify their use of continuous sedation until death and which factors they report as playing a part in the decision-making process. In-depth interviews were held with 28 physicians and 22 nurses of 27 cancer patients in Belgium who had received continuous sedation until death in hospitals, palliative care units or at home. Our findings indicate that medical decision-making for continuous sedation is not only based on clinical indications but also related to morally complex issues such as the social context and the personal characteristics and preferences of individual patient and their relatives. The complex role of non-clinical factors in palliative sedation decision-making needs to be further studied to assess which medically or ethically relevant arguments are underlying daily clinical practice. Finally, our findings suggest that in some cases continuous sedation was resorted to as an alternative option at the end of life when euthanasia, a legally regulated option in Belgium, was no longer practically possible.
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Affiliation(s)
- L Robijn
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - K Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - K Raus
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Bioethics Institute Ghent, Department of Philosophy and Moral Science, Ghent University, Ghent, Belgium
| | - J Rietjens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - L Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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Hoek P, Grandjean I, Verhagen CAHHVM, Jansen-Landheer MLEA, Schers HJ, Galesloot C, Vissers KCP, Engels Y, Hasselaar JG. Addressing Palliative Sedation during Expert Consultation: A Descriptive Analysis of the Practice of Dutch Palliative Care Consultation Teams. PLoS One 2015; 10:e0136309. [PMID: 26301746 PMCID: PMC4547749 DOI: 10.1371/journal.pone.0136309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 08/02/2015] [Indexed: 11/24/2022] Open
Abstract
Main Objective Since palliative sedation is considered a complex intervention, consultation teams are increasingly established to support general practice. This study aims to offer insight into the frequency and characteristics of expert consultations regarding palliative sedation. Methods We performed a retrospective analysis of a longitudinal database. This database contained all patient-related consultations by Dutch Palliative Care Consultation teams, that were requested between 2004 and 2011. We described the frequency and characteristics of these consultations, in particular of the subgroup of consultations in which palliative sedation was addressed (i.e. PSa consultations). We used multivariate regression analysis to explore consultation characteristics associated with a higher likelihood of PSa consultations. Main Results and Their Significance Of the 44,443 initial consultations, most were requested by general practitioners (73%) and most concerned patients with cancer (86%). Palliative sedation was addressed in 18.1% of all consultations. Palliative sedation was relatively more often discussed during consultations for patients with a neurologic disease (OR 1.79; 95% CI: 1.51–2.12) or COPD (OR 1.39; 95% CI: 1.15–1.69) than for patients with cancer. We observed a higher likelihood of PSa consultations if the following topics were also addressed during consultation: dyspnoea (OR 1.30; 95% CI: 1.22–1.40), agitation/delirium (OR 1.57; 95% CI: 1.47–1.68), exhaustion (OR 2.89; 95% CI: 2.61–3.20), euthanasia-related questions (OR 2.65; 95% CI: 2.37–2.96) or existential issues (OR 1.55; 95% CI: 1.31–1.83). Conclusion In conclusion, PSa consultations accounted for almost one-fifth of all expert consultations and were associated with several case-related characteristics. These characteristics may help clinicians in identifying patients at risk for a more complex disease trajectory at the end of life.
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Affiliation(s)
- Patrick Hoek
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- * E-mail:
| | - Ilse Grandjean
- Comprehensive Cancer Centre the Netherlands, Utrecht, the Netherlands
| | | | | | - Henk J. Schers
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Cilia Galesloot
- Comprehensive Cancer Centre the Netherlands, Utrecht, the Netherlands
| | - Kris C. P. Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen G.J. Hasselaar
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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Abarshi E, Rietjens J, Caraceni A, Payne S, Deliens L, Van Den Block L. Towards a standardised approach for evaluating guidelines and guidance documents on palliative sedation: study protocol. BMC Palliat Care 2014; 13:34. [PMID: 25028571 PMCID: PMC4099031 DOI: 10.1186/1472-684x-13-34] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 06/26/2014] [Indexed: 11/20/2022] Open
Abstract
Background Sedation in palliative care has received growing attention in recent years; and so have guidelines, position statements, and related literature that provide recommendations for its practice. Yet little is known collectively about the content, scope and methodological quality of these materials. According to research, there are large variations in palliative sedation practice, depending on the definition and methodology used. However, a standardised approach to comparing and contrasting related documents, across countries, associations and governmental bodies is lacking. This paper reports on a protocol designed to enable thorough and systematic comparison of guidelines and guidance documents on palliative sedation. Methods and design A multidisciplinary and international group of palliative care researchers, identified themes and clinical issues on palliative sedation based on expert consultations and evidence drawn from the EAPC (European Association of Palliative Care) framework for palliative sedation and AGREE II (Appraisal Guideline Research and Evaluation) instrument for guideline assessment. The most relevant themes were selected and built into a comprehensive checklist. This was tested on people working closely with practitioners and patients, for user-friendliness and comprehensibility, and modified where necessary. Next, a systematic search was conducted for guidelines in English, Dutch, Flemish, or Italian. The search was performed in multiple databases (PubMed, CancerLit, CNAHL, Cochrane Library, NHS Evidence and Google Scholar), and via other Internet resources. Hereafter, the final version of the checklist will be used to extract data from selected literature, and the same will be compiled, entered into SPSS, cleaned and analysed systematically for publication. Discussion We have together developed a comprehensive checklist in a scientifically rigorous manner to allow standardised and systematic comparison. The protocol is applicable to all guidelines on palliative sedation, and the approach will contribute to rigorous and systematic comparison of international guidelines on any challenging topic such as this. Results from the study will provide valuable insights into common core elements and differences between the selected guidelines, and the extent to which recommendations are derived from, or match those in the EAPC framework. The outcomes of the study will be disseminated via peer-reviewed journals and directly to appropriate audiences.
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Affiliation(s)
- Ebun Abarshi
- International Observatory on End-of-Life Care, Lancaster University, Lancaster LA1 4YG, UK
| | - Judith Rietjens
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands ; End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Augusto Caraceni
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy ; European Palliative Care Research Center, Trondheim Norway, EAPC Research Network, Milan, Italy
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster LA1 4YG, UK
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Vrije Universiteit Brussel (VUB), Brussels, Belgium ; Vrije University Medical Center, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Lieve Van Den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Vrije Universiteit Brussel (VUB), Brussels, Belgium ; Department of Family Medicine, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Bruinsma SM, Brown J, van der Heide A, Deliens L, Anquinet L, Payne SA, Seymour JE, Rietjens JAC. Making sense of continuous sedation in end-of-life care for cancer patients: an interview study with bereaved relatives in three European countries. Support Care Cancer 2014; 22:3243-52. [PMID: 25022759 DOI: 10.1007/s00520-014-2344-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 06/29/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of the study was to explore relatives' descriptions and experiences of continuous sedation in end-of-life care for cancer patients and to identify and explain differences between respondents from the Netherlands, Belgium, and the UK. METHODS In-depth interviews were held between January 2011 and May 2012 with 38 relatives of 32 cancer patients who received continuous sedation until death in hospitals, the community, and hospices/palliative care units. RESULTS Relatives' descriptions of the practice referred to the outcome, to practical aspects, and to the goals of sedation. While most relatives believed sedation had contributed to a 'good death' for the patient, yet many expressed concerns. These related to anxieties about the patient's wellbeing, their own wellbeing, and questions about whether continuous sedation had shortened the patient's life (mostly UK), or whether an alternative approach would have been better. Such concerns seemed to have been prompted by relatives witnessing unexpected events such as the patient coming to awareness during sedation. In the Netherlands and in Belgium, several relatives reported that the start of the sedation allowed for a planned moment of 'saying goodbye'. In contrast, UK relatives discerned neither an explicit point at which sedation was started nor a specific moment of farewell. CONCLUSIONS Relatives believed that sedation contributed to the patient having a good death. Nevertheless, they also expressed concerns that may have been provoked by unexpected events for which they were unprepared. There seems to exist differences in the process of saying goodbye between the NL/BE and the UK.
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Affiliation(s)
- S M Bruinsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands,
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Palliative sedation in Dutch general practice from 2005 to 2011: a dynamic cohort study of trends and reasons. Br J Gen Pract 2014; 63:e669-75. [PMID: 24152481 DOI: 10.3399/bjgp13x673676] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Little is known about the quantity and reasons for use of palliative sedation in general practice. AIM To gain more insight into the trends of and reasons for palliative sedation in Dutch general practice. DESIGN AND SETTING Dynamic cohort study using registrations and questionnaire data of Dutch GPs. Method Data collected in the years from 2005 until 2011 in the Dutch Sentinel General Practice Network were analysed. Trends and reasons for use of palliative sedation were analysed using multilevel analyses to control for clustering of observations within general practices. RESULTS From 2005-2011, 183 cases were reported from 56 general practices. The incidence of palliative sedation fluctuated between 33.7 per 100 000 patients in 2006 and 15.2 in 2011. No rise or decline during the period was observed. Palliative sedation was applied in 5.7% of all deaths and most frequently used in younger patients with cancer. The mean number of refractory symptoms was 2.6 (SD 1.2); pain (69.4%), dyspnoea (53.0%), and fear (39.3%). Patient involvement in decision making before the start of palliative sedation (87.4%) was less frequently present in patients suffering from cardiovascular or chronic obstructive pulmonary disease and in older patients compared to patients with cancer (P<0.05). Pending euthanasia requests were present in 20.8% of cases; the choice for palliative sedation in these cases was clearly motivated. CONCLUSION Palliative sedation is performed in a small proportion of dying patients in Dutch general practice, without a rise or decline observed from 2005 to 2011. Patients with non-cancer diseases are less frequently involved in decision making than patients with cancer, possibly related to sudden deterioration.
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Sercu M, Pype P, Christiaens T, Derese A, Deveugele M. Belgian general practitioners' perspectives on the use of palliative sedation in end-of-life home care: a qualitative study. J Pain Symptom Manage 2014; 47:1054-63. [PMID: 24095283 DOI: 10.1016/j.jpainsymman.2013.06.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 06/17/2013] [Accepted: 07/07/2013] [Indexed: 11/21/2022]
Abstract
CONTEXT Palliative sedation (PS) is a far-reaching palliative measure with a life-shortening potential. Guidelines provide only for a restricted use of PS and as a last resort. OBJECTIVES To explore PS practice in end-of-life (EoL) home care. METHODS This was a qualitative analysis of semi-structured interviews with 52 general practitioners (GPs) of Flanders, Belgium. RESULTS Apart from GPs who adhere to the existing prerequisites for PS, opinions diverge among GPs on the indication area for PS and on possible life-shortening intentions. The key to GPs' broadened view on "which suffering merits PS" is the fragile context of EoL home care, and the key to GPs' possible life-shortening intentions is their need to facilitate the dying process, when trying or lengthy. When honoring a terminally ill patient's request for euthanasia, several GPs prefer slow euthanasia using PS to a lethal injection. CONCLUSION PS home practice deviates from the PS guidelines' recommendations. In addition to the GPs' shortage of knowledge, the guidelines' recommendations do not always meet the particular needs of EoL home care. If one consideration of EoL home care is to respect a patient's wish to die at home, then the pre-emptive use of PS to avoid a futile transfer to the hospital in the case of an undesirable turn of events deserves more attention in the PS debate.
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Affiliation(s)
- Maria Sercu
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium.
| | - Peter Pype
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Thierry Christiaens
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Anselme Derese
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Myriam Deveugele
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
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The use of palliative sedation: A comparison of attitudes of French-speaking physicians from Quebec and Switzerland. Palliat Support Care 2014; 13:839-47. [PMID: 24825473 DOI: 10.1017/s1478951514000364] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Previous literature has suggested that laws and regulations may impact the use of palliative sedation. Our present study compares the attitudes of French-speaking physicians practicing in the Quebec and Swiss environments, where different laws are in place regarding physician-assisted suicide. METHOD Data were drawn from two prior studies, one by Blondeau and colleagues and another by Beauverd and coworkers, employing the same two-by-two experimental design with length of prognosis and type of suffering as independent variables. Both the effect of these variables and the effect of their interaction on Swiss and Quebec physicians' attitudes toward sedation were compared. The written comments of respondents were submitted to a qualitative content analysis and summarized in a comparative perspective. RESULTS The analysis of variance showed that only the type of suffering had an effect on physicians' attitudes toward sedation. The results of the Wilcoxon test indicated that the attitudes of physicians from Quebec and Switzerland tended to be different for two vignettes: long-term prognosis with existential suffering (p = 0.0577) and short-term prognosis with physical suffering (p = 0.0914). In both cases, the Swiss physicians were less prone to palliative sedation. SIGNIFICANCE OF RESULTS The attitudes of physicians from Quebec and Switzerland toward palliative sedation, particularly regarding prognosis and type of suffering, seem similar. However, the results suggest that physicians from Quebec could be slightly more open to palliative sedation, even though most were not in favor of this practice as an answer to end-of-life existential suffering.
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Abarshi EA, Papavasiliou ES, Preston N, Brown J, Payne S. The complexity of nurses' attitudes and practice of sedation at the end of life: a systematic literature review. J Pain Symptom Manage 2014; 47:915-925.e11. [PMID: 24075400 DOI: 10.1016/j.jpainsymman.2013.06.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 06/01/2013] [Accepted: 06/14/2013] [Indexed: 11/20/2022]
Abstract
CONTEXT Sedation is administered to some palliative care patients at the end of their life. Nurses play an important role in this practice. OBJECTIVES To systematically review the evidence on nurses' attitudes and practice of end-of-life sedation. METHODS We searched eight electronic databases, four key palliative care journals, and reference lists for empirical studies published in English, between 1990 and 2012, on nurses and their attitudes toward and practice of sedation until a patient's death. A total of 10 studies met the inclusion criteria. RESULTS Data were generated from 7515 nurses in four main settings (specialized palliative care unit, home, nursing home, and acute hospital) from seven countries (Belgium, Canada, Japan, The Netherlands, Norway, U.K., and U.S.). On average, the quality of the evidence was good; hence, we analyzed all selected studies. Based on the findings from a previous review, we categorized the emerging themes into: 1) important factors leading to the patient receiving palliative sedation (PS), 2) nurses' attitudes toward PS, and 3) nurses' experience of PS at the end of a patient's life. In general, nurses had a positive but cautious attitude toward the practice of PS. Most saw it as a last resort treatment for relieving suffering and refractory symptoms, and its practice was often influenced by their level of education, expertise, and the roles they played per setting. CONCLUSION Most nurses administered sedation until death only within the given circumstances because of the anticipatory benefits in controlling refractory symptoms and suffering. Some of them experienced burdens during PS delivery; these could be supported by operational guidelines and task-related training.
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Affiliation(s)
- Ebun A Abarshi
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom.
| | | | - Nancy Preston
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom
| | - Jayne Brown
- Centre for the Promotion of Excellence in Palliative Care, De Montfort University, Leicester, United Kingdom
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom
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Rietjens JAC, Voorhees JR, van der Heide A, Drickamer MA. Approaches to suffering at the end of life: the use of sedation in the USA and Netherlands. JOURNAL OF MEDICAL ETHICS 2014; 40:235-240. [PMID: 22982490 DOI: 10.1136/medethics-2012-100561] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Studies describing physicians' experiences with sedation at the end of life are indispensible for informed palliative care practice, but they are scarce. We describe the accounts of physicians from the USA and the Netherlands, two countries with different regulations on end-of-life decisions regarding their use of sedation. METHODS Qualitative face-to-face interviews were held in 2007-2008 with 36 physicians (18 from the Netherlands, 18 from the USA), including primary care physicians and specialists. We applied purposive sampling and conducted constant comparative analyses. RESULTS In both countries, the use of sedation was described in diverse terms, especially in the USA, and was often experienced as emotionally challenging. Respondents stated different and sometimes multiple intentions for their use of sedation. Besides alleviating severe suffering, most Dutch respondents justified its use by stating that it does not hasten death, while most American respondents indicated that it might hasten death but that this was justifiable as long as that was not their primary intention. While many Dutch respondents indicated that they initiated open discussions about sedation proactively to inform patients about their options and to allow planning, the accounts of American respondents showed fewer and less-open discussions, mostly late in the dying process and with the patient's relatives. CONCLUSIONS The justification for sedation and the openness with which it is discussed were found to differ in the accounts of respondents from the USA and the Netherlands. Further clarification of practices and research into the effect and effectiveness of the use of sedation is recommended to enhance informed reflection and policy making.
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Affiliation(s)
- Judith A C Rietjens
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
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Jylhänkangas L, Smets T, Cohen J, Utriainen T, Deliens L. Descriptions of euthanasia as social representations: comparing the views of Finnish physicians and religious professionals. SOCIOLOGY OF HEALTH & ILLNESS 2014; 36:354-368. [PMID: 24033568 DOI: 10.1111/1467-9566.12057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In many western societies health professionals play a powerful role in people's experiences of dying. Religious professionals, such as pastors, are also confronted with the issues surrounding death and dying in their work. It is therefore reasonable to assume that the ways in which death-related topics, such as euthanasia, are constructed in a given culture are affected by the views of these professionals. This qualitative study addresses the ways in which Finnish physicians and religious professionals perceive and describe euthanasia and conceptualises these descriptions and views as social representations. Almost all the physicians interviewed saw that euthanasia does not fit the role of a physician and anchored it to different kinds of risks such as the slippery slope. Most of the religious and world-view professionals also rejected euthanasia. In this group, euthanasia was rejected on the basis of a religious moral code that forbids killing. Only one of the religious professionals - the freethinker with an atheist world-view - accepted euthanasia and described it as a personal choice, as did the one physician interviewed who accepted it. The article shows how the social representations of euthanasia are used to protect professional identities and to justify their expert knowledge of death and dying.
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Abstract
PURPOSE OF REVIEW Physician-assisted suicide (PAS) and euthanasia have been increasingly discussed in end-of-life care, as PAS and euthanasia have now been legalized in three European countries and PAS has been legalized in Washington, Oregon, and Montana in the USA. This review focuses on some aspects of PAS and euthanasia and discusses deep terminal sedation (DTS), which is increasingly used to treat intractable symptoms at the end of life. RECENT FINDINGS PAS and euthanasia present potential risks for vulnerable populations, such as the depressed and disabled. The Oregon experience does not allow specific analysis regarding disabled patients, but fewer psychiatric consultations are being done to evaluate patients for depression. In the Netherlands, a small number of patients undergo euthanasia without an explicit request. Twenty percent of cases go unreported, raising questions of whether they met legal standards. The use of DTS in all countries has increased, but in a significant number of cases, DTS is used with an explicit intent to hasten death. Double-effect arguments to justify DTS may not actually apply. SUMMARY Caution is warranted regarding PAS and euthanasia, as vulnerable patients may still be at risk. More research is needed to characterize the use (and misuse) of DTS.
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Anquinet L, Rietjens J, van der Heide A, Bruinsma S, Janssens R, Deliens L, Addington-Hall J, Smithson WH, Seymour J. Physicians' experiences and perspectives regarding the use of continuous sedation until death for cancer patients in the context of psychological and existential suffering at the end of life. Psychooncology 2013; 23:539-46. [PMID: 24307235 PMCID: PMC4282582 DOI: 10.1002/pon.3450] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 09/07/2013] [Accepted: 10/21/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The use of continuous sedation until death for terminally ill cancer patients with unbearable and untreatable psychological and existential suffering remains controversial, and little in-depth insight exists into the circumstances in which physicians resort to it. METHODS Our study was conducted in Belgium, the Netherlands, and the UK in hospitals, PCUs/hospices, and at home. We held interviews with 35 physicians most involved in the care of cancer patients who had psychological and existential suffering and had been continuously sedated until death. RESULTS In the studied countries, three groups of patients were distinguished regarding the origin of their psychological and existential suffering. The first group had preexisting psychological problems before they became ill, the second developed psychological and existential suffering during their disease trajectory, and the third presented psychological symptoms that were characteristic of their disease. Before they resorted to the use of sedation, physicians reported that they had considered an array of pharmacological and psychological interventions that were ineffective or inappropriate to relieve this suffering. Necessary conditions for using sedation in this context were for most physicians the presence of refractory symptoms, a short life expectancy, and an explicit patient request for sedation. CONCLUSIONS Physicians in our study used continuous sedation until death in the context of psychological and existential suffering after considering several pharmacological and psychological interventions. Further research and debate are needed on how and by whom this suffering at the end of life should be best treated, taking into account patients' individual preferences.
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Affiliation(s)
- Livia Anquinet
- VUB-UGent End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
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van Deijck RH, Hasselaar JG, Verhagen SC, Vissers KC, Koopmans RT. Determinants of the Administration of Continuous Palliative Sedation: A Systematic Review. J Palliat Med 2013; 16:1624-32. [DOI: 10.1089/jpm.2013.0173] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Jeroen G.J. Hasselaar
- Department of Anesthesiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Kris C.P. Vissers
- Department of Anesthesiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Raymond T.C.M. Koopmans
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Bruinsma S, Rietjens J, van der Heide A. Palliative sedation: a focus group study on the experiences of relatives. J Palliat Med 2013; 16:349-55. [PMID: 23421537 DOI: 10.1089/jpm.2012.0410] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Most studies that have investigated the practice of palliative sedation have focused on physicians' practices and attitudes. OBJECTIVE The aim of this study was to explore relatives' experiences with palliative sedation and to gain more insight in positive and negative elements in their evaluation of palliative sedation. DESIGN Focus groups and individual interviews. SETTING Various care settings in the Netherlands. SUBJECTS A total of 14 relatives of patients who received palliative sedation until death participated. RESULTS Most relatives evaluated the provision of palliative sedation of their dying family member positively. Positive experiences were related to: the beneficial impact of palliative sedation on the patient's suffering, the opportunity that was offered to prepare for the patient's death, their involvement in the decision-making and care for the patient, and the pleasant care environment. However, the majority of the relatives were unsatisfied with one or more aspects of how information was being provided for. Some relatives were frustrated about the fact that nurses were not authorized to make decisions about the care for the patient and about the absence of physicians during weekends. None of the relatives mentioned the loss of the ability to communicate with the patient during the sedation and the possibility of "hastening death" as disadvantages of palliative sedation. CONCLUSION Relatives tend to evaluate the provision of palliative sedation to their severely suffering family member positively because it contributes to a peaceful dying process. However, relatives indicated discontent with how information was being provided and with the communication in general.
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Affiliation(s)
- Sophie Bruinsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
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Bruinsma SM, Rietjens JAC, Seymour JE, Anquinet L, van der Heide A. The experiences of relatives with the practice of palliative sedation: a systematic review. J Pain Symptom Manage 2012; 44:431-45. [PMID: 22658470 DOI: 10.1016/j.jpainsymman.2011.09.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 09/14/2011] [Accepted: 09/15/2011] [Indexed: 01/03/2023]
Abstract
CONTEXT Guidelines about palliative sedation typically include recommendations to protect the well-being of relatives. OBJECTIVES The aim of this study was to systematically review evidence on the experiences of relatives with the practice of palliative sedation. METHODS PubMed, Embase, Web of Science, PsycINFO, and CINAHL were searched for empirical studies on relatives' experiences with palliative sedation. We investigated relatives' involvement in the decision-making and sedation processes, whether they received adequate information and support, and relatives' emotions. RESULTS Of the 564 studies identified, 39 were included. The studies (30 quantitative, six qualitative, and three mixed methods) were conducted in 16 countries; three studies were based on relatives' reports, 26 on physicians' and nurses' proxy reports, seven on medical records, and three combined different sources. The 39 studies yielded a combined total of 8791 respondents or studied cases. Caregivers involved relatives in the decision making in 69%-100% of all cases (19 quantitative studies), and in 60%-100% of all cases, relatives were reported to have received adequate information (five quantitative studies). Only two quantitative studies reported on relatives' involvement in the provision of sedation. Despite the fact that the majority of relatives were reported to be comfortable with the use of palliative sedation (seven quantitative studies, four qualitative studies), several studies found that relatives were distressed by the use of sedation (five quantitative studies, five qualitative studies). No studies reported specifically about the support provided to the relatives. CONCLUSION Relatives' experiences with palliative sedation are mainly studied from the perspective of proxies, mostly professional caregivers. The majority of relatives seems to be comfortable with the use of palliative sedation; however, they may experience substantial distress by the use of sedation.
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Affiliation(s)
- Sophie M Bruinsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
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Anquinet L, Rietjens JAC, Seale C, Seymour J, Deliens L, van der Heide A. The practice of continuous deep sedation until death in Flanders (Belgium), the Netherlands, and the U.K.: a comparative study. J Pain Symptom Manage 2012; 44:33-43. [PMID: 22652134 DOI: 10.1016/j.jpainsymman.2011.07.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 07/11/2011] [Accepted: 07/20/2011] [Indexed: 11/20/2022]
Abstract
CONTEXT Existing empirical evidence shows that continuous deep sedation until death is given in about 15% of all deaths in Flanders, Belgium (BE), 8% in The Netherlands (NL), and 17% in the U.K. OBJECTIVES This study compares characteristics of continuous deep sedation to explain these varying frequencies. METHODS In Flanders, BE (2007) and NL (2005), death certificate studies were conducted. Questionnaires about continuous deep sedation and other decisions were sent to the certifying physicians of each death from a stratified sample (Flanders, BE: n=6927; NL: n=6860). In the U.K. in 2007-2008, questionnaires were sent to 8857 randomly sampled physicians asking them about the last death attended. RESULTS The total number of deaths studied was 11,704 of which 1517 involved continuous deep sedation. In Dutch hospitals, continuous deep sedation was significantly less often provided (11%) compared with hospitals in Flanders, BE (20%) and the U.K. (17%). In U.K. home settings, continuous deep sedation was more common (19%) than in Flanders, BE (10%) or NL (8%). In NL in both settings, continuous deep sedation more often involved benzodiazepines and lasted less than 24 hours. Physicians in Flanders combined continuous deep sedation with a decision to provide physician-assisted death more often. Overall, men, younger patients, and patients with malignancies were more likely to receive continuous deep sedation, although this was not always significant within each country. CONCLUSION Differences in the prevalence of continuous deep sedation appear to reflect complex legal, cultural, and organizational factors more than differences in patients' characteristics or clinical profiles. Further in-depth studies should explore whether these differences also reflect differences between countries in the quality of end-of-life care.
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Affiliation(s)
- Livia Anquinet
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium.
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Hoefler JM, Vejlgaard TB. Something's ironic in Denmark: An otherwise progressive welfare state lags well behind in care of patients at the end of life. Health Policy 2011; 103:297-304. [DOI: 10.1016/j.healthpol.2010.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 11/23/2010] [Accepted: 11/24/2010] [Indexed: 11/29/2022]
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Seymour J, Rietjens J, Brown J, van der Heide A, Sterckx S, Deliens L. The perspectives of clinical staff and bereaved informal care-givers on the use of continuous sedation until death for cancer patients: The study protocol of the UNBIASED study. BMC Palliat Care 2011; 10:5. [PMID: 21375747 PMCID: PMC3056823 DOI: 10.1186/1472-684x-10-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 03/04/2011] [Indexed: 11/29/2022] Open
Abstract
Background A significant minority of dying people experience refractory symptoms or extreme distress unresponsive to conventional therapies. In such circumstances, sedation may be used to decrease or remove consciousness until death occurs. This practice is described in a variety of ways, including: 'palliative sedation', 'terminal sedation', 'continuous deep sedation until death', 'proportionate sedation' or 'palliative sedation to unconsciousness'. Surveys show large unexplained variation in incidence of sedation at the end of life across countries and care settings and there are ethical concerns about the use, intentions, risks and significance of the practice in palliative care. There are also questions about how to explain international variation in the use of the practice. This protocol relates to the UNBIASED study (UK Netherlands Belgium International Sedation Study), which comprises three linked studies with separate funding sources in the UK, Belgium and the Netherlands. The aims of the study are to explore decision-making surrounding the application of continuous sedation until death in contemporary clinical practice, and to understand the experiences of clinical staff and decedents' informal care-givers of the use of continuous sedation until death and their perceptions of its contribution to the dying process. The UNBIASED study is part of the European Association for Palliative Care Research Network. Methods/Design To realize the study aims, a two-phase study has been designed. The study settings include: the domestic home, hospital and expert palliative care sites. Phase 1 consists of: a) focus groups with health care staff and bereaved informal care-givers; and b) a preliminary case notes review to study the range of sedation therapy provided at the end of life to cancer patients who died within a 12 week period. Phase 2 employs qualitative methods to develop 30 patient-centred case studies in each country. These involve interviews with staff and informal care-givers closely involved in the care of cancer patients who received continuous sedation until death. Discussion To our knowledge, this is one of the few studies which seek to take a qualitative perspective on clinical decision making surrounding the use of continuous sedation until death and the only one which includes the perspectives of nurses, physicians, as well as bereaved informal care-givers. It has several potential strengths, weaknesses, opportunities and threats associated with the specific design of the study, as well as with the sensitive nature of the topic and the different frameworks for ethical review in the participating countries.
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Affiliation(s)
- Jane Seymour
- School of Nursing, Midwifery and Physiotherapy, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.
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How the mass media report social statistics: a case study concerning research on end-of-life decisions. Soc Sci Med 2010; 71:861-8. [PMID: 20609508 DOI: 10.1016/j.socscimed.2010.05.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 05/21/2010] [Accepted: 05/28/2010] [Indexed: 11/23/2022]
Abstract
The issue of whether it is right to be concerned about the accuracy with which mass media report social scientific research is explored through a detailed case study of media reporting of two surveys of UK doctors' end-of-life decision-making. Data include press releases, emails and field notes taken during periods of media interest supplemented by a collection of print and broadcast media reports. The case study contributes to existing knowledge about the ways in which mass media establish, exaggerate and otherwise distort the meaning of statistical findings. Journalists ignored findings that did not fit into existing media interest in the 'assisted dying' story and were subject to pressure from interest groups concerned to promote their own interpretations and viewpoints. Rogue statistics mutated as they were set loose from their original research report context and were 'laundered' as they passed from one media report to another. Yet media accounts of the research, fuelling an already heated public debate about ethical issues in end-of-life care, arguably acted as a conduit for introducing new considerations into this debate, such as the role played by sedation at the end of life, the extent to which euthanasia is practiced outside the law, and the extent of medical opposition to the legalisation of assisted dying. The expectation that accuracy and comprehensiveness should be the sole criteria for judging journalists' reports is, finally, considered to be unrealistic and it is argued that social scientists need to understand and adapted to the conditions under which mass media reporting operates if they are to succeed in introducing the findings of social research into public debates.
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