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Ferraz-Gonçalves JA, Flores A, Silva AA, Simões A, Pais C, Melo C, Pirra D, Coelho D, Conde L, Real L, Feio M, Barbosa M, Martins MDL, Areias M, Muñoz-Romero R, Ferreira RC, Freitas S. Continuous Sedation in Palliative Care in Portugal: A Prospective Multicentric Study. J Palliat Care 2024:8258597241256874. [PMID: 38794900 DOI: 10.1177/08258597241256874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Objective: This study aimed to survey the practice of palliative sedation in Portugal, where data on this subject were lacking. Methods: This was a prospective multicentric study that included all patients admitted to each team that agreed to participate. Patients were followed until death, discharge, or after 3 months of follow-up. Results: The study included 8 teams: 4 as palliative care units (PCU), 1 as a hospital palliative care team (HPCT), 2 as home care (HC), and 1 as HPCT and HC. Of the 361 patients enrolled, 52% were male, the median age was 76 years, and 285 (79%) had cancer. Continuous sedation was undergone by 49 (14%) patients: 26 (53%) were male, and the median age was 76. Most patients, 46 (94%), had an oncological diagnosis. Only in a minority of cases, the family, 16 (33%), or the patient, 5 (10%), participated in the decision to sedate. Delirium was the most frequent symptom leading to sedation. The medication most used was midazolam (65%). In the multivariable analysis, only age and the combined score were independently associated with sedation; patients <76 years and those with higher levels of suffering had a higher probability of being sedated. Conclusions: The practice of continuous palliative sedation in Portugal is within the range reported in other studies. One particularly relevant point was the low participation of patients and their families in the decision-making process. Each team must have a deep discussion on this aspect.
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Affiliation(s)
| | - Alice Flores
- Department of Palliative Care, Unidade Local de Saúde do Nordeste, Macedo de Cavaleiros, Portugal
| | - Ana Abreu Silva
- Department of Palliative Care, Serviço de Saúde da Região Autónoma da Madeira (SESARAM), Funchal, Portugal
| | - Ana Simões
- Hospital Palliative Care Team and Home Care Unit, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Carmen Pais
- Clinical Academic Center of Trás-os-Montes and Alto Douro - Professor Doctor Nuno Grande - CACTMAD, Vila Real, Portugal
| | - Clarisse Melo
- Community Team of Palliative Care, ACES Lisboa Ocidental e Oeiras, Lisbon, Portugal
| | - Diana Pirra
- Department of Palliative Care, Hospital Santa Luzia, Elvas, Portugal
| | - Dora Coelho
- Department of Palliative Care, Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | - Lília Conde
- Community Team of Palliative Care, Maia/Valongo, Portugal
| | - Lorena Real
- Department of Palliative Care, Hospital Santa Luzia, Elvas, Portugal
| | - Madalena Feio
- Hospital Palliative Care Team and Home Care Unit, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Manuel Barbosa
- Community Team of Palliative Care, Maia/Valongo, Portugal
| | - Maria de Lurdes Martins
- Clinical Academic Center of Trás-os-Montes and Alto Douro - Professor Doctor Nuno Grande - CACTMAD, Vila Real, Portugal
| | - Marlene Areias
- Department of Palliative Care, Unidade Local de Saúde do Nordeste, Macedo de Cavaleiros, Portugal
| | - Rafael Muñoz-Romero
- Department of Palliative Care, Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | - Rita Cunha Ferreira
- Community Team of Palliative Care, ACES Lisboa Ocidental e Oeiras, Lisbon, Portugal
| | - Susete Freitas
- Department of Palliative Care, Serviço de Saúde da Região Autónoma da Madeira (SESARAM), Funchal, Portugal
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Guité-Verret A, Boivin J, Hanna AMR, Downar J, Bush SH, Marcoux I, Guay D, Tapp D, Lapenskie J, Gagnon B. Continuous palliative sedation until death: a qualitative study of palliative care clinicians' experiences. BMC Palliat Care 2024; 23:104. [PMID: 38637812 PMCID: PMC11027280 DOI: 10.1186/s12904-024-01426-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 04/02/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The practice of continuous palliative sedation until death is the subject of much medical and ethical debate, which is reflected in the inconsistency that persists in the literature regarding the definition and indications of palliative sedation. AIM This study aims to gain a better understanding of palliative care clinicians' experiences with continuous palliative sedation. DESIGN We conducted a qualitative study based on focus group discussions. SETTING/PARTICIPANTS We conducted six focus groups with a total of 28 palliative care clinicians (i.e., 15 nurses, 12 physicians, and 1 end-of-life doula) from diverse care settings across Canada, where assisted dying has recently been legalized. RESULTS An interpretative phenomenological analysis was used to consolidate the data into six key themes: responding to suffering; grappling with uncertainty; adapting care to ensure ongoing quality; grounding clinical practice in ethics; combining medical expertise, relational tact, and reflexivity; and offering an alternative to assisted death. CONCLUSIONS Interaction with the patient's family, uncertainty about the patient's prognosis, the concurrent practice of assisted dying, and the treatment of existential suffering influence the quality of sedation and indicate a lack of clear palliative care guidelines. Nevertheless, clinicians exhibit a reflective and adaptive capacity that can facilitate good practice.
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Affiliation(s)
- Alexandra Guité-Verret
- Department of Psychology, Université du Québec à Montréal, Montréal, Canada
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
| | - Jessica Boivin
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, Canada
- CHU Québec-Université Laval Research Centre, Québec, Canada
| | | | - James Downar
- Bruyère Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Shirley H Bush
- Bruyère Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Isabelle Marcoux
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Diane Guay
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Québec, Canada
| | - Diane Tapp
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- CHU Québec-Université Laval Research Centre, Québec, Canada
- Faculty of Nursing, Université Laval, Québec, Canada
| | - Julie Lapenskie
- Bruyère Research Institute, Ottawa, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Bruno Gagnon
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada.
- CHU Québec-Université Laval Research Centre, Québec, Canada.
- Bruyère Research Institute, Ottawa, Canada.
- Department of Family and Emergency Medicine, Université Laval, Québec, Canada.
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Kremling A, Bausewein C, Klein C, Nadolny S, Ostgathe C, Schildmann E, Ziegler K, Schildmann J. Terminological Confusion About Sedation in Palliative Care: Results of an International Online Vignette Survey. J Palliat Med 2024; 27:487-494. [PMID: 38330403 PMCID: PMC10998700 DOI: 10.1089/jpm.2023.0159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 02/10/2024] Open
Abstract
Background: Terminological problems concerning sedation in palliative care and consequences for research and clinical decision making have been reported frequently. Objectives: To gather data on the application of definitions of sedation practices in palliative care to clinical cases and to analyze implications for high-quality definitions. Design: We conducted an online survey with a convenience sample of international experts involved in the development of guidelines on sedation in palliative care and members of the European Association for Palliative Care (EAPC). Participants were asked to apply four published definitions to four case vignettes. Data were analyzed using descriptive statistics. Results: A total of 32 experts and 271 EAPC members completed the survey. The definitions were applied correctly in n = 2200/4848 cases (45.4%). The mean number of correct applications of the definitions (4 points max.) was 2.2 ± 1.14 for the definition of the SedPall study group, 1.8 ± 1.03 for the EAPC definition, 1.7 ± 0.98 for the definition of the Norwegian Medical Association, and 1.6 ± 1.01 for the definition of the Japanese Society of Palliative Medicine. The rate of correct applications for the 16 vignette-definition pairs varied between 70/303 (23.1%) and 227/303 (74.9%). The content of definitions and vignettes together with free-text comments explains participants' decisions and misunderstandings. Conclusions: Definitions of sedation in palliative care are frequently incorrectly applied to clinical case scenarios under simplified conditions. This suggests that clinical communication and research might be negatively influenced by misunderstandings and inconsistent labeling or reporting of data. Clinical Trial Registration Number: DRKS00015047.
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Affiliation(s)
- Alexander Kremling
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, Ludwig Maximilian University München, Comprehensive Cancer Centre Munich (CCCM), Germany
| | - Carsten Klein
- Department of Palliative Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Stephan Nadolny
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
- Institute for Educational and Health-Care Research in the Health Sector, Hochschule Bielefeld—University of Applied Sciences and Arts, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, LMU University Hospital, Ludwig Maximilian University München, Comprehensive Cancer Centre Munich (CCCM), Germany
- Palliative Medicine, Faculty of Medicine, University of Augsburg, Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jan Schildmann
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
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Thomas C, Alici Y, Breitbart W, Bruera E, Blackler L, Sulmasy DP. Addressing Challenges With Sedation in End-of-Life Care. J Pain Symptom Manage 2024; 67:346-349. [PMID: 38158164 PMCID: PMC10939822 DOI: 10.1016/j.jpainsymman.2023.12.016] [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] [Received: 10/03/2023] [Revised: 12/04/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
In 2009, Quill and colleagues stipulated that there are three types of sedation practices at the end of life: ordinary sedation, proportionate palliative sedation (PPS), and palliative sedation to unconsciousness (PSU). Of the three, PPS and PSU are described as "last-resort options" to relieve refractory symptoms, and PSU as the most ethically controversial type that "should be quite rare." Unfortunately, little is known about actual sedation practices at the end of life in the United States. This may be due in part to a lack of conceptual clarity about sedation in end-of-life care. We argue that, until more is known about what sedation practices occur at the end of life, and how practices can be improved by research and more specific guidelines, "palliative sedation" will remain more misunderstood and controversial than it might otherwise be. In our view, overcoming the challenges posed by sedation in end-of-life care requires: 1) greater specificity regarding clinical situations and approaches to sedation, 2) research tailored to focused clinical questions, and 3) improved training and safeguards in sedation practices. Terms like PPS and PSU are relatively simple to understand in the abstract, but their application comprises various clinical situations and approaches to sedation. An obvious barrier to empirical research on sedation practices in end-of-life care is the challenge of determining these elements, especially if not clearly communicated. Additionally, we argue that training for palliative care specialists and others should include monitoring and rescue techniques as required competencies.
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Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics (C.T., D.P.S.), Georgetown University, Washington, District of Columbia, USA.
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences (Y.A., W.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College (Y.A.), New York, New York, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences (Y.A., W.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine (E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Liz Blackler
- Ethics Committee (L.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics (C.T., D.P.S.), Georgetown University, Washington, District of Columbia, USA; Departments of Medicine and Philosophy (D.P.S.), Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, District of Columbia, USA
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Beauverd M, Mazzoli M, Pralong J, Tomczyk M, Eychmüller S, Gaertner J. Palliative sedation - revised recommendations. Swiss Med Wkly 2024; 154:3590. [PMID: 38579308 DOI: 10.57187/s.3590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
Palliative sedation is defined as the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) to relieve the burden of otherwise intractable suffering in a manner ethically acceptable to the patient, their family, and healthcare providers. In Switzerland, the prevalence of continuous deep sedation until death increased from 4.7% in 2001 to 17.5% of all deceased in 2013, depending on the research method used and on regional variations. Yet, these numbers may be overestimated due to a lack of understanding of the term "continuous deep sedation" by for example respondents of the questionnaire-based study. Inadequately trained and inexperienced healthcare professionals may incorrectly or inappropriately perform palliative sedation due to uncertainties regarding its definitions and practice. Therefore, the expert members of the Bigorio group and the authors of this manuscript believe that national recommendations should be published and made available to healthcare professionals to provide practical, terminological, and ethical guidance. The Bigorio group is the working group of the Swiss Palliative Care Society whose task is to publish clinical recommendations at a national level in Switzerland. These recommendations aim to provide guidance on the most critical questions and issues related to palliative sedation. The Swiss Society of Palliative Care (palliative.ch) mandated a writing board comprising four clinical experts (three physicians and one ethicist) and two national academic experts to revise the 2005 Bigorio guidelines. A first draft was created based on a narrative literature review, which was internally reviewed by five academic institutions (Lausanne, Geneva, Bern, Zürich, and Basel) and the heads of all working groups of the Swiss Society of Palliative Care before finalising the guidelines. The following themes are discussed regarding palliative sedation: (a) definitions and clinical aspects, (b) the decision-making process, (c) communication with patients and families, (d) patient monitoring, (e) pharmacological approaches, and (f) ethical and controversial issues. Palliative sedation must be practised with clinical and ethical accuracy and competence to avoid harm and ethically questionable use. Specialist palliative care teams should be consulted before initiating palliative sedation to avoid overlooking other potential treatment options for the patient's symptoms and suffering.
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Affiliation(s)
- Michel Beauverd
- Service de soins palliatifs et de support, Département de médecine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | | | | | - Martyna Tomczyk
- Institute of Humanities in Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Steffen Eychmüller
- Universitäres Zentrum für Palliative Care (UZP), Inselspital, University Hospital, Bern, Switzerland
| | - Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland
- Department of Clinical Research, University of Basel, Switzerland
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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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Rodrigues P, Ostyn J, Mroz S, Ronse A, Menten J, Gastmans C. Palliative care physicians' decision-making about palliative sedation for existential suffering: A Belgian nationwide qualitative study. Palliat Support Care 2024; 22:119-127. [PMID: 36503696 DOI: 10.1017/s1478951522001559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES This study aims to provide an in-depth understanding of the content and process of decision-making about palliative sedation for existential suffering (PS-ES) as perceived by Belgian palliative care physicians. METHODS This Belgian nationwide qualitative study follows a grounded theory approach. We conducted semistructured interviews with 25 palliative care physicians working in 19 Belgian hospital-based palliative care units and 4 stand-alone hospices. We analyzed the data using the Qualitative Analysis Guide of Leuven, and we followed the Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ). RESULTS Analysis of the data identified several criteria that physicians apply in their decision-making about PS-ES, namely, the importance of the patient's demand, PS-ES as a last resort option after all alternatives have been applied, the condition of unbearable suffering combined with other kinds of suffering, and the condition of being in a terminal stage. Regarding the process of decision-making itself, physicians refer to the need for multidisciplinary perspectives supported by an interpretative dialogue with the patient and all other stakeholders. The decision-making process involves a specific temporality and physicians' inner conviction about the need of PS-ES. SIGNIFICANCE OF RESULTS Belgian palliative care physicians are not sure about the criteria regarding decision-making in PS-ES. To deal with complex existential suffering in end-of-life situations, they stress the importance of participation by all stakeholders (patient, relatives, palliative care team, other physicians, nurses, social workers, physiotherapists, occupational therapists, chaplains, etc.) in the decision-making process to prevent inadequate decisions being made.
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Affiliation(s)
| | - Jozefien Ostyn
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | - Sarah Mroz
- End-of-Life Care Research Group, Free University of Brussels (VUB), Brussels, Belgium
| | - Axelle Ronse
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | - Johan Menten
- Department of Oncology, Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
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Frasca M, Jonveaux T, Lhuaire Q, Bidegain-Sabas A, Chanteclair A, Francis-Oliviero F, Burucoa B. Sedation practices in palliative care services across France: a nationwide point-prevalence analysis. BMJ Support Palliat Care 2024; 13:e1326-e1334. [PMID: 37463761 PMCID: PMC10850836 DOI: 10.1136/spcare-2023-004261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/30/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVES Terminally ill patients may require sedation to relieve refractory suffering. The prevalence and modalities of this practice in palliative care services remain unclear. This study estimated the prevalence of all sedation leading to a deep unconsciousness, whether transitory, with an undetermined duration, or maintained until death, for terminally ill patients referred to a home-based or hospital-based palliative care service. METHODS We conducted a national, multicentre, observational, prospective, cross-sectional study. In total, 331 centres participated, including academic/non-academic and public/private institutions. The participating institutions provided hospital-based or home-based palliative care for 5714 terminally ill patients during the study. RESULTS In total, 156 patients received sedation (prevalence of 2.7%; 95% CI, 2.3 to 3.2); these patients were equally distributed between 'transitory', 'undetermined duration' and 'maintained until death' sedation types. The prevalence was 0.7% at home and 8.0% in palliative care units. The median age of the patients was 70 years (Q1-Q3: 61-83 years); 51% were women and 78.8% had cancers. Almost all sedation events occurred at a hospital (90.4%), mostly in specialised beds (74.4%). In total, 39.1% of patients were unable to provide consent; only two had written advance directives. A collegial procedure was implemented in 80.4% of sedations intended to be maintained until death. Midazolam was widely used (85.9%), regardless of the sedation type. CONCLUSIONS This nationwide study provides insight into sedation practices in palliative care institutions. We found a low prevalence for all practices, with the highest prevalence among most reinforced palliative care providers, and an equal frequency of all practices.
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Affiliation(s)
- Matthieu Frasca
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France
| | - Thérèse Jonveaux
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
| | - Quentin Lhuaire
- Unité Méthodes d'Evaluation en Santé (UMES), University Hospital of Bordeaux, Bordeaux, France
| | - Adèle Bidegain-Sabas
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
| | - Alex Chanteclair
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France
| | | | - Benoît Burucoa
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
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9
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Podda MG, Schiavello E, Nigro O, Clerici CA, Simonetti F, Luksch R, Terenziani M, Ferrari A, Casanova M, Spreafico F, Meazza C, Chiaravalli S, Biassoni V, Gattuso G, Puma N, Bergamaschi L, Sironi G, Massimino M. Palliative sedation in paediatric solid tumour patients: choosing the best drugs. BMJ Support Palliat Care 2024; 13:e1141-e1148. [PMID: 36418035 DOI: 10.1136/bmjspcare-2022-003534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/25/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Cancer remains the leading cause of mortality by disease in childhood in high-income countries. For terminally ill children, care focuses on quality of life, and patient management fundamentally affects grieving families. This paper describes our experience of palliative sedation (PS) for children with refractory symptoms caused by solid tumours, focusing on the drugs involved. METHODS We retrospectively collected data on all children treated for cancer who died at the pediatric oncology unit of the Fondazione IRCCS Istituto Nazionale dei Tumori between January 2016 and December 2020. RESULTS Of the 29 patients eligible for the study, all but 4 received PS. Midazolam was always used, combined in 16 cases with other drugs (mainly classic neuroleptics, alpha-2 agonists and antihistamines). Throughout the period of PS and on the day of death, patients with sarcoma were given higher doses of midazolam and morphine, and more often received combinations of drugs than patients with brain tumours. Sarcoma causes significant symptoms, while brain tumours require less intensive analgesic-sedative therapies because they already impair a patient's state of consciousness. CONCLUSIONS Optimising pharmacological treatments demands a medical team that knows how drugs (often developed for other indications) work. Emotional and relational aspects are important too, and any action to lower a patient's consciousness should be explained to the family and justified. Parents should not feel like helpless witnesses. Guidelines on PS in paediatrics could help, providing they acknowledge that a child's death is always a unique case.
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Affiliation(s)
- Marta Giorgia Podda
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Elisabetta Schiavello
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Olga Nigro
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Carlo Alfredo Clerici
- Psychology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
- Department of Oncology and Hematology, Università degli Studi di Milano, Milano, Italy
| | - Fabio Simonetti
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Roberto Luksch
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Monica Terenziani
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Michela Casanova
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Filippo Spreafico
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Cristina Meazza
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Stefano Chiaravalli
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Veronica Biassoni
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Giovanna Gattuso
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Nadia Puma
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Luca Bergamaschi
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Givanna Sironi
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Maura Massimino
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
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Liao X, Lin J, Shu X, Hong S, Yao Y, Li H. Regional versus systemic dexmedetomidine as an adjuvant to lidocaine for intravenous regional anaesthesia in healthy volunteers: a randomized crossover study. Ann Med 2024; 55:2300663. [PMID: 38175807 PMCID: PMC10769556 DOI: 10.1080/07853890.2023.2300663] [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: 09/01/2023] [Accepted: 12/23/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Dexmedetomidine enhances the quality and duration of lidocaine intravenous regional anaesthesia (IVRA). However, the two administration routes have not been directly compared regarding effects on tourniquet tolerance time with lidocaine IVRA. Additionally, it remains unclear whether the prolonged tourniquet tolerance stems from the direct peripheral action of dexmedetomidine or indirect systemic analgesic effects. METHODS We conducted forearm IVRA in 12 healthy volunteers using a crossover design on two separate study days. One day, the systemic dexmedetomidine group received an intravenous infusion of 0.5 μg/kg dexmedetomidine (20 mL) in one arm, followed by 0.5% lidocaine (25 mL) forearm IVRA in the contralateral arm. On the other day, the regional dexmedetomidine group received an intravenous 0.9% saline infusion (20 mL) in one arm, followed by combined 0.5% lidocaine (25 mL) and 0.5 μg/kg dexmedetomidine forearm IVRA in the opposite arm. After a two-week washout period, participants crossed over to receive the alternate treatment. The primary outcome was tourniquet tolerance time, from initiating IVRA until the patient-reported tourniquet pain numerical rating scale exceeded three. RESULTS The tourniquet tolerance time was longer with regional versus systemic dexmedetomidine (36.9 ± 7.6 min vs 23.3 ± 6.2 min, respectively), with a 13.6 min mean difference (95% CI: 10.8 to 16.4 min, p < 0.001). Regional dexmedetomidine also hastened sensory onset and extended sensory recovery compared to systemic administration. Delayed sedation after tourniquet release occurred in 5 of 12 subjects receiving regional dexmedetomidine. CONCLUSION The addition of regional dexmedetomidine to lidocaine prolonged tourniquet tolerance time in forearm IVRA to a greater extent compared to systemic dexmedetomidine in healthy volunteers. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2300067978.
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Affiliation(s)
- Xincheng Liao
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Jie Lin
- Department of Anesthesiology, People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Xinru Shu
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Shisen Hong
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Yusheng Yao
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
- Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Hao Li
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
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Mercadante S, Lo Cascio A, Casuccio A. Mortality rate and palliative sedation in an acute palliative care unit. BMJ Support Palliat Care 2023:spcare-2023-004669. [PMID: 38154922 DOI: 10.1136/spcare-2023-004669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/15/2023] [Indexed: 12/30/2023]
Abstract
AIM To assess the mortality rate and the use of palliative sedation (PS) in an advanced long-standing acute palliative care unit (APCU) METHODS: The charts of patients who died and eventually received PS, consecutively admitted to the APCU for 4 years, were reviewed. Patients' characteristics and symptom intensity were recorded at admission, 3 days before death and the day before death (T0, T-3, T-end, respectively). For patients who were administered midazolam for PS, initial and final doses of drugs, as well as duration of PS until death, were recorded. RESULTS One hundred and forty-eight patients died in APCU (8.9%), and 45 of them (30.4%) received PS. Younger patients and those reporting high levels of dyspnoea at T-3 and T-end were more likely to be sedated (p=0.002, p=0.013 and 0.002, respectively). The mean duration of PS was 27.47 hours. Mean initial and final doses of midazolam were 35.45 mg/day (SD 19.7) and 45.57 mg/day (SD 20.6), respectively (p=0.001). CONCLUSION Mortality rate in APCU was very low. As a percentage of the number of deaths, PS rate was similar to that reported in other settings. PS does not seem to accelerate impending death.
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Affiliation(s)
| | - Alessio Lo Cascio
- Pain Relief and Supportive Care, Private Hospital La Maddalena, Palermo, Italy
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12
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Bush SH, Bronicki K, Dionne M, Lelievre N, Lawlor PG, Kabir M. Implementation of the Richmond Agitation-Sedation Scale (palliative version) on an inpatient palliative care unit. BMC Palliat Care 2023; 22:171. [PMID: 37924037 PMCID: PMC10625230 DOI: 10.1186/s12904-023-01298-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND The Richmond Agitation-Sedation Scale - Palliative version (RASS-PAL) tool is a brief observational tool to quantify a patient's level of agitation or sedation. The objective of this study was to implement the RASS-PAL tool on an inpatient palliative care unit and evaluate the implementation process. METHODS Quality improvement implementation project using a short online RASS-PAL self-learning module and point-of-care tool. Participants were staff working on a 31-bed inpatient palliative care unit who completed the RASS-PAL self-learning module and online evaluation survey. RESULTS The self-learning module was completed by 49/50 (98%) of regular palliative care unit staff (nurses, physicians, allied health, and other palliative care unit staff). The completion rate of the self-learning module by both regular and casual palliative care unit staff was 63/77 (82%). The follow-up online evaluation survey was completed by 23/50 (46%) of respondents who regularly worked on the palliative care unit. Respondents agreed (14/26; 54%) or strongly agreed (10/26; 38%) that the self-learning module was implemented successfully, with 100% agreement that it was effective for their educational needs. CONCLUSION Using an online self-learning module is an effective method to engage and educate interprofessional staff on the RASS-PAL tool as part of an implementation strategy.
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Affiliation(s)
- Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.
- Bruyère Research Institute, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Bruyère Continuing Care, Ottawa, ON, Canada.
| | - Katarzyna Bronicki
- Department of Radiation Medicine, The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Michel Dionne
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyère Continuing Care, Ottawa, ON, Canada
| | | | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Continuing Care, Ottawa, ON, Canada
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13
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Ostgathe C, Bausewein C, Schildmann E, Bazata J, Handtke V, Heckel M, Klein C, Kremling A, Kurkowski S, Meesters S, Seifert A, Torres Cavazos JL, Ziegler K, Jäger C, Schildmann J. Expert-approved best practice recommendations on the use of sedative drugs and intentional sedation in specialist palliative care (SedPall). BMC Palliat Care 2023; 22:126. [PMID: 37667303 PMCID: PMC10476406 DOI: 10.1186/s12904-023-01243-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND The use of sedative drugs and intentional sedation in end-of-life care is associated with clinical, ethical and legal challenges. In view of these and of the issue's great importance to patients undergoing intolerable suffering, we conducted a project titled SedPall ("From anxiolysis to deep continuous sedation - Development of recommendations for sedation in palliative care") with the purpose of developing best practice recommendations on the use of sedative drugs and intentional sedation in specialist palliative care and obtaining feedback and approval from experts in this area. DESIGN Our stepwise approach entailed drafting the recommendations, obtaining expert feedback, conducting a single-round Delphi study, and convening a consensus conference. As an interdisciplinary group, we created a set of best practice recommendations based on previously published guidance and empirical and normative analysis, and drawing on feedback from experts, including patient representatives and of public involvement participants. We set the required agreement rate for approval at the single-round Delphi and the consensus conference at ≥80%. RESULTS Ten experts commented on the recommendations' first draft. The Delphi panel comprised 50 experts and patient and public involvement participants, while 46 participants attended the consensus conference. In total, the participants in these stages of the process approved 66 recommendations, covering the topics "indications", "intent/purpose [of sedation]", "decision-making", "information and consent", "medication and type of sedation", "monitoring", "management of fluids and nutrition", "continuing other measures", "support for relatives", and "team support". The recommendations include suggestions on terminology and comments on legal issues. CONCLUSION Further research will be required for evaluating the feasibility of the recommendations' implementation and their effectiveness. The recommendations and the suggested terminology may serve as a resource for healthcare professionals in Germany on the use of sedative drugs and intentional sedation in specialist palliative care and may contribute to discussion on the topic at an international level. TRIAL REGISTRATION DRKS00015047 (German Clinical Trials Register).
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Affiliation(s)
- Christoph Ostgathe
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich- Alexander-Universität Erlangen-Nürnberg (FAU), Werner-von-Siemens-Straße 34, Erlangen, 91052, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University of Augsburg, Stenglinstraße 2, Augsburg, 86156, Germany
| | - Jeremias Bazata
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Violet Handtke
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Maria Heckel
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich- Alexander-Universität Erlangen-Nürnberg (FAU), Werner-von-Siemens-Straße 34, Erlangen, 91052, Germany.
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich- Alexander-Universität Erlangen-Nürnberg (FAU), Werner-von-Siemens-Straße 34, Erlangen, 91052, Germany
| | - Alexander Kremling
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Sandra Kurkowski
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich- Alexander-Universität Erlangen-Nürnberg (FAU), Werner-von-Siemens-Straße 34, Erlangen, 91052, Germany
| | - Sophie Meesters
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Andreas Seifert
- Paderborn Centre for Educational Research and Teacher Education - PLAZ Professional School, Paderborn University, Warburger Str. 100, 33098, Paderborn, Germany
| | - Jorge Luis Torres Cavazos
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich- Alexander-Universität Erlangen-Nürnberg (FAU), Werner-von-Siemens-Straße 34, Erlangen, 91052, Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schillerstraße 1, 91054, Erlangen, Germany
| | - Christian Jäger
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schillerstraße 1, 91054, Erlangen, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
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Colburn B, Johnston B. Palliative sedation: autonomy, suffering, and euthanasia. Curr Opin Support Palliat Care 2023; 17:214-218. [PMID: 37428181 DOI: 10.1097/spc.0000000000000665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
PURPOSE OF REVIEW This contemporary and novel review of palliative sedation explores some of the distinctive ethical problems associated with that intervention. It is timely in light of recent reviews of palliative care guidelines on the topic and given the current public debates around the related but distinct practice of euthanasia. RECENT FINDINGS The main themes discussed are patient autonomy, the nature of suffering and how to alleviate it, and the relationship between palliative sedation and euthanasia. SUMMARY First, palliative sedation poses a significant problem for patient autonomy, both in terms of securing informed consent and in terms of the ongoing effect on individual well-being. Second, as an intervention to alleviate suffering, it is appropriate only in limited cases and counterproductive in others, for example, where an individual values their ongoing psychological or social agency more than the relief of pain or negative experience. Third, people's ethical views about palliative sedation are often coloured by their understanding of the legal and moral status of assisted dying and euthanasia; this is unhelpful and occludes the interesting and urgent ethical questions raised by palliative sedation as a distinct end-of-life intervention.
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Affiliation(s)
| | - Bridget Johnston
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
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15
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Cuviello A, Ang N, Morgan K, Baker JN, Anghelescu DL. Palliative Sedation Therapy Practice Comparison - A Survey of Pediatric Palliative Care and Pain Management Specialists. Am J Hosp Palliat Care 2023; 40:977-986. [PMID: 36475873 DOI: 10.1177/10499091221138298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Context: Palliative sedation therapy (PST) can relieve suffering at end-of-life (EOL) in children with intolerable and refractory symptoms. However, updated and consistent guidance on PST practices are imperative. Objectives: We investigate current variations in clinical practice and PST implementation among pediatric palliative care (PPC) and pain management (PM) specialists. Methods: We distributed an IRB-exempt electronic anonymous survey via email through the Society of Pediatric Pain Medicine, and the American Academy of Hospice and Palliative Medicine. Survey responses were collated and descriptively reported. Results: Of 83 survey responses, the majority (75%) represented large academic children's hospitals. The distribution between PPC and pediatric pain management specialists' responses was 60% and 40%, respectively. Most respondents reported having designated pain management and/or palliative care teams (70% and 90%, respectively). Approximately half (48%) reported following an institutional PST protocol, most not requiring formal ethics consult (69%). Only 54% of respondents noted that the Do Not Resuscitate (DNR) order was required prior to PST initiation. PST was primarily utilized for children with oncologic diagnoses (76%). The primary and secondary medications of choice for PST implementation were reported to be opioids (39%) and benzodiazepines (36%) by pain management specialists, and benzodiazepines (52%) and barbiturates (28%) by palliative care specialists. Conclusions: Our study highlights the variability in the practice and implementation of PST. Further educational efforts are key for establishing PST practices and efficient protocol development.
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Affiliation(s)
| | - Nicholas Ang
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Kyle Morgan
- University of Tennessee Health Science Center, Memphis, TN, USA
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Lojo-Cruz C, Mora-Delgado J, Rivas Jiménez V, Carmona Espinazo F, López-Sáez JB. Survival Outcomes in Palliative Sedation Based on Referring Versus On-Call Physician Prescription. J Clin Med 2023; 12:5187. [PMID: 37629229 PMCID: PMC10455353 DOI: 10.3390/jcm12165187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
This study sought to determine the survival duration of patients who underwent palliative sedation, comparing those who received prescriptions from referring physicians versus on-call physicians. It included all patients over 18 years old who died in the Palliative Care, Internal Medicine, and Oncology units at the Hospital Universitario of Jerez de la Frontera between 1 January 2019, and 31 December 2019. Various factors were analyzed, including age, gender, oncological or non-oncological disease, type of primary tumor and refractory symptoms. Statistical analysis was employed to compare survival times between patients who received palliative sedation from referring physicians and those prescribed by on-call physicians, while accounting for other potential confounding variables. This study revealed that the median survival time after the initiation of palliative sedation was 25 h, with an interquartile range of 8 to 48 h. Notably, if the sedation was prescribed by referring physicians, the median survival time was 30 h, while it decreased to 17 h when prescribed by on-call physicians (RR 0.357; 95% CI 0.146-0.873; p = 0.024). Furthermore, dyspnea as a refractory symptom was associated with a shorter survival time (RR 0.307; 95% CI 0.095-0.985; p = 0.047). The findings suggest that the on-call physician often administered palliative sedation to rapidly deteriorating patients, particularly those experiencing dyspnea, which likely contributed to the shorter survival time following sedation initiation. This study underscores the importance of careful patient selection and prompt initiation of palliative sedation to alleviate suffering.
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Affiliation(s)
- Cristina Lojo-Cruz
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Juan Mora-Delgado
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Víctor Rivas Jiménez
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Fernando Carmona Espinazo
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Puerta del Mar, Avenida Ana de Viya 21, 11009 Cádiz, Spain;
| | - Juan-Bosco López-Sáez
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Puerto Real, Calle Romería 7, 11510 Puerto Real, Spain;
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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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Klein C, Voss R, Ostgathe C, Ansgar Schildmann J. Sedation in Palliative Care—a Clinically Oriented Overview of Guidelines and Treatment Recommendations. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:235-242. [PMID: 36851822 PMCID: PMC10282508 DOI: 10.3238/arztebl.m2023.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 08/29/2022] [Accepted: 02/02/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND The appropriate provision of sedation as a last resort for the relief of suffering in palliative care is dealt with variably in actual practice. This article is intended as an overview of practically relevant information found in treatment recommendations and guidelines. METHODS A systematic literature search was conducted in the PubMed, Scopus, and Google Scholar databases, and a manual search was carried out online. Recommendations that were not available in either German or English, or that were specific to pediatric practice, were excluded. Publication quality was assessed with the AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II). The recommendations in the documents were qualitatively evaluated. RESULTS 29 publications (11 journal articles, 18 other) of varying quality according to AGREE II were included. All recommendations and guidelines were essentially based on expert consensus. The common indications for sedation are otherwise intractable delirium, dyspnea, and pain, in patients with a life expectancy of no more than two weeks. Existential distress is a controversial indication. The drug of first choice is midazolam. As the sedating effect of opioids is hard to predict, they should not be used as sedatives. The risks of sedation include respiratory and circulatory depression, as well as the loss of communicative ability, control, and autonomy. It is generally recommended that the patient's symptom burden and depth of sedation should be monitored; clinical and technically supported monitoring are recommended in some publications as well, depending on the situation. CONCLUSION There is a broad consensus in favor of sedation to relieve suffering in the last days and hours of life. Recommendations vary for patients with a longer life expectancy and for those with existential distress, and with respect to monitoring.
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Affiliation(s)
- Carsten Klein
- Department of Palliative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nürnberg
| | - Rafaela Voss
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg
| | - Christoph Ostgathe
- Department of Palliative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nürnberg
| | - Jan Ansgar Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg
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19
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Rijpstra M, Kuip E, Hasselaar J, Vissers K. The clinical practice of palliative sedation in patients dying from COVID-19: a retrospective chart review. BMC Palliat Care 2023; 22:34. [PMID: 37013598 PMCID: PMC10071268 DOI: 10.1186/s12904-023-01156-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 03/28/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Clinical experts experienced challenges in the practice of palliative sedation (PS) during the COVID-19 pandemic. Rapid deterioration in patients' situation was observed while the indications for starting PS seemed to differ compared to other terminal patients. It is unclear to which extent clinical trajectories of PS differ for these COVID patients compared to regular clinical practice of PS. OBJECTIVES To describe the clinical practice of PS in patients with COVID versus non-COVID patients. METHODS A retrospective analysis of data from a Dutch tertiary medical centre was performed. Charts of adult patients who died with PS during hospitalisation between March '20 and January '21 were included. RESULTS During the study period, 73 patients received PS and of those 25 (34%) had a COVID infection. Refractory dyspnoea was reported as primary indication for starting PS in 84% of patients with COVID compared to 33% in the other group (p < 0.001). Median duration of PS was significantly shorter in the COVID group (5.8 vs. 17.1 h, p < 0.01). No differences were found for starting dosages, but median hourly dose of midazolam was higher in the COVID group (4.2 mg/hr vs. 2.4 mg/hr, p < 0.001). Time interval between start PS and first medication adjustments seemed to be shorter in COVID patients (1.5 vs. 2.9 h, p = 0.08). CONCLUSION PS in COVID patients is characterized by rapid clinical deterioration in all phases of the trajectory. What is manifested by earlier dose adjustments and higher hourly doses of midazolam. Timely evaluation of efficacy is recommended in those patients.
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Affiliation(s)
- Maaike Rijpstra
- Department of Pain, Anaesthesiology and Palliative Medicine, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
- Department of Primary and Community Care, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.
| | - Evelien Kuip
- Department of Pain, Anaesthesiology and Palliative Medicine, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Jeroen Hasselaar
- Department of Primary and Community Care, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kris Vissers
- Department of Pain, Anaesthesiology and Palliative Medicine, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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20
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Hilbert MT, Henkel ND, Spetz SL, Malaiyandi DP. The Rising Status of Phenobarbital: A Case for Use in Severe Refractory Hyperactive Poststroke Delirium. Neurologist 2023; 28:123-125. [PMID: 35534002 DOI: 10.1097/nrl.0000000000000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Up to 48% of patients who have had a stroke will experience poststroke delirium (PSD) that can be hyperactive, hypoactive, or mixed. Literature on treatment of the hyperactive subtype is specifically lacking. This case report describes the rapid resolution of severe refractory hyperactive PSD with phenobarbital. CASE REPORT A 58-year-old man with a left middle cerebral artery stroke presented with severe hyperactive PSD of 12 days duration, refractory to antipsychotics, alpha-2 agonists, gabapentin, therapeutic valproic acid, benzodiazepines, and ketamine infusion. An oral dose of phenobarbital 30.4 mg, followed by oral maintenance therapy was initiated on day 13 of admission with dramatic improvement. As his Richmond Agitation-Sedation score trended downwards to 0, he was able to cooperate with therapies. This allowed for discharge to a skilled nursing facility for rehabilitation and subsequently home 2 weeks later. CONCLUSION Hyperactive PSD is a common complication of stroke with little evidence to guide treatment strategies. This report suggests that phenobarbital, because of its varied mechanisms of action and unique neurochemistry, may be an unrecognized potential therapy.
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Affiliation(s)
- Morgan T Hilbert
- Department of Pharmacy, ProMedica Toledo Hospital/Russell J. Ebeid Children's Hospital
| | - Nicholas D Henkel
- Department of Neurosciences and Neurological Disorders, University of Toledo
| | - Samantha L Spetz
- Department of Pharmacy, ProMedica Toledo Hospital/Russell J. Ebeid Children's Hospital
| | - Deepa P Malaiyandi
- Division of Neurocritical Care, Department of Neurology, University of Toledo College of Medicine
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH
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21
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Keramida K, Kostoulas A, Kostoulas A. Dyspnea in Oncological Patients: a Brain Teaser. Eur Cardiol 2023; 18:e03. [PMID: 36844934 PMCID: PMC9947930 DOI: 10.15420/ecr.2021.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 08/14/2022] [Indexed: 02/05/2023] Open
Abstract
Dyspnea is one of the most common symptoms in oncological patients with greater prevalence in lung cancer and advanced disease states. Causes of dyspnea can be directly or indirectly associated with cancer, anti-neoplastic therapies and comorbidities unrelated to cancer. Routine screening of dyspnea is suggested for all oncological patients by using unidimensional, simple scales and multidimensional tools to capture more domains affected by this symptom and to assess the effectiveness of interventions. The first step in the treatment algorithm of dyspnea is the identification of potentially reversible causes; if no specific cause is depicted, symptomatic treatment with non-pharmacological and pharmacological interventions is suggested. Referral to palliative care and continuous palliative sedation are the last resort in patients with a very limited life expectancy of not more than a few days for symptomatic relief and to decrease of the distress of patients and caregivers.
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Affiliation(s)
- Kalliopi Keramida
- Cardiology Department, General Anti-Cancer Oncological Hospital, Agios SavvasAthens, Greece
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22
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Garcia ACM, Isidoro GM, Paiva EMDC, Silva AE, Costa ICP, Bornemann-Cimenti H. Palliative Sedation at Home: A Scoping Review. Am J Hosp Palliat Care 2023; 40:173-182. [PMID: 35466700 DOI: 10.1177/10499091221096412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Palliative Sedation (PS) is an effective measure for the relief of refractory symptoms in end-of-life patients. This intervention can be performed at home, respecting the patients' and their families' decisions. A scoping review was performed to map the available evidence in the literature on the performance of PS at home. This review included 23 studies. Most were conducted in European countries with adult cancer patients. Patients, family members and healthcare providers participated in the decision making regarding the use of PS at home. PS was used primarily to manage refractory symptoms (pain, delirium, dyspnea, and others), and in 1 of the studies PS was mentioned as a possible intervention for shortening life. The most commonly used medication was midazolam and the average duration ranged from 4 h to 7 days. There are few reports on adverse events related to PS. This intervention seems to be a feasible possibility for the management of refractory symptoms in patients at the end of life, despite the fact that it can represent specific challenges for healthcare providers, patients and families. However, the literature is limited regarding PS in children and in people with diseases other than cancer, as well as on the evaluation of possible adverse effects related to this intervention. Furthermore, it is essential to have a broad ethical, clinical and legal debate on whether to consider the use of PS for the purpose of shortening life in specific cases.
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Affiliation(s)
| | | | | | - Alexandre E Silva
- Nursing Department - Campus Centro-Oeste Dona Lindu, 74383Federal University of São João del-Rei, Divinópolis, Brazil
| | | | - Helmar Bornemann-Cimenti
- Departement of Anesthesiology and Intensive Care Medicine, 31475Medical University of Graz, Graz, Austria
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23
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Ijaopo EO, Zaw KM, Ijaopo RO, Khawand-Azoulai M. A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness. Gerontol Geriatr Med 2023; 9:23337214231183243. [PMID: 37426771 PMCID: PMC10327414 DOI: 10.1177/23337214231183243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/23/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Background: World population is not only aging but suffering from serious chronic illnesses, requiring an increasing need for end-of-life care. However, studies show that many healthcare providers involved in the care of dying patients sometimes express challenges in knowing when to stop non-beneficial investigations and futile treatments that tend to prolong undue suffering for the dying person. Objective: To evaluate the clinical signs and symptoms that show end-of-life is imminent in individuals with advanced illness. Design: Narrative review. Methods: Computerized databases, including PubMed, Embase, Medline,CINAHL, PsycInfo, and Google Scholar were searched from 1992 to 2022 for relevant original papers written in or translated into English language that investigated clinical signs and symptoms of imminent death in individuals with advanced illness. Results: 185 articles identified were carefully reviewed and only those that met the inclusion criteria were included for review. Conclusion: While it is often difficult to predict the timing of death, the ability of healthcare providers to recognize the clinical signs and symptoms of imminent death in terminally-ill individuals may lead to earlier anticipation of care needs and better planning to provide care that is tailored to individual's needs, and ultimately results in better end-of-life care, as well as a better bereavement adjustment experience for the families.
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Affiliation(s)
| | - Khin Maung Zaw
- University of Miami Miller School of Medicine, FL, USA
- Miami VA Medical Center, FL, USA
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24
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Van der Elst M, Payne S, Arantzamendi M, Preston N, Hasselaar J, Centeno C, Belar A, Jaspers B, Brunsch H, Surges S, Adile C, Menten J. An analysis of the experiences of bereaved relatives and health care providers following palliative sedation: a study protocol for a qualitative international multicenter case study. BMC Palliat Care 2022; 21:227. [PMID: 36550539 PMCID: PMC9783747 DOI: 10.1186/s12904-022-01117-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients at the end-of-life may experience refractory symptoms of which pain, delirium, vomiting and dyspnea are the most frequent. Palliative sedation can be considered a last resort option to alleviate one or more refractory symptoms. There are only a limited number of (qualitative) studies exploring the experiences of relatives of sedated patients and their health care professionals (HCPs). The aims of this study protocol are: 1) to elicit the experiences of bereaved relatives and health care professionals of patients treated with palliative sedation and 2) to explore the understanding of the decision-making process to start palliative sedation across care settings in 5 European countries. METHODS This study protocol is part of the larger HORIZON 2020 Palliative Sedation project. Organisational case study methodology will be used to guide the study design. In total, 50 cases will be conducted in five European countries (10 per country). A case involves a semi-structured interview with a relative and an HCP closely involved in the care of a deceased patient who received some type of palliative sedation at the end-of-life. Relatives and health care professionals of deceased patients participating in a linked observational cohort study of sedated patients cared for in hospital wards, palliative care units and hospices will be recruited. The data will be analyzed using a framework analysis approach. The first full case will be analyzed by all researchers after being translated into English using a pre-prepared code book. Afterwards, bimonthly meetings will be organized to coordinate the data analysis. DISCUSSION The study aims to have a better understanding of the experiences of relatives and professional caregivers regarding palliative sedation and this within different settings and countries. Some limitations are: 1) the sensitivity of the topic may deter some relatives from participation, 2) since the data collection and analysis will be performed by at least 5 different researchers in 5 countries, some differences may occur which possibly makes it difficult to compare cases, but using a rigorous methodology will minimize this risk.
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Affiliation(s)
- M. Van der Elst
- grid.5596.f0000 0001 0668 7884Department of Oncology, Laboratory of Experimental Radiotherapy, Katholieke Universiteit Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - S. Payne
- grid.9835.70000 0000 8190 6402International Observatory On End of Life Care, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4AT UK
| | - M. Arantzamendi
- grid.5924.a0000000419370271Institute for Culture and Society-ATLANTES, Universidad de Navarra, Calle Universidad 6, Navarra 31009 Pamplona, Spain ,grid.508840.10000 0004 7662 6114IdISNA- Instituto de Investigación Sanitaria de Navarra. Palliative Medicine, Pamplona, Spain
| | - N. Preston
- grid.9835.70000 0000 8190 6402International Observatory On End of Life Care, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4AT UK
| | - J. Hasselaar
- grid.5590.90000000122931605Department of Anesthesiology, Pain and Palliative Medicine, Radboud University and Radboudumc, Geert Grote Plein 10, HB6500 Nijmegen, Netherlands
| | - C. Centeno
- grid.5924.a0000000419370271Institute for Culture and Society-ATLANTES, Universidad de Navarra, Calle Universidad 6, Navarra 31009 Pamplona, Spain ,grid.508840.10000 0004 7662 6114IdISNA- Instituto de Investigación Sanitaria de Navarra. Palliative Medicine, Pamplona, Spain ,grid.411730.00000 0001 2191 685XClínica Universidad de Navarra, Palliative Medicine Department, Pamplona, Spain
| | - A. Belar
- grid.5924.a0000000419370271Institute for Culture and Society-ATLANTES, Universidad de Navarra, Calle Universidad 6, Navarra 31009 Pamplona, Spain ,grid.508840.10000 0004 7662 6114IdISNA- Instituto de Investigación Sanitaria de Navarra. Palliative Medicine, Pamplona, Spain
| | - B. Jaspers
- grid.15090.3d0000 0000 8786 803XDepartment of Palliative Medicine, Universitätsklinikum Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - H. Brunsch
- grid.15090.3d0000 0000 8786 803XDepartment of Palliative Medicine, Universitätsklinikum Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - S. Surges
- grid.15090.3d0000 0000 8786 803XDepartment of Palliative Medicine, Universitätsklinikum Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - C. Adile
- grid.10776.370000 0004 1762 5517La Maddalena Cancer Center, Via San Lorenzo 312, 90146 Palermo, Italy
| | - J. Menten
- grid.5596.f0000 0001 0668 7884Department of Oncology, Laboratory of Experimental Radiotherapy, Katholieke Universiteit Leuven, Herestraat 49, 3000 Leuven, Belgium
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25
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Sim J, Goh WY, Wiryasaputra L, Hum AYM, Neo HY, Poi CH. Use of Phenobarbitone for Palliative Sedation in Dyspneic Crises Due to COVID-19 Pneumonia - A Case Series. J Pain Palliat Care Pharmacother 2022; 36:242-248. [PMID: 36005904 DOI: 10.1080/15360288.2022.2113596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Patients who suffer from dyspnea while dying from COVID-19 are treated with opioids and benzodiazepines. In some instances, patients may experience refractory dyspnea at the end of life. Palliative sedation can be prescribed to alleviate such patients' suffering. We describe two patients being treated for severe COVID-19 pneumonia in a tertiary hospital. Both developed intractable dyspneic crises despite high-dose opioids and benzodiazepines. This led to their requirement of palliative sedation in the general ward using subcutaneous phenobarbitone (phenobarbital). We outline clinical considerations for the use of palliative sedation in COVID-19 related dyspnea. In particular, we discuss the evidence for, benefits and limitations of using phenobarbitone for palliative sedation in COVID-19 patients.
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Affiliation(s)
- Jingwei Sim
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Wen Yang Goh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Lynn Wiryasaputra
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Allyn Yin-Mei Hum
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Han Yee Neo
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Choo Hwee Poi
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
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26
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Hwang IC. Current Status and Future Directions of Research on Palliative Sedation. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2022; 25:193-197. [PMID: 37674671 PMCID: PMC10179994 DOI: 10.14475/jhpc.2022.25.4.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 09/08/2023]
Abstract
Patients with terminal cancer experience very severe symptoms during the end of life, and palliative sedation (PS) may be considered if those symptoms are refractory to any other treatment. This brief report presents ethical considerations, practices, and recent concerns on PS. PS is quite different from euthanasia. There is a lack of consensus and standards on protocols, but its notable effects have been reported in hospice care settings. Most studies to date have reported no difference in survival between patients receiving PS and those not, and PS must be conducted proportionally with the lightest level of sedation. The most common indication for PS is delirium, and midazolam is the main sedative used. It is recommended that information regarding PS should be provided to patients and their caregivers repeatedly as early as possible. Existential suffering alone is not an indication for PS, and there is a lack of evidence on bispectral analysis. Additional research on PS is needed in Korea.
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Affiliation(s)
- In Cheol Hwang
- Department of Family Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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27
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Buchhold B, Jülich A, Glöckner F, Neumann T, Schneidewind L, Schmidt CA, Heidel FH, Krüger WH. Comparison of inpatient and outpatient palliative sedation practice - A prospective observational study. Palliat Support Care 2022:1-7. [PMID: 36397281 DOI: 10.1017/s1478951522001523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Palliative sedation (PS) is an intrusive measure to relieve patients at the end of their life from otherwise untreatable symptoms. Intensive discussion of the advantages and limitations of palliative care with the patients and their relatives should precede the initiation of PS since PS is terminated by the patient's death in most cases. Drugs for PS are usually administered intravenously. Midazolam is widely used, either alone or in combination with other substances. PS can be conducted in both inpatient and outpatient settings; however, a quality analysis comparing both modalities was missing so far. PATIENTS AND METHODS This prospective observational study collected data from patients undergoing PS inpatient at the palliative care unit (PCU, n = 26) or outpatient at a hospice (n = 2) or at home (specialized outpatient palliative care [SAPV], n = 31) between July 2017 and June 2018. Demographical data, indications for PS, and drug protocols were analyzed. The depth of sedation according to the Richmond Agitation Sedation Scale (RASS) and the degree of satisfaction of staff members and patient's relatives were included as parameters for quality assessment. RESULTS Patients undergoing PS at the PCU were slightly younger compared to outpatients (hospice and SAPV combined). Most patients suffered from malignant diseases, and midazolam was the backbone of sedation for inpatients and outpatients. The median depth of sedation was between +1 and -3 according to the RASS with a trend to deeper sedation prior to death. The median degree of satisfaction was "good," scored by staff members and by patient's relatives. Significant differences between inpatients and outpatients were not seen in protocols, depth of sedation, and degree of satisfaction. CONCLUSION The data support the thesis that PS is possible for inpatients and outpatients with comparable results. For choosing the best place for PS, other aspects such as patient's and relative's wishes, stress, and medical reasons should be considered.
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Affiliation(s)
- Britta Buchhold
- Department of Medical Psychology, University Medicine Greifswald, Greifswald, Germany
| | - Andreas Jülich
- Clinic for Internal Medicine C - Haematology and Oncology, Stem Cell Transplantation and Palliative Care, University Medicine Greifswald, Greifswald, Germany
| | - Franziska Glöckner
- Clinic for Internal Medicine C - Haematology and Oncology, Stem Cell Transplantation and Palliative Care, University Medicine Greifswald, Greifswald, Germany
| | - Thomas Neumann
- Clinic for Internal Medicine C - Haematology and Oncology, Stem Cell Transplantation and Palliative Care, University Medicine Greifswald, Greifswald, Germany
| | | | - Christian-Andreas Schmidt
- Clinic for Internal Medicine C - Haematology and Oncology, Stem Cell Transplantation and Palliative Care, University Medicine Greifswald, Greifswald, Germany
| | - Florian H Heidel
- Clinic for Internal Medicine C - Haematology and Oncology, Stem Cell Transplantation and Palliative Care, University Medicine Greifswald, Greifswald, Germany
| | - William H Krüger
- Clinic for Internal Medicine C - Haematology and Oncology, Stem Cell Transplantation and Palliative Care, University Medicine Greifswald, Greifswald, Germany
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28
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Heino L, Stolt M, Haavisto E. The practices of nurses about palliative sedation on palliative care wards: A qualitative study. J Adv Nurs 2022; 78:3733-3744. [PMID: 35774002 PMCID: PMC9796790 DOI: 10.1111/jan.15350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/02/2022] [Accepted: 06/20/2022] [Indexed: 01/07/2023]
Abstract
AIM To describe the practices of nurses concerning palliative sedation in palliative care wards in hospitals. DESIGN Qualitative descriptive design. METHODS A total of 27 nurses were interviewed in six focus groups and one pair interview; the nurses worked on four palliative care wards in three Finnish hospitals and the interviews took place between May and November 2019. The data were analysed using inductive content analysis. The COREQ checklist was used as a guide for reporting this study. FINDINGS Three main categories describing nurses' practices concerning palliative sedation were identified: participation in palliative sedation decision-making, sedation implementation and monitoring and information sharing and compassionate care for the patient and relatives. CONCLUSIONS Nurses play a key role throughout palliative sedation on palliative care wards in hospitals. To develop the quality of care, it is recommended to specify the role of nurses in palliative sedation, increase cooperation between nurses and physicians, and enhance palliative sedation education for nurses.
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Affiliation(s)
- Linda Heino
- Department of Nursing ScienceUniversity of TurkuTurkuFinland
| | - Minna Stolt
- Department of Nursing ScienceUniversity of Turku, Turku University HospitalTurkuFinland
| | - Elina Haavisto
- Department of Nursing ScienceUniversity of TurkuTurkuFinland,Department of Health SciencesTampere University, Tampere University HospitalTampereFinland,Satakunta Hospital DistrictPoriFinland
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29
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Pandey S, Dolan A, Norton-Westbrook M, Desai AV. "Knock Me Out": The Challenges of Managing Pain Due to Cutaneous T Cell Lymphomas: A Case Report. J Palliat Med 2022; 25:1740-1746. [PMID: 35420490 PMCID: PMC9836697 DOI: 10.1089/jpm.2021.0561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Cutaneous T cell lymphomas are associated with distressing symptoms, including pain and pruritus that negatively impact quality of life. Early involvement of palliative care can provide relief of symptoms and address multifaceted distress. This case highlights the complex management of cutaneous T cell lymphoma pain and associated symptoms, including existential and psychosocial distress. Our patient required frequent titration and rotation of high-dose opioids and adjuvant analgesics, ultimately requiring transfer to the intensive care unit for analgosedation. Total skin loss and disease complications led to his death after a compassionate withdrawal of life support. Cutaneous T cell lymphoma pain can be successfully managed with an interdisciplinary approach, early palliative care, and aggressive pain management. Complications from advanced disease, superinfection, and multidimensional distress complicate the efficacy of a multimodal analgesic approach. Further research is needed to deepen our understanding of how to optimally alleviate suffering within this vulnerable population.
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Affiliation(s)
- Shila Pandey
- Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrea Dolan
- Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Moe Norton-Westbrook
- Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anjali V Desai
- Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
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30
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Surges SM, Garralda E, Jaspers B, Brunsch H, Rijpstra M, Hasselaar J, Van der Elst M, Menten J, Csikós Á, Mercadante S, Mosoiu D, Payne S, Centeno C, Radbruch L. Review of European Guidelines on Palliative Sedation: A Foundation for the Updating of the European Association for Palliative Care Framework. J Palliat Med 2022; 25:1721-1731. [PMID: 35849746 DOI: 10.1089/jpm.2021.0646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In 2009, the European Association for Palliative Care (EAPC) developed a framework on palliative sedation, acknowledging this practice as an important and ethically acceptable intervention of last resort for terminally ill patients experiencing refractory symptoms. Before and after that, other guidelines on palliative sedation have been developed in Europe with variations in terminology and concepts. As part of the Palliative Sedation project (Horizon 2020 Funding No. 825700), a revision of the EAPC framework is planned. The aim of this article is to analyze the most frequently used palliative sedation guidelines as reported by experts from eight European countries to inform the discussion of the new framework. The three most reported documents per country were identified through an online survey among 124 clinical experts in December 2019. Those meeting guideline criteria were selected. Their content was assessed against the EAPC framework on palliative sedation. The quality of their methodology was evaluated with the Appraisal Guideline Research and Evaluation (AGREE) II instrument. Nine guidelines were included. All recognize palliative sedation as a last-resort treatment for refractory symptoms, but the criterion of refractoriness remains a matter of debate. Most guidelines recognize psychological or existential distress as (part of) an indication and some make specific recommendations for such cases. All agree that the assessment should be multiprofessional, but they diverge on the expertise required by the attending physician/team. Regarding decisions on hydration and nutrition, it is proposed that these should be independent of those for palliative sedation, but there is no clear consensus on the decision-making process. Several weaknesses were highlighted, particularly in areas of rigor of development and applicability. The identified points of debate and methodological weaknesses should be considered in any update or revision of the guidelines analyzed to improve the quality of their content and the applicability of their recommendations.
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Affiliation(s)
- Séverine M Surges
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Eduardo Garralda
- ATLANTES Global Palliative Care Observatory, Institute for Culture and Society, University of Navarra, Pamplona, Spain.,IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Birgit Jaspers
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany.,Department of Palliative Medicine, University Medicine Goettingen, Goettingen, Germany
| | - Holger Brunsch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Maaike Rijpstra
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre (Radboudumc), Nijmegen, the Netherlands
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre (Radboudumc), Nijmegen, the Netherlands
| | | | - Johan Menten
- Laboratory of Experimental Radiotherapy, UH & KU Leuven, Leuven, Belgium
| | - Ágnes Csikós
- Department of Primary Health Care, Department of Hospice-Palliative Care, University of Pecs Medical School, Pecs, Hungary
| | - 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, Brasov, Romania.,Education and National Development Department, Hospice Casa Sperantei, Brasov, Brasov, Romania
| | - Sheila Payne
- International Observatory on End-of-Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Carlos Centeno
- ATLANTES Global Palliative Care Observatory, Institute for Culture and Society, University of Navarra, Pamplona, Spain.,IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
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Wang J, Lu C, Zhang J, Gao M, Liu D, Yang P, Yu T, Wang X, Zhang X, Liu Y. LYTIC COCKTAIL ATTENUATES CATECHOLAMINE SURGE AFTER SEVERE BURNS BY BLOCKING HISTAMINE H1 RECEPTOR/PKA/CREB/TYROSINE HYDROXYLASE SIGNALING IN CHROMAFFIN CELLS. Shock 2022; 58:158-168. [PMID: 35953455 DOI: 10.1097/shk.0000000000001963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Severe burns develop a catecholamine surge, inducing severe damage to the organism, raising the possibility of multisystem organ failure, and even death. The mechanisms of catecholamine surge have not been fully elucidated, and few strategies are generally acceptable to reduce catecholamine surge postburn. Thus, it is valuable to investigate the underlying mechanisms of catecholamine surge postburn to develop targeted interventions to attenuate it. We have found that the lytic cocktail alleviates the surge of catecholamine and organ injury after severe burn; however, the underlying mechanisms were still unclear. Moreover, the lytic cocktail has side effects, such as significant arterial hypotension and breathing depression, limiting its clinical application. This study aims to investigate the therapeutic mechanism of the lytic cocktail in regulating catecholamine levels postburn. We find that promethazine, a classic histamine H1 receptor blocker and a component of the lytic cocktail, can effectively reduce catecholamine surge and organ injury postburn. Our study confirms that blood histamine levels increase after severe burns. We find that histamine can amplify the catecholamine surge by elevating tyrosine hydroxylase expression and catecholamine synthesis in chromaffin cells through the histamine H1 receptor/Protein Kinase A /cAMP-response element binding protein signaling pathway. In summary, for the first time, we find that histamine plays a vital role in catecholamine surge postburn. We also confirm that the lytic cocktail effectively alleviates catecholamine surge and organ injury postburn through promethazine.
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Affiliation(s)
- Jizhuang Wang
- Department of Burn, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Hedman C, Rosso A, Häggström O, Nordén C, Fürst CJ, Schelin MEC. Sedation in specialized palliative care: A cross-sectional study. PLoS One 2022; 17:e0270483. [PMID: 35802571 PMCID: PMC9269455 DOI: 10.1371/journal.pone.0270483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/12/2022] [Indexed: 11/19/2022] Open
Abstract
Background Palliative sedation is used to relieve refractory symptoms and is part of clinical practice in Sweden. Yet we do not know how frequently this practice occurs, how decision-making takes place, or even which medications are preferentially used. Objectives To understand the current practice of palliative sedation in Sweden. Methods We conducted a retrospective cross-sectional medical record-based study. For 690 consecutive deceased patients from 11 of 12 specialized palliative care units in the southernmost region of Sweden who underwent palliative sedation during 2016, we collected data on whether the patient died during sedation and, for sedated patients, the decision-making process, medication used, and depth of sedation. Results Eight percent of patients were sedated. Almost all (94%) were given midazolam, sometimes in combination with propofol. The proportions of sedation were similar in the patient groups with and without cancer. The largest proportion of the sedated patients died in inpatient care, but 23% died at home, with specialized palliative home care. Among the patients with a decision to sedate, 42% died deeply unconscious, while for those without such a decision the corresponding figure was 16%. In only one case was there more than one physician involved in the decision to use palliative sedation. Conclusion 8% of patients in specialized palliative care received palliative sedation, which is lower than international measures but much increased compared to an earlier Swedish assessment. The level of consciousness achieved often did not correspond to the planned level; this, together with indications of a scattered decision process, shows a need for clear guidelines.
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Affiliation(s)
- Christel Hedman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
- R&D Department, Stockholms Sjukhem Foundation, Stockholm, Sweden
- * E-mail:
| | - Aldana Rosso
- Division of Geriatric Medicine, Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
| | - Ola Häggström
- Unit of Palliative Care Kristianstad, Region Skåne, Kristianstad, Sweden
| | | | - Carl Johan Fürst
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
| | - Maria E. C. Schelin
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
- Department of Research and Development, Skåne University Hospital, Lund, Sweden
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Salzmann L, Alt-Epping B, Simon A. Palliative sedation in amyotrophic lateral sclerosis: results of a nationwide survey among neurologists and palliative care practitioners in Germany. BMC Neurol 2022; 22:161. [PMID: 35490234 PMCID: PMC9055769 DOI: 10.1186/s12883-022-02681-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/20/2022] [Indexed: 12/12/2022] Open
Abstract
Background Palliative sedation has become widely accepted as a method to alleviate refractory symptoms in terminally ill patients. Controversies regarding this topic especially concern the use of palliative sedation for psychological symptoms, the use in patients who are not imminently dying and the simultaneous withdrawal of life-sustaining measures. Amyotrophic lateral sclerosis (ALS) is characterized by symptoms including muscle weakness, dysphagia, dysarthria, muscle spasms and progressive respiratory insufficiency. Due to these characteristic symptoms, palliative sedation might be considered to be necessary to alleviate refractory suffering in ALS patients. However, palliative sedation in ALS is only rarely discussed in current medical literature and guidelines. Methods A questionnaire survey was conducted among neurologists and palliative care practitioners in Germany. The participants were asked to evaluate the use of palliative sedation in different situations. Results Two hundred and ninety-six completed questionnaires were analyzed. The results suggest high levels of support for the use of palliative sedation in ALS patients. 42% of the participants stated that they had already used palliative sedation in the treatment of ALS patients. Acceptance of palliative sedation was higher in case of physical symptoms than in case of psychological symptoms. Refusal of artificial nutrition did not lead to a lower acceptance of palliative sedation. Doctors with specialist training in palliative care had already used palliative sedation in ALS patients more often and they were more likely to accept palliative sedation in different situations than the participants without a background in palliative care. Conclusion Our survey showed that palliative sedation in ALS is widely accepted by the attending doctors. In case of psychological symptoms, palliative sedation is looked at with more concern than in case of physical symptoms. The refusal of artificial nutrition does not result in a decreased acceptance of palliative sedation. Doctors with specialist training in palliative care are more likely to approve of palliative sedation in ALS. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02681-7.
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Affiliation(s)
- Laura Salzmann
- Department of Hematology, Oncology and Palliative Medicine, Medical Center Bad Hersfeld, Bad Hersfeld, Germany
| | - Bernd Alt-Epping
- Department of Palliative Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Alfred Simon
- Academy of Ethics in Medicine, University Medical Center Goettingen, Goettingen, Germany.
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Cocker A, Singy P, Jox RJ. How should health care providers inform about palliative sedation? A qualitative study with palliative care professionals. Eur J Cancer Care (Engl) 2022; 31:e13602. [PMID: 35488398 PMCID: PMC9541839 DOI: 10.1111/ecc.13602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 12/24/2021] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
Abstract
Objective In Switzerland, palliative sedation consists of using sedatives to relieve terminally ill patients. It is divided into several steps, with one of them consisting of informing patients and relatives about the procedure. In the current recommendations, there is a lack of orientation about how and when this discussion should take place. Hence, we aim to explore perceptions and experiences of palliative care professionals regarding these questions. Methods Qualitative semi‐structured interviews with five physicians and five nurses working in specialised palliative care were conducted. They were then analysed with thematic analysis. Results Results showed a uniformity around definition, goals and indications of palliative sedation. However, there was a lack of consistency regarding the process of delivering this information to patients and relatives. Finally, some participants strongly opposed the idea of systematically informing patients in specialised palliative care, while others were more divided on this question. Conclusion Despite a common understanding of the concept of palliative sedation, there is no standard practice when informing patients on palliative sedation among palliative care professionals. Therefore, this study demonstrates the need for further guidelines on this question and calls for a better understanding and knowledge of palliative sedation among health professionals outside palliative care.
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Affiliation(s)
- Allan Cocker
- Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Pascal Singy
- Liaison Psychiatry, CHUV, University of Lausanne, Lausanne, Switzerland
| | - Ralf J Jox
- Geriatric Palliative Care, CHUV, University of Lausanne, Lausanne, Switzerland.,Institute of Humanities in Medicine, CHUV, University of Lausanne, Lausanne, Switzerland
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Lucena A, Yuguero O. Systematic Review of Common Refractory Symptoms in the End-Of-Life Situation and Its Relation With Euthanasia. OMEGA-JOURNAL OF DEATH AND DYING 2022:302228221089123. [PMID: 35441562 DOI: 10.1177/00302228221089123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To analyse the available evidence regarding refractory symptoms to treatment in patients receiving palliative/terminal healthcare. DESIGN A systematic review of various databases between September and December 2020; Pubmed; Cochrane; Scopus and ScienceDirect. Study eligibility criteria: Studies published between 1st January 2015 and 31st of March 2020, in Spanish, English or Catalan conducted in elderly people or terminal patients. The study included systematic reviews, clinical trials and interventions. RESULTS The search returned 782 articles, of which 22 articles were finally reviewed. Of the selected articles, 16 were systematic reviews and three were clinical trials. Three refractory symptoms are notable; breathlessness, delirium and existential suffering. There are various therapeutic approaches for the first two symptoms, but palliative sedation seems to be most effective for existential suffering. CONCLUSIONS Although palliative care enables controlling these symptoms effectively, and following a multidisciplinary approach, there remains a group of patients for whom euthanasia could save foreseeable suffering that is difficult to manage.
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Affiliation(s)
- Alba Lucena
- Surgery Department, Faculty of Medicine, 16739University of Lleida, Lleida, Spain
| | - Oriol Yuguero
- Surgery Department, Faculty of Medicine, 16739University of Lleida, Lleida, Spain
- 219654Institut de Recerca Biomèdica de Lleida (IRBLLEIDA), Lleida, Spain
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Benini F, Avagnina I, Giacomelli L, Papa S, Mercante A, Perilongo G. Pediatric Palliative Care in Oncology: Basic Principles. Cancers (Basel) 2022; 14:cancers14081972. [PMID: 35454879 PMCID: PMC9031296 DOI: 10.3390/cancers14081972] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary About 4 million children with an oncological disease worldwide require palliative care due to the nature of their condition. The WHO defines pediatric palliative care (PPC) as the prevention and relief of suffering in patients with life-threatening or life-limiting disease and their families. PPC relies on the comprehensive and multidisciplinary management of the child and the family’s physical, psychological, spiritual, and social needs. Importantly, PPC begins at the diagnosis of incurability, or supposed incurability, and continues regardless of whether the patient receives any oncological treatment. As such, PPC is a general approach continuing over the entire disease trajectory, which includes, but is not limited to, end-of-life care. This review addresses the value of integrating PPC in treating children with cancer, focusing on the basic principles of PPC and its application in pediatric oncology. Abstract About 4 million children with an oncological disease worldwide require pediatric palliative care (PPC) due to the nature of their condition. PPC is not limited to end-of-life care; it is a general approach continuing over the entire disease trajectory, regardless of whether the patient receives any oncological treatment. This review addresses the value of integrating PPC in treating children with cancer, focusing on the basic principles of PPC and its application in pediatric oncology. Moreover, models for PPC implementation in oncology, end-of-life care, and advanced care planning are discussed.
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Affiliation(s)
- Franca Benini
- Paediatric Palliative Care, Pain Service, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy;
- Correspondence:
| | - Irene Avagnina
- Paediatric Palliative Care, Pain Service, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy;
| | | | | | - Anna Mercante
- Pediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy; (A.M.); (G.P.)
| | - Giorgio Perilongo
- Pediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy; (A.M.); (G.P.)
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Rodrigues P, Ostyn J, Mroz S, Ronsse A, Menten J, Gastmans C. Ethics of sedation for existential suffering: palliative medicine physician perceptions - qualitative study. BMJ Support Palliat Care 2022; 13:209-217. [PMID: 35418444 DOI: 10.1136/bmjspcare-2021-003395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/28/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Palliative sedation for existential suffering (PS-ES) is considered a controversial practice to control refractory suffering at the end of life. This study aims to explore Belgian palliative care physicians' perceptions regarding the ethics of PS-ES. METHODS This nationwide qualitative study follows a Grounded Theory approach. We conducted semistructured interviews with 25 palliative care physicians working in 23 Belgian hospitals and hospices (Flanders, Brussels, Wallonia). We analysed the data using the Qualitative Analysis Guide Of Leuven and we followed the Consolidated Criteria for Reporting Qualitative Research guidelines. RESULTS The data revealed that Belgian palliative care physicians have difficulty characterising ES and distinguishing it from other types of suffering. They express mixed attitudes towards PS-ES and employ a wide range of ethical arguments in favour and against it, which are mainly linked to the four principles of biomedical ethics. CONCLUSION Since there is a lack of consensus among Belgian palliative care physicians about PS-ES, further research is needed to clarify their attitudes. A better understanding of physicians' underlying presuppositions can provide more insight into their perceptions of ES and PS-ES and provide further insight for establishing good practices in ES management at the end of life.
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Affiliation(s)
- Paulo Rodrigues
- ETHICS EA 7446, Université Catholique de Lille, Lille, France
| | - Jozefien Ostyn
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sarah Mroz
- Vrije Universiteit Brussel, Brussel, Belgium
| | - Axelle Ronsse
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Johan Menten
- Radiation-Oncology and Palliatiev Care, UZ Gasthuisberg, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
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Kremling A, Bausewein C, Klein C, Schildmann E, Ostgathe C, Ziegler K, Schildmann J. Intentional Sedation as a Means to Ease Suffering: A Systematically Constructed Terminology for Sedation in Palliative Care. J Palliat Med 2022; 25:793-796. [PMID: 35073180 PMCID: PMC9081045 DOI: 10.1089/jpm.2021.0428] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Alexander Kremling
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine Ludwig-Maximilian-Universität, Comprehensive Cancer Centre Munich (CCCM), LMU University Hospital, Munich, Germany
| | - Carsten Klein
- Department of Palliative Medicine, Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Eva Schildmann
- Department of Palliative Medicine Ludwig-Maximilian-Universität, Comprehensive Cancer Centre Munich (CCCM), LMU University Hospital, Munich, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle, Germany
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Belar A, Arantzamendi M, Menten J, Payne S, Hasselaar J, Centeno C. The Decision-Making Process for Palliative Sedation for Patients with Advanced Cancer-Analysis from a Systematic Review of Prospective Studies. Cancers (Basel) 2022; 14:301. [PMID: 35053464 PMCID: PMC8773810 DOI: 10.3390/cancers14020301] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The involvement of patients in decision making about their healthcare plans is being emphasized. In the context of palliative sedation, it is unclear how these decisions are made and who are involved in. The aim of the study is to understand how this decision-making is taken. METHOD Information from a systematic review on clinical aspects of palliative sedation prospective studies were included. PubMed, CINAHL, Cochrane, MEDLINE, and EMBASE were searched (January 2014-December 2019). Data extraction and analysis regarded: (a) When and by whom the decision-making process is initiated; (b) patient involvement; (c) family involvement and (d) healthcare involvement. RESULTS Data about decision making were reported in 8/10 included articles. Palliative sedation was reported in 1137 patients (only 16 of them were non-cancer). Palliative sedation was introduced by the palliative care team during the disease process, at admission, or when patients experienced refractory symptoms. Only two studies explicitly mentioned the involvement of patients in decision making. Co-decision between families and the regular health care professionals was usual, and the health care professionals involved had been working in palliative care services. CONCLUSION Patient participation in decision making appeared to be compromised by limited physical or cognitive capacity and family participation is described. The possibility of palliative sedation should be discussed earlier in the disease process.
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Affiliation(s)
- Alazne Belar
- Institute for Culture and Society-Atlantes, Universidad de Navarra, 31009 Pamplona, Spain; (A.B.); (C.C.)
- IdiSNA—Instituto de Investigacion Sanitaria de Navarra, 31008 Pamplona, Spain
| | - Maria Arantzamendi
- Institute for Culture and Society-Atlantes, Universidad de Navarra, 31009 Pamplona, Spain; (A.B.); (C.C.)
- IdiSNA—Instituto de Investigacion Sanitaria de Navarra, 31008 Pamplona, Spain
| | - Johan Menten
- Department of Oncology, Laboratory of Experimental Radiotherapy, Katholieke Universiteit, 3000 Leuven, Belgium;
| | - Sheila Payne
- Division of Health Research, Lancaster University, Lancaster LA1 4YW, UK;
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands;
| | - Carlos Centeno
- Institute for Culture and Society-Atlantes, Universidad de Navarra, 31009 Pamplona, Spain; (A.B.); (C.C.)
- IdiSNA—Instituto de Investigacion Sanitaria de Navarra, 31008 Pamplona, Spain
- Departamento Medicina Paliativa, Clínica Universidad de Navarra, 31001 Pamplona, Spain
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Basilicata P, Giugliano P, Vacchiano G, Simonelli A, Guadagni R, Silvestre A, Pieri M. Forensic Toxicological and Medico-Legal Evaluation in a Case of Incongruous Drug Administration in Terminal Cancer Patients. TOXICS 2021; 9:toxics9120356. [PMID: 34941790 PMCID: PMC8704381 DOI: 10.3390/toxics9120356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/03/2021] [Accepted: 12/15/2021] [Indexed: 11/28/2022]
Abstract
Background: In most cases, palliative care is prescribed to adults diagnosed with cancer. The definition of the most suitable therapy for an effective sedation in terminal cancer patients still represents one of the most challenging goals in medical practice. Due to their poor health, the correct dosing of drugs used for deep palliative sedation in terminal cancer patients, often already on polypharmacological therapy, can be extremely complicated, also considering possible drug-to-drug interactions that could lead to an increased risk of overdose and/or incongruous administration with fatal outcomes. The case of a terminal cancer patient is presented, focusing on the “adequacy” of administered therapy. Materials and Methods: A young male, affected by Ewing sarcoma, attending a palliative care at his own home, died soon after midazolam administration. Toxicological and histological analyses were performed on body fluids and organ fragments. Results and Discussion: Morphological reliefs evidenced a neoplastic mass, composed of lobulated tissue with a lardy, pinkish-gray consistency, extending from the pleural surface to the lung parenchyma, also present at the sacrum region (S1–S5), at the anterior mediastinum level, occupying the entire left pleural cavity, and infiltrating the ipsilateral lung. Metastatic lesions diffused to rachis and lumbar structures. The brain presented edema and congestion. Toxicological analyses evidenced blood midazolam concentrations in the range of 0.931–1.690 µg/mL, while morphine was between 0.266 and 0.909 µg/mL. Death was attributed to cardiorespiratory depression because of a synergic action between morphine and midazolam. The pharmacological interaction between midazolam and morphine is discussed considering the clinical situation of the patient. The opportunity to proceed with midazolam administration is discussed starting from guidelines recommendation. Finally, professional liability outlines are highlighted.
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Affiliation(s)
- Pascale Basilicata
- Legal Medicine Section, Department of Advanced Biomedical Science, University of Naples “Federico II”, 80131 Naples, Italy; (P.B.); (A.S.); (R.G.); (A.S.)
| | - Pasquale Giugliano
- Legal Medicine Section, AORN “Sant’Anna e San Sebastiano” Caserta, 81100 Caserta, Italy;
| | - Giuseppe Vacchiano
- Department of Law, Economics and Mathematical Methods, University of Sannio, 82100 Benevento, Italy;
| | - Angela Simonelli
- Legal Medicine Section, Department of Advanced Biomedical Science, University of Naples “Federico II”, 80131 Naples, Italy; (P.B.); (A.S.); (R.G.); (A.S.)
| | - Rossella Guadagni
- Legal Medicine Section, Department of Advanced Biomedical Science, University of Naples “Federico II”, 80131 Naples, Italy; (P.B.); (A.S.); (R.G.); (A.S.)
| | - Angela Silvestre
- Legal Medicine Section, Department of Advanced Biomedical Science, University of Naples “Federico II”, 80131 Naples, Italy; (P.B.); (A.S.); (R.G.); (A.S.)
| | - Maria Pieri
- Legal Medicine Section, Department of Advanced Biomedical Science, University of Naples “Federico II”, 80131 Naples, Italy; (P.B.); (A.S.); (R.G.); (A.S.)
- Correspondence: ; Tel.: +39-0817463474; Fax: +39-0817464726
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Ramos-Rincon JM, Moreno-Perez O, Gomez-Martinez N, Priego-Valladares M, Climent-Grana E, Marti-Pastor A, Portilla-Sogorb J, Sanchez-Martinez R, Merino E. Palliative Sedation in COVID-19 End-of-Life Care. Retrospective Cohort Study. ACTA ACUST UNITED AC 2021; 57:medicina57090873. [PMID: 34577796 PMCID: PMC8470831 DOI: 10.3390/medicina57090873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/20/2021] [Accepted: 08/22/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Descriptions of end-of-life in COVID-19 are limited to small cross-sectional studies. We aimed to assess end-of-life care in inpatients with COVID-19 at Alicante General University Hospital (ALC) and compare differences according to palliative and non-palliative sedation. Material and Methods: This was a retrospective cohort study in inpatients included in the ALC COVID-19 Registry (PCR-RT or antigen-confirmed cases) who died during conventional admission from 1 March to 15 December 2020. We evaluated differences among deceased cases according to administration of palliative sedation. Results: Of 747 patients evaluated, 101 died (13.5%). Sixty-eight (67.3%) died in acute medical wards, and 30 (44.1%) received palliative sedation. The median age of patients with palliative sedation was 85 years; 44% were women, and 30% of cases were nosocomial. Patients with nosocomial acquisition received more palliative sedation than those infected in the community (81.8% [9/11] vs 36.8% [21/57], p = 0.006), and patients admitted with an altered mental state received it less (20% [6/23] vs. 53.3% [24/45], p = 0.032). The median time from admission to starting palliative sedation was 8.5 days (interquartile range [IQR] 3.0–14.5). The main symptoms leading to palliative sedation were dyspnea at rest (90%), pain (60%), and delirium/agitation (36.7%). The median time from palliative sedation to death was 21.8 h (IQR 10.4–41.1). Morphine was used in all palliative sedation perfusions: the main regimen was morphine + hyoscine butyl bromide + midazolam (43.3%). Conclusions: End-of-life palliative sedation in patients with COVID-19 was initiated quite late. Clinicians should anticipate the need for palliative sedation in these patients and recognize the breathlessness, pain, and agitation/delirium that foreshadow death.
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Affiliation(s)
- Jose-Manuel Ramos-Rincon
- Internal Medicine Department, Alicante General University Hospital—Alicante Institute of Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain; (A.M.-P.); (J.P.-S.); (R.S.-M.)
- Clinical Medicine Department, Miguel Hernández University, 03550 Elche, Spain;
- Correspondence:
| | - Oscar Moreno-Perez
- Clinical Medicine Department, Miguel Hernández University, 03550 Elche, Spain;
- Endocrinology and Nutrition Department, Alicante General University Hospital—Alicante Institute of Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain;
| | - Nazaret Gomez-Martinez
- Endocrinology and Nutrition Department, Alicante General University Hospital—Alicante Institute of Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain;
| | - Manuel Priego-Valladares
- Palliative Care Unit and Internal Medicine Department, Alicante General University Hospital—Alicante Institute of Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain;
| | - Eduardo Climent-Grana
- Pharmacy Department, Alicante General University Hospital—Alicante Institute of Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain;
| | - Ana Marti-Pastor
- Internal Medicine Department, Alicante General University Hospital—Alicante Institute of Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain; (A.M.-P.); (J.P.-S.); (R.S.-M.)
| | - Joaquin Portilla-Sogorb
- Internal Medicine Department, Alicante General University Hospital—Alicante Institute of Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain; (A.M.-P.); (J.P.-S.); (R.S.-M.)
- Clinical Medicine Department, Miguel Hernández University, 03550 Elche, Spain;
| | - Rosario Sanchez-Martinez
- Internal Medicine Department, Alicante General University Hospital—Alicante Institute of Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain; (A.M.-P.); (J.P.-S.); (R.S.-M.)
| | - Esperanza Merino
- Unit of Infectious Diseases, Alicante General University Hospital—Alicante Institute of Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain;
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Palliative sedation in patients with advanced cancer in a specialized unit in a middle-income country: A retrospective cohort study. Palliat Support Care 2021; 20:491-495. [PMID: 34425935 DOI: 10.1017/s1478951521001371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To describe the 5-year practice on palliative sedation in a specialized palliative care unit in a deprived region in Brazil, and to compare survival of patients with advanced cancer who were and were not sedated during their end-of-life care. METHOD Retrospective cohort study in a tertiary teaching hospital. We described the practice of palliative sedation and compared the survival time between patients who were and were not sedated in their last days of life. RESULTS We included 906 patients who were admitted to the palliative care unit during the study period, of whom, 92 (10.2%) received palliative sedation. Patients who were sedated were younger, presented with higher rates of delirium, and reported more pain, suffering, and dyspnea than those who were not sedated. Median hospital survival of patients who received palliative sedation was 9.30 (CI 95%, 7.51-11.81) days and of patients who were not sedated was 8.2 (CI 95%, 7.3-9.0) days (P = 0.31). Adjusted for age and sex, palliative sedation was not significantly associated with hospital survival (hazard ratio = 0.93; CI 95%, 0.74-1.15). SIGNIFICANCE OF RESULTS Palliative sedation can be accomplished even in a deprived area. Delirium, dyspnea, and pain were more common in patients who were sedated. Median survival was not reduced in patients who were sedated.
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Jones JF, Hirst JM, Edmonds KP, Atayee RS. A Case Report of Phenobarbital for Proportionate Sedation to Control Refractory Symptoms at the End of Life in an Opioid Tolerant Patient. J Pain Palliat Care Pharmacother 2021; 35:167-174. [PMID: 34264774 DOI: 10.1080/15360288.2021.1931631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
End of life (EoL) and refractory symptom management is a growing clinical topic and there is minimal literature to support effective treatment strategies, especially in individuals with a substance use disorder or opioids and/or benzodiazepine tolerance. We report the successful use of phenobarbital for proportionate EoL sedation in a 57-year-old man with opioid use disorder (heroin) and metastatic urothelial carcinoma presenting to an acute care hospital with intractable back pain related to bone metastases. During his hospitalization, his daily opioid requirement exceeded 1 gram of morphine equivalent daily dose (MEDD) with suboptimal pain control. The patient's clinical course was complicated by active heroin withdrawal, psychosocial suffering, and disease progression. Despite use of high-dose opioids and benzodiazepines, pain and anxiety were poorly controlled. After an acute medical decompensation, a goals of care discussion was held with his family and a determination with informed consent was made to change patient status to do not attempt resuscitation and proportionate sedation with phenobarbital was initiated to target refractory pain and agitation. Phenobarbital was continued for approximately 15 hours before patient peacefully died. Findings from this case report demonstrate the successful use of phenobarbital in opioid use disorder and benzodiazepine tolerance with intractable pain.
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Koksvik GH, Richards N, Gerson SM, Materstvedt LJ, Clark D. Medicalisation, suffering and control at the end of life: The interplay of deep continuous palliative sedation and assisted dying. Health (London) 2020; 26:512-531. [PMID: 33307828 PMCID: PMC9163770 DOI: 10.1177/1363459320976746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Medicalisation is a pervasive feature of contemporary end of life and dying in Western Europe and North America. In this article, we focus on the relationship between two specific aspects of the medicalisation of dying: deep continuous palliative sedation until death and assisted dying. We draw upon a qualitative interview study with 29 health professionals from three jurisdictions where assisted dying is lawful: Flanders, Belgium; Oregon, USA; and Quebec, Canada. Our findings demonstrate that the relationship between palliative sedation and assisted dying is often perceived as fluid and complex. This is inconsistent with current laws as well as with ethical and clinical guidelines according to which the two are categorically distinct. The article contributes to the literature examining health professionals’ opinions and experiences. Moreover, our findings inform a discussion about emergent themes: suffering, timing, autonomy and control – which appear central in the wider discourse in which both palliative sedation and assisted dying are situated, and which in turn relate to the wider ideas about what constitutes a ‘good death’.
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