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Mori M, Yamaguchi T, Suzuki K, Matsuda Y, Matsunuma R, Watanabe H, Ikari T, Matsumoto Y, Imai K, Yokomichi N, Miwa S, Yamauchi T, Okamoto S, Inoue S, Inoue A, Hui D, Morita T, Satomi E. Do Types of Opioids Matter for Terminal Cancer Dyspnea? A Preliminary Multicenter Cohort Study. J Pain Symptom Manage 2023; 66:e177-e184. [PMID: 37080479 DOI: 10.1016/j.jpainsymman.2023.04.009] [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: 02/06/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/22/2023]
Abstract
CONTEXT Dyspnea is among the most distressing symptoms in the last weeks to days of life (terminal dyspnea). While physicians frequently use parenteral opioids other than morphine for terminal dyspnea, little is known about their effects in cancer patients. OBJECTIVES To explore the effectiveness and safety of parenteral morphine, oxycodone, and hydromorphone for cancer patients with terminal dyspnea. METHODS This was a secondary analysis of a multicenter cohort study that consecutively enrolled advanced cancer patients with moderate/severe terminal dyspnea. Participating palliative care physicians initiated parenteral opioids (morphine/oxycodone/hydromorphone), utilizing a standardized treatment algorithm. We examined the dyspnea intensity (Integrated Palliative care Outcome Scale [IPOS]) at 24 and 48 hours. RESULTS Of 108 patients (mean age = 72), 66 (61%), 34 (32%), and 8 (7.4%) received morphine, oxycodone, and hydromorphone, respectively. At 24 hours, mean dyspnea IPOS scores significantly decreased from 3.0 (standard error (SE) = 0.1) at the baseline to 1.6 (0.1), 2.9 (0.1) to 2.0 (0.2), and 3.5 (0.2) to 1.2 (0.4) in the morphine (P < 0.001), oxycodone (P < 0.001), and hydromorphone (P = 0.011) groups, respectively. At 48 hours, the IPOS scores significantly reduced from 2.9 (0.1) at the baseline to 1.4 (0.1), 2.9 (0.1) to 1.6 (0.2), and 3.5 (0.2) to 1.2 (0.2) in the morphine (P < 0.001), oxycodone (P < 0.001), and hydromorphone (P = 0.004) groups, respectively. No significant differences in mean scores were found among the three groups at 24 (P = 0.080) and 48 hours (P = 0.322). Adverse events were rare. CONCLUSION Parenteral morphine, oxycodone, and hydromorphone may be similarly effective and safe for cancer patients with terminal dyspnea.
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Affiliation(s)
- Masanori Mori
- Palliative and Supportive Care Division (M.M., N.Y., T.M.), Seirei Mikatahara General Hospital, Hamamatsu, Japan.
| | - Takashi Yamaguchi
- Department of Palliative Medicine (T.Y.), Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kozue Suzuki
- Department of Palliative Care (K.S.), Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine (Y.M.), National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Ryo Matsunuma
- Division of Palliative Care (R.M.), Department of Medicine, Konan Medical Center, Kobe, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care (H.W.), Komaki City Hospital, Komaki, Japan
| | - Tomoo Ikari
- Department of Palliative Medicine (T.I., A.I.), Tohoku University School of Medicine, Sendai, Japan
| | - Yoshihisa Matsumoto
- Department of Palliative Therapy (Y.M.), Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kengo Imai
- Seirei Hospice (K.I., S.M., T.Y., S.O., S.I.), Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Naosuke Yokomichi
- Palliative and Supportive Care Division (M.M., N.Y., T.M.), Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Satoru Miwa
- Seirei Hospice (K.I., S.M., T.Y., S.O., S.I.), Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Toshihiro Yamauchi
- Seirei Hospice (K.I., S.M., T.Y., S.O., S.I.), Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Soichiro Okamoto
- Seirei Hospice (K.I., S.M., T.Y., S.O., S.I.), Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Satoshi Inoue
- Seirei Hospice (K.I., S.M., T.Y., S.O., S.I.), Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Akira Inoue
- Department of Palliative Medicine (T.I., A.I.), Tohoku University School of Medicine, Sendai, Japan
| | - David Hui
- Department of Palliative (D.H.), Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tatsuya Morita
- Palliative and Supportive Care Division (M.M., N.Y., T.M.), Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Eriko Satomi
- Department of Palliative Medicine (E.S.), National Cancer Center Hospital, Tokyo, Japan
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Yang CH, Chen PJ, Mori M, Morita T, Cheng SY, Suh SY, Kim SH, Yokomichi N, Imai K, Ito S, Yamaguchi T, Hiratsuka Y, Tsuneto S, Maeda S. Cross-cultural comparison of continuous deep sedation for advanced cancer patients in East Asian countries: prospective cohort study. Jpn J Clin Oncol 2023:7145896. [PMID: 37114920 DOI: 10.1093/jjco/hyad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
OBJECTIVE Cultural, social, and legal factors have been known to affect physicians' practice of continuous deep sedation. There have been few quantitative studies to compare continuous deep sedation practice in Asian countries. We aimed to describe and compare clinical characteristics of continuous deep sedation in Japan, Korea and Taiwan. METHODS Patients with advanced cancer admitted to participating palliative care units were enrolled from January 2017 to September 2018. We evaluated and compared (i) the prevalence of continuous deep sedation, (ii) the characteristics of sedated and non-sedated groups in each country, and (iii) continuous deep sedation administration patterns among the three countries. RESULTS A total of 2158 participants were included in our analysis, and 264 received continuous deep sedation. The continuous deep sedation prevalence was 10, 16 and 22% in Japan, Korea and Taiwan, respectively. Delirium was the most frequent target symptom in all countries, along with dyspnoea (in Japan) and psychological symptoms (in Korea). Midazolam was most frequently used in Japan and Taiwan, but not in Korea (P < 0.001). Among the patients receiving continuous deep sedation, the hydration amount on the final day was significantly different, with median volumes of 200, 500 and 0 mL in Japan, Korea and Taiwan, respectively (P < 0.001). In Korea, 33% of the continuous deep sedation administration caused a high degree of physicians' discomfort, but 3% in Japan and 5% in Taiwan (P < 0.001). CONCLUSIONS Clinical practices of continuous deep sedation and physicians' discomfort related to continuous deep sedation initiation highly varied across countries. We need to develop optimal decision-making models of continuous deep sedation and hydration during continuous deep sedation in each country.
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Affiliation(s)
- Chiu-Hsien Yang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ping-Jen Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Sang-Yeon Suh
- Department of Family Medicine, Dongguk University Ilsan Hospital, Goyang-si, South Korea
- Department of Medicine, Dongguk University Medical School, Seoul, South Korea
| | - Sun-Hyun Kim
- Department of Family Medicine, School of Medicine, Catholic Kwandong University, International St. Mary's Hospital, Incheon, South Korea
| | - Naosuke Yokomichi
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Satoko Ito
- Hospice, The Japan Baptist Hospital, Kyoto, Japan
| | - Takashi Yamaguchi
- Division of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yusuke Hiratsuka
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sayaka Maeda
- Department of Palliative Medicine, Kyoto University Hospital, Kyoto, Japan
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Mori M, Miwa S, Ikari T, Kako J, Hasegawa T, Matsunuma R, Suzuki K, Matsuda Y, Watanabe H, Morita T, Yamaguchi T. Current Management Options for Dyspnea in Cancer Patients. Curr Treat Options Oncol 2023; 24:565-579. [PMID: 37037975 DOI: 10.1007/s11864-023-01081-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 04/12/2023]
Abstract
OPINION STATEMENT Dyspnea is one of the most frequent and distressing symptoms in patients with advanced cancer. As dyspnea deteriorates patients' quality of life markedly and tends to worsen as the disease progresses, comprehensive assessment and timely treatment of the underlying etiologies are essential. International guidelines recommend various non-pharmacological and pharmacological management options. However, there is a scarcity of confirmatory clinical trials on cancer dyspnea, and the overall level of evidence is weak. Recently, observational and survey studies indicated a wide range of practice patterns of palliative care specialists, providing important insight into the real-world management of dyspnea. In this paper, we summarize current management options for dyspnea in cancer patients, highlight major controversies in the literature, and propose future research directions toward quality care for patients with dyspnea and their families.
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Affiliation(s)
- Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, 433-8558, Japan.
| | - Satoru Miwa
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tomoo Ikari
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan
| | - Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Ryo Matsunuma
- Division of Palliative Care, Konan Medical Center, Konan, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan
| | | | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, 433-8558, Japan
| | - Takashi Yamaguchi
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Imai K, Morita T, Mori M, Kiuchi D, Yokomichi N, Miwa S, Okamoto S, Yamauchi T, Naito AS, Matsuda Y, Maeda I, Sugano K, Ikenaga M, Inoue S, Satomi E. Visualizing How to Use Antipsychotics for Agitated Delirium in the Last Days of Life. J Pain Symptom Manage 2023; 65:479-489. [PMID: 36682673 DOI: 10.1016/j.jpainsymman.2023.01.004] [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] [Received: 10/11/2022] [Revised: 12/30/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
CONTEXT How physicians use antipsychotics for agitated delirium in the last days of life varies markedly, which could hamper the quality of care. OBJECTIVES To examine adherence to an algorithm-based treatment for terminal agitated delirium, and explore its effectiveness and safety. METHODS A single-center, prospective, observational study was conducted in a 27-bed palliative care unit in Japan. All adult cancer patients who developed agitated delirium with a modified Richmond Agitation-Sedation Scale (RASS) of +1 or more were included; the palliative care specialists determined that the etiology was irreversible, the estimated survival was three weeks or less, and the Eastern Cooperative Oncology Group (ECOG) performance status was three or four. Patients were treated with an algorithm to visualize how to use antipsychotics, with the treatment goal defined as no agitation (RASS≤0) or acceptable agitation for patients and families. We provided all patients nonpharmacological management to alleviate the symptoms of delirium and administered antipsychotic medications when the nonpharmacological approach was insufficient. We measured the adherence rate, RASS, Nursing Delirium Screening Scale items 2, 3, 4 (Nu-DESC), and Agitation Distress Scale item 2 (ADS) on days 0, 1, 3, 7, 14, 21, and 24 hours before death. RESULTS A total of 164 patients were enrolled. Adherence rates were 99, 94, and 89%, and treatment goals were achieved in 66, 83, and 93% on days one, three, and seven, respectively. The mean RASS decreased from +1.41 to -0.84 on day three; Nu-DESC decreased from 4.19 to 1.83, and ADS decreased from 1.54 to 0.38. There were seven severe adverse events (Common Terminology Criteria for Adverse Events (CTCAE) of 3), including aspiration (n = 3), apnea (n = 2), tremor (n = 1), and muscle rigidity (n = 1) on day three. CONCLUSION The algorithm-based treatment could be feasible, effective, and safe. Visualizing how palliative care specialists provide pharmacological management could be beneficial for nonspecialist clinicians, and clinical, educational, and research implications warrant further empirical testing.
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Affiliation(s)
- Kengo Imai
- Seirei Hospice (K.I., S.M., T.Y., S.I.), Seirei Miyahara General Hospital, Hamamatsu, Japan.
| | - Tatsuya Morita
- Division of Palliative and Supportive Care (T.M., M.M., N.Y.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | - Masanori Mori
- Division of Palliative and Supportive Care (T.M., M.M., N.Y.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | - Daisuke Kiuchi
- Department of Palliative Medicine (D.K., E.S.), National Cancer Center Hospital, Tokyo, Japan
| | - Naosuke Yokomichi
- Division of Palliative and Supportive Care (T.M., M.M., N.Y.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | - Satoru Miwa
- Seirei Hospice (K.I., S.M., T.Y., S.I.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | | | - Toshihiro Yamauchi
- Seirei Hospice (K.I., S.M., T.Y., S.I.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | - Akemi Shirado Naito
- Department of Palliative Care (A.S.N.), Miyazaki Medical Association Hospital, Miyazaki, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine (Y.M.), National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Isseki Maeda
- Department of Palliative Care (I.M.), Seri-Chuo Hospital, Toyonaka, Japan
| | - Koji Sugano
- Division of Respiratory Medicine (K.S.), Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Masayuki Ikenaga
- Department of Palliative Medicine (M.I.), Yodogawa Christian Hospital, Osaka, Japan
| | - Satoshi Inoue
- Seirei Hospice (K.I., S.M., T.Y., S.I.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | - Eriko Satomi
- Department of Palliative Medicine (D.K., E.S.), National Cancer Center Hospital, Tokyo, Japan
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Imai K, Morita T, Yokomichi N, Mori M, Naito AS, Yamauchi T, Tsukuura H, Uneno Y, Tsuneto S, Inoue S. Association of the RASS Score with Intensity of Symptoms, Discomfort, and Communication Capacity in Terminally Ill Cancer Patients Receiving Palliative Sedation: Is RASS an Appropriate Outcome Measure? Palliat Med Rep 2022; 3:47-54. [PMID: 35558868 PMCID: PMC9080998 DOI: 10.1089/pmr.2021.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Palliative sedation is sometimes needed for refractory symptoms, and the Richmond Agitation–Sedation Scale (RASS) is one of the key measures. The primary aim of this study was to explore the association between RASS and degree of distress quantified by other measures: Item “symptom control” of Support Team Assessment Schedule (STAS, item 2), Discomfort Scale for Dementia of Alzheimer Type (Discomfort Scale), and Noncommunicative Patient's Pain Assessment Instrument (NOPPAIN), as well as a communication capacity measured by the Communication Capacity Scale (CCS), item 4. Methods: This was a prospective observational study on terminally ill cancer patients with palliative sedation in a palliative care unit of a designated cancer hospital. Primarily responsible palliative care physicians rated RASS, Discomfort Scale, NOPPAIN, and CCS just before sedation and 1, 4, 24, and 48 hours after, and ward nurses rated STAS at the same time. Since the ward nurses evaluated STAS during palliative sedation, we regarded STAS as a standard of distress measure. Results: A total of 249 assessments were performed for 55 patients. RASS was moderately to highly associated with symptom intensity measured by STAS, discomfort measured by the Discomfort Scale, and pain measured by NOPPAIN (r = 0.63 to 0.73). But communication capacity measured by CCS is not parallel with RASS and demonstrated a valley shape. In 82 assessments with an RASS score of −1 to −3, 11 patients (13%) had physical symptoms of STAS of 2 or more. Conclusions: RASS can roughly estimate physical distress in patients with palliative sedation, but a measure to more precisely quantify the symptom experience is needed.
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Affiliation(s)
- Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Naosuke Yokomichi
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Akemi Shirado Naito
- Department of Palliative Care, Miyazaki Medical Association Hospital, Miyazaki, Japan
| | | | | | - Yu Uneno
- Department of Therapeutic Oncology and Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoshi Inoue
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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Mori M, Morita T, Bruera E, Hui D. Prognostication of the last days of life: Review article. Cancer Res Treat 2022; 54:631-643. [PMID: 35381165 PMCID: PMC9296934 DOI: 10.4143/crt.2021.1573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 03/26/2022] [Indexed: 12/01/2022] Open
Abstract
Accurate prediction of impending death (i.e., last few days of life) is essential for terminally-ill cancer patients and their families. International guidelines state that clinicians should identify patients with impending death, communicate the prognosis with patients and families, help them with their end-of-life decision-making, and provide sufficient symptom palliation. Over the past decade, several national and international studies have been conducted that systematically investigated signs and symptoms of impending death as well as how to communicate such a prognosis effectively with patients and families. In this article, we summarize the current evidence on prognostication and communication regarding the last days of life of patients with cancer, and future directions of clinical research.
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Morita T, Imai K, Mori M, Yokomichi N, Tsuneto S. Defining “Continuous Deep Sedation” Using Treatment Protocol: A Proposal Article. Palliat Med Rep 2022; 3:8-15. [PMID: 36262550 PMCID: PMC8900204 DOI: 10.1089/pmr.2021.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/13/2022] Open
Abstract
Context: Continuous deep sedation (CDS) is regarded as a far-reaching form of sedative use for symptom control, but there are no established uniform definitions. Objectives: To propose types of sedative use related to CDS using treatment protocols with three parameters: documented treatment goals, rapidity of dose titration, and planned duration of treatment. Methods: Opinion article. Results: We propose four types of sedative use potentially related to CDS: (1) proportional sedation (treatment goal is symptom relief with regular monitoring to maximize patient communication, not a decrease in consciousness; with gradual use of sedatives; there is a chance to cease sedatives), (2) rapid proportional sedation (treatment goal is symptom relief with a rapid loading phase, followed by regular monitoring to maximize patient communication; there is a chance to cease sedatives), (3) deep sedation with a chance of cessation (deep sedation intended initially, followed by regular assessments of appropriateness of treatment goal; there is a chance to cease sedatives), and (4) continuous deep sedation until death (deep sedation indicated from initiation and maintained until death). Conclusion: This article proposes an idea that the use of treatment protocols that visualize treatment goals, rapidity of dose titration, and planned duration of treatment may help understand the existing variations in sedative use over the world. The use of treatment protocols in the same way when defining a medical treatment in other specialty fields might clear up the current confusion about the use of sedatives.
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Affiliation(s)
- Tatsuya Morita
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Masanori Mori
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Naosuke Yokomichi
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Satoru Tsuneto
- Division of Palliative Medicine, Kyoto University, Kyoto, Japan
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