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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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Knox M, Wagg A. Contemplating the Impacts of Canadian Healthcare Institutions That Refuse to Provide Medical Assistance in Dying: A Framework-Based Discussion of Potential Health Access Implications. Am J Hosp Palliat Care 2023; 40:1154-1162. [PMID: 36802722 PMCID: PMC10571375 DOI: 10.1177/10499091231155854] [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: 02/22/2023] Open
Abstract
INTRODUCTION Following the historic Canadian legislation on medical assistance in dying (MAiD) in 2016, many implementation challenges and ethical quandaries have formed the focus of further scholarly investigation and policy revisions. Of these, conscientious objections held by some healthcare institutions have involved relatively less scrutiny, despite indicating possible hurdles to the universal availability of MAiD services in Canada. METHODS In this paper, we contemplate potential accessibility concerns that pertain specifically to service access, with the hope to trigger further systematic research and policy analysis on this frequently overlooked aspect of MAiD implementation. We organize our discussion using two important health access frameworks: Levesque and colleagues' Conceptual Framework for Access to Health and the Provisional Framework for MAiD System Information Needs (Canadian Institute for Health Information). RESULTS Our discussion is organized along five framework dimensions through which institutional non-participation may generate or exacerbate inequities in MAiD utilization. Considerable overlaps are revealed across framework domains, indicating the complexity of the problem and the need for further investigation. CONCLUSION Conscientious dissensions on the part of healthcare institutions form a likely barrier to ethical, equitable, and patient-oriented MAiD service provision. Comprehensive, systematic evidence is urgently needed to understand the nature and scope of resulting impacts. We urge Canadian healthcare professionals, policymakers, ethicists, and legislators to attend to this crucial issue in future research and in policy discussions.
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Affiliation(s)
- Michelle Knox
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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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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4
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Elst S, Launois AC, Lecocq D. Pratiques et enjeux de la sédation palliative en Belgique. LA REVUE DE L'INFIRMIÈRE 2023; 72:32-35. [PMID: 37024193 DOI: 10.1016/j.revinf.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
In Belgium, continuous sedation in palliative care is considered a symptomatic treatment. There is no specific legislation to govern it. Its proper use is based on a set of recommendations that ensure both effective treatment and respect for the patient's preferences, within a rigorous ethical framework.
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Robijn L, Deliens L, Scherrens AL, Pauwels NS, Pype P, Rietjens J, Chambaere K. A systematic review of quality improvement initiatives for continuous sedation until death. Palliat Med 2021; 35:670-682. [PMID: 33722107 DOI: 10.1177/0269216321996990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Extensive debate surrounds the practice of continuous sedation until death within end-of-life care. AIM To provide insight into existing initiatives to support the practice of continuous sedation until death and assess their feasibility and effectiveness. DESIGN Systematic review and narrative synthesis, registered on PROSPERO (CRD42020149630). DATA SOURCES Records were searched through MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science from inception to April 16 2020. Peer-reviewed studies reporting original data on initiatives to support the practice of continuous sedation were included for review. RESULTS Twenty-one studies met the criteria and were included. Initiatives were focused on assessment tools of consciousness and discomfort (9), the use of guidelines and protocols (8), and expert consultation (3). All initiatives were reported as useful, acceptable, and feasible. Studies on the use of monitoring devices showed that a small proportion of patients were found to be awake, despite the patient being unresponsive according to the observer-based sedation scales. However, the wide range of values of these monitoring devices for comfortable and adequately sedated patients seems to hamper its overall implementation in daily clinical practice. Physicians reported changes in practice conform to guideline recommendations but the shift was modest at best. Expert consultation was regarded as supportive when sufficient expertise is lacking and helpful in avoiding possibly unnecessary sedations. CONCLUSIONS The reviewed initiatives may contribute to improvement of continuous sedation until death, though their evidence base is rather limited. More insight is needed into their feasibility, preconditions for effective implementation and impact in actual practice.
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Affiliation(s)
- Lenzo Robijn
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Luc Deliens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Anne-Lore Scherrens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Nele S Pauwels
- Ghent University, Knowledge Management Center Ghent, Ghent, Belgium
| | - Peter Pype
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Judith Rietjens
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Kenneth Chambaere
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
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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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7
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Cayetano-Penman J, Malik G, Whittall D. Nurses' Perceptions and Attitudes About Euthanasia: A Scoping Review. J Holist Nurs 2020; 39:66-84. [PMID: 32448052 DOI: 10.1177/0898010120923419] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Nurses have a critical role in providing holistic care for people with life-limiting conditions. However, they experience internal moral conflict and powerlessness when patients request them to assist in the dying process. A scoping review was undertaken to determine what is known about nurses' perceptions and attitudes of euthanasia. Review Methods: Several databases were searched that yielded both qualitative and quantitative primary peer-reviewed research studies that focused on nurses, their perceptions and attitudes about euthanasia. Descriptive and explorative analyses of the data set from the research studies were undertaken. Results: A total of 23 studies were included in the review. Opinions about euthanasia were mixed. Two key concepts emerged from the review: some nurses were positive and/or supportive of euthanasia, while some were negative and/or unsupportive of euthanasia. The main factors associated with being positive and/or supportive were because of (a) extreme uncontrollable pain, unbearable suffering, or other distressing experiences of the patient, (b) legality of euthanasia, and (c) right of the patient to die. The factors that determined nurses' negative and/or unsupportive attitude included (a) religion, (b) moral/ethical dilemmas, (c) role of gender of the health professional, and, (d) poor palliative care. Conclusions: The matter of euthanasia has challenged nurses considerably in their aim to deliver holistic care. There were several crucial factors influencing nurses' perceptions and attitudes, and these were affected by their personal, professional and transpersonal perspectives. The potential implications to nurses relate to education, practice, and research. Nurses need to be informed of existing legislation and provided in-depth education and professional guidelines to help direct action. Further research is needed to explore the impact on nurses' emotional well-being, clarify their role/s and determine the support they might require when involved with euthanasia.
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8
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Wright DK, Gastmans C, Vandyk A, de Casterlé BD. Moral identity and palliative sedation: A systematic review of normative nursing literature. Nurs Ethics 2019; 27:868-886. [DOI: 10.1177/0969733019876312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: In the last two decades, nursing authors have published ethical analyses of palliative sedation—an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care. Research aim: The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses’ moral identities are portrayed within this literature. Research design: We reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher’s Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors’ portrayal of the nursing role. Findings: Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses’ proximity to patients and families in end-of-life care. Discussion and conclusion: Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples’ moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation.
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9
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Bravo G, Rodrigue C, Arcand M, Downie J, Dubois MF, Kaasalaine S, Hertogh CM, Pautex S, Van den Block L. Nurses' perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada. Geriatr Nurs 2018; 39:393-399. [PMID: 29306500 DOI: 10.1016/j.gerinurse.2017.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/26/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
We conducted a survey in a random sample of 514 Quebec nurses caring for the elderly to assess their attitudes towards extending medical aid in dying to incompetent patients and to explore associated factors. Attitudes were measured using clinical vignettes featuring a hypothetical patient with Alzheimer disease. Vignettes varied according to the stage of the disease (advanced or terminal) and the presence or absence of a written request. Of the 291 respondents, 83.5% agreed with the current legislation that allows physicians to administer aid in dying to competent patients who are at the end of life and suffer unbearably. A similar proportion (83%, p = 0.871) were in favor of extending medical aid in dying to incompetent patients who are at the terminal stage of Alzheimer disease, show signs of distress, and have made a written request before losing capacity.
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Affiliation(s)
- G Bravo
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada; Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada.
| | - C Rodrigue
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
| | - M Arcand
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada; Department of Family Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - J Downie
- Schulich School of Law and Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - M-F Dubois
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada; Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
| | - S Kaasalaine
- Department of Family Medicine, School of Nursing, McMaster University, Hamilton, ON, Canada
| | - C M Hertogh
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - S Pautex
- Department of Community Medicine and Primary Care, Geneva University Hospital, Geneva, Switzerland
| | - L Van den Block
- VUB-UGhent End-of-life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Weixler D, Roider-Schur S, Likar R, Bozzaro C, Daniczek T, Feichtner A, Gabl C, Hammerl-Ferrari B, Kletecka-Pulker M, Körtner UHJ, Kössler H, Meran JG, Miksovsky A, Pusswald B, Wienerroither T, Watzke H. [Austrian guideline for palliative sedation therapy (long version) : Results of a Delphi process of the Austrian Palliative Society (OPG)]. Wien Med Wochenschr 2016; 167:31-48. [PMID: 27924420 DOI: 10.1007/s10354-016-0533-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 11/18/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Palliative sedation therapy (PST) is an important and ethically accepted therapy in the care of selected palliative care patients with otherwise unbearable suffering from refractory distress. PST is increasingly used in end-of-life care. Austria does not have a standardized ethical guideline for this exceptional practice near end of life, but there is evidence that practice varies throughout the country. OBJECTIVE The Austrian Palliative Society (OPG) nominated a multidisciplinary working group of 16 palliative care experts and ethicists who established the national guideline on the basis of recent review work with the aim to adhere to the Europeans Association of Palliative Care's (EAPC) framework on palliative sedation therapy respecting Austrians legal, structural and cultural background. METHODS Consensus was achieved by a four-step sequential Delphi process. The Delphi-process was strictly orientated to the recently published EUROIMPACT-sedation-study-checklist and to the AGREE-2-tool. Additionally national stakeholders participated in the reflection of the results. RESULTS As a result of a rigorous consensus process the long version of the Austrian National Palliative Sedation Guideline contains 112 statements within eleven domains and is supplemented by a philosophers excursus on suffering. CONCLUSIONS By establishing a national guideline for palliative sedation therapy using the Delphi technique for consensus and stakeholder involvement the Austrian Palliative Society aims to ensure nationwide good practice of palliative sedation therapy. Screening for the practicability and efficacy of this guideline will be a future task.
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Affiliation(s)
- Dietmar Weixler
- Palliativkonsiliardienst, Mobiles Palliativteam, Landesklinikum Horn-Allentsteig, Spitalgasse 10, 3580, Horn, Österreich.
| | - Sophie Roider-Schur
- Universitätsklinik für Innere Medizin I, Klinische Abteilung für Palliativmedizin, Medizinische Universität Wien, 1090, Wien, Österreich
| | - Rudolf Likar
- Abteilung für Anästhesiologie und Intensivmedizin, Zentrum für Interdisziplinäre Schmerztherapie und Palliativmedizin - ZISOP, Landeskrankenanstalten-Betriebsgesellschaft - KABEG, KLINIKUM Klagenfurt am Wörthersee, Feschnigstraße 11, 9020, Klagenfurt, Österreich
| | - Claudia Bozzaro
- Institut für Ethik und Geschichte der Medizin, Stefan-Meier-Straße 26, 79104, Freiburg, Deutschland
| | - Thomas Daniczek
- Abteilung für Neurologie, Palliativmedizinische Einrichtung, Landeskrankenhaus Judenburg-Knittelfeld, Gaaler Straße 8 u. 10, 8720, Knittelfeld, Österreich
| | | | - Christoph Gabl
- Mobiles Palliativteam, Tiroler Hospiz-Gemeinschaft, Hallerstraße 180, 6020, Innsbruck, Österreich
| | - Bernhard Hammerl-Ferrari
- 5. Med. Abteilung, Palliativstation, Krankenhaus Hietzing, Wolkersbergenstraße 1, 1130, Wien, Österreich
| | - Maria Kletecka-Pulker
- Institut für Ethik und Recht in der Medizin, Spitalgasse 2-4, Hof 2.8, 1090, Wien, Österreich
| | - Ulrich H J Körtner
- Institut für Ethik und Recht in der Medizin, Spitalgasse 2-4, Hof 2.8, 1090, Wien, Österreich
| | - Hilde Kössler
- Mobiles Palliativteam Baden, Mühlgasse 74, 2500, Baden, Österreich
| | - Johannes G Meran
- Krankenhaus der Barmherzigen Brüder Wien, Johannes-von-Gott-Platz 1, 1120, Wien, Österreich
| | - Aurelia Miksovsky
- Interne Abteilung, Palliativstation, Krankenhaus St. Elisabeth Wien, Landstraßer Hauptstraße 4A, 1030, Wien, Österreich
| | - Bettina Pusswald
- Mobiles Palliativteam Fürstenfeld/Feldbach, Krankenhausgasse 1, 8280, Fürstenfeld, Österreich
| | - Thomas Wienerroither
- Klinische Psychologie, Palliativabteilung, Salzkammergut Klinikum Vöcklabruck, Dr. Wilhelm Bock Straße 1, 4840, Vöcklabruck, Österreich
| | - Herbert Watzke
- Universitätsklinik für Innere Medizin I, Klinische Abteilung für Palliativmedizin, Medizinische Universität Wien, 1090, Wien, Österreich
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11
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La sédation continue jusqu’à la mort. Une voie française pour les soins de fin de vie ? Presse Med 2016; 45:670-5. [DOI: 10.1016/j.lpm.2016.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 03/24/2016] [Accepted: 04/19/2016] [Indexed: 01/04/2023] Open
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Ethical dilemmas faced by hospice nurses when administering palliative sedation to patients with terminal cancer. Palliat Support Care 2016; 15:148-157. [PMID: 27323872 DOI: 10.1017/s1478951516000419] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Palliative sedation is a method of symptom management frequently used in hospices to treat uncontrolled symptoms at the end of life. There is a substantial body of literature on this subject; however, there has been little research into the experiences of hospice nurses when administering palliative sedation in an attempt to manage the terminal restlessness experienced by cancer patients. METHOD Semistructured interviews were conducted with a purposive sample of seven hospice nurses who had cared for at least one patient who had undergone palliative sedation within the past year in a hospice in the south of England in the United Kingdom. A phenomenological approach and Colaizzi's stages of analysis were employed to develop themes from the data. RESULTS Facilitating a "peaceful death" was the primary goal of the nurses, where through the administration of palliative sedation they sought to enable and support patients to be "comfortable," "relaxed," and "calm" at the terminal stage of their illness. Ethical dilemmas related to decision making were a factor in achieving this. These were: medication decisions, "juggling the drugs," "causing the death," sedating young people, the family "requesting" sedation, and believing that hospice is a place where death is hastened. SIGNIFICANCE OF RESULTS Hospice nurses in the U.K. frequently encounter ethical and emotional dilemmas when administering palliative sedation. Making such decisions about using palliative sedation causes general discomfort for them. Undertaking this aspect of care requires confidence and competence on the part of nurses, and working within a supportive hospice team is of fundamental importance in supporting this practice.
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Foley RA, Johnston WS, Bernard M, Canevascini M, Currat T, Borasio GD, Beauverd M. Attitudes Regarding Palliative Sedation and Death Hastening Among Swiss Physicians: A Contextually Sensitive Approach. DEATH STUDIES 2015; 39:473-482. [PMID: 26107119 DOI: 10.1080/07481187.2015.1029142] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In Switzerland, where assisted suicide but not euthanasia is permitted, the authors sought to understand how physicians integrate palliative sedation in their practice and how they reflect on existential suffering and death hastening. They interviewed 31 physicians from different care settings. Five major attitudes emerged. Among specialized palliative care physicians, convinced, cautious and doubtful attitudes were evident. Within unspecialized settings, palliative sedation was more likely to be considered as death hastening: clinicians either avoid it with an inexperienced attitude or practice it with an ambiguous attitude, raising the issue of unskilled and abusive uses of sedatives at the end of life.
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Affiliation(s)
- Rose-Anna Foley
- a Institute of Health Research , University of Health Sciences (HESAV, HES-SO) , Lausanne , Switzerland
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Anquinet L, Rietjens JA, Mathers N, Seymour J, van der Heide A, Deliens L. Descriptions by general practitioners and nurses of their collaboration in continuous sedation until death at home: in-depth qualitative interviews in three European countries. J Pain Symptom Manage 2015; 49:98-109. [PMID: 24906190 DOI: 10.1016/j.jpainsymman.2014.05.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 04/23/2014] [Accepted: 05/06/2014] [Indexed: 11/24/2022]
Abstract
CONTEXT One palliative care approach that is increasingly being used at home for relieving intolerable suffering in terminally ill patients is continuous sedation until death. Its provision requires a multidisciplinary team approach, with adequate collaboration and communication. However, it is unknown how general practitioners (GPs) and home care nurses experience being involved in the use of sedation at home. OBJECTIVES To present case-based GP and nurse descriptions of their collaboration, roles, and responsibilities during the process of continuous sedation until death at home in Belgium, The Netherlands, and the U.K. METHODS We held in-depth qualitative interviews with 25 GPs and 26 nurses closely involved in the care of 29 adult cancer patients who received continuous sedation until death at home. RESULTS We found that, in Belgium and The Netherlands, it was the GP who typically made the final decision to use sedation, whereas in the U.K., it was predominantly the nurse who both encouraged the GP to prescribe anticipatory medication and decided when to use the prescription. Nurses in the three countries reported that they commonly perform and monitor sedation in the absence of the GP, which they reported to experience as "emotionally burdensome." CONCLUSION We found variety among the countries studied regarding the decision making and provision of continuous sedation until death at home. These differences, among others, may be the result of different organizational contexts in the three countries such as the use of anticipatory medication in the U.K.
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Affiliation(s)
- Livia Anquinet
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Judith A Rietjens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium; Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
| | - Nigel Mathers
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, United Kingdom
| | - Jane Seymour
- Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, School of Nursing, Midwifery and Physiotherapy, University of Nottingham, Nottingham, United Kingdom
| | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium; Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
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Seymour J, Rietjens J, Bruinsma S, Deliens L, Sterckx S, Mortier F, Brown J, Mathers N, van der Heide A. Using continuous sedation until death for cancer patients: a qualitative interview study of physicians' and nurses' practice in three European countries. Palliat Med 2015; 29:48-59. [PMID: 25062816 PMCID: PMC4266692 DOI: 10.1177/0269216314543319] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Extensive debate surrounds the practice of continuous sedation until death to control refractory symptoms in terminal cancer care. We examined reported practice of United Kingdom, Belgian and Dutch physicians and nurses. METHODS Qualitative case studies using interviews. SETTING Hospitals, the domestic home and hospices or palliative care units. PARTICIPANTS In all, 57 Physicians and 73 nurses involved in the care of 84 cancer patients. RESULTS UK respondents reported a continuum of practice from the provision of low doses of sedatives to control terminal restlessness to rarely encountered deep sedation. In contrast, Belgian respondents predominantly described the use of deep sedation, emphasizing the importance of responding to the patient's request. Dutch respondents emphasized making an official medical decision informed by the patient's wish and establishing that a refractory symptom was present. Respondents employed rationales that showed different stances towards four key issues: the preservation of consciousness, concerns about the potential hastening of death, whether they perceived continuous sedation until death as an 'alternative' to euthanasia and whether they sought to follow guidelines or frameworks for practice. CONCLUSION This qualitative analysis suggests that there is systematic variation in end-of-life care sedation practice and its conceptualization in the United Kingdom, Belgium and the Netherlands.
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Affiliation(s)
- Jane Seymour
- School of Health Sciences, Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Judith Rietjens
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Sophie Bruinsma
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Sigrid Sterckx
- Bioethics Institute Ghent, Ghent University, Ghent, Belgium Department of Philosophy and Moral Sciences, Vrije Universiteit Brussel, Brussels, Belgium
| | - Freddy Mortier
- Bioethics Institute Ghent, Ghent University, Ghent, Belgium
| | - Jayne Brown
- School of Nursing and Midwifery, Center for the Promotion of Excellence in Palliative Care, De Montfort University, Leicester, UK
| | - Nigel Mathers
- Academic Unit of Primary Medical Care, Northern General Hospital, University of Sheffield, Sheffield, UK
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Seale C, Raus K, Bruinsma S, van der Heide A, Sterckx S, Mortier F, Payne S, Mathers N, Rietjens J, Addington-Hall J, Anquinet L, Brown J, Bruinsma S, Deliens L, Mathers N, Mortier F, Payne S, Raus K, Rietjens J, Seale C, Seymour J, Smithson WH, Sterckx S, Janssens R, van der Heide A. The language of sedation in end-of-life care: The ethical reasoning of care providers in three countries. Health (London) 2014; 19:339-54. [DOI: 10.1177/1363459314555377] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The application of ethically controversial medical procedures may differ from one place to another. Drawing on a keyword and text-mining analysis of 156 interviews with doctors and nurses involved in end-of-life care (‘care providers’), differences between countries in care providers’ ethical rationales for the use of sedation are reported. In the United Kingdom, an emphasis on titrating doses proportionately against symptoms is more likely, maintaining consciousness where possible. The potential harms of sedation are perceived to be the potential hastening of social as well as biological death. In Belgium and the Netherlands, although there is concern to distinguish the practice from euthanasia, rapid inducement of deep unconsciousness is more acceptable to care providers. This is often perceived to be a proportionate response to unbearable suffering in a context where there is also greater pressure to hasten dying from relatives and others. This means that sedation is more likely to be organised like euthanasia, as the end ‘moment’ is reached, and family farewells are organised before the patient is made unconscious for ever. Medical and nursing practices are partly responses to factors outside the place of care, such as legislation and public sentiment. Dutch guidelines for sedation largely tally with the practices prevalent in the Netherlands and Belgium, in contrast with those produced by the more international European Association for Palliative Care whose authors describe an ethical framework closer to that reportedly used by UK care providers.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Judith Rietjens
- Erasmus MC, Netherlands; Ghent University & Vrije Universiteit Brussel, Belgium
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The use of palliative sedation: A comparison of attitudes of French-speaking physicians from Quebec and Switzerland. Palliat Support Care 2014; 13:839-47. [PMID: 24825473 DOI: 10.1017/s1478951514000364] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Previous literature has suggested that laws and regulations may impact the use of palliative sedation. Our present study compares the attitudes of French-speaking physicians practicing in the Quebec and Swiss environments, where different laws are in place regarding physician-assisted suicide. METHOD Data were drawn from two prior studies, one by Blondeau and colleagues and another by Beauverd and coworkers, employing the same two-by-two experimental design with length of prognosis and type of suffering as independent variables. Both the effect of these variables and the effect of their interaction on Swiss and Quebec physicians' attitudes toward sedation were compared. The written comments of respondents were submitted to a qualitative content analysis and summarized in a comparative perspective. RESULTS The analysis of variance showed that only the type of suffering had an effect on physicians' attitudes toward sedation. The results of the Wilcoxon test indicated that the attitudes of physicians from Quebec and Switzerland tended to be different for two vignettes: long-term prognosis with existential suffering (p = 0.0577) and short-term prognosis with physical suffering (p = 0.0914). In both cases, the Swiss physicians were less prone to palliative sedation. SIGNIFICANCE OF RESULTS The attitudes of physicians from Quebec and Switzerland toward palliative sedation, particularly regarding prognosis and type of suffering, seem similar. However, the results suggest that physicians from Quebec could be slightly more open to palliative sedation, even though most were not in favor of this practice as an answer to end-of-life existential suffering.
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Abarshi EA, Papavasiliou ES, Preston N, Brown J, Payne S. The complexity of nurses' attitudes and practice of sedation at the end of life: a systematic literature review. J Pain Symptom Manage 2014; 47:915-925.e11. [PMID: 24075400 DOI: 10.1016/j.jpainsymman.2013.06.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 06/01/2013] [Accepted: 06/14/2013] [Indexed: 11/20/2022]
Abstract
CONTEXT Sedation is administered to some palliative care patients at the end of their life. Nurses play an important role in this practice. OBJECTIVES To systematically review the evidence on nurses' attitudes and practice of end-of-life sedation. METHODS We searched eight electronic databases, four key palliative care journals, and reference lists for empirical studies published in English, between 1990 and 2012, on nurses and their attitudes toward and practice of sedation until a patient's death. A total of 10 studies met the inclusion criteria. RESULTS Data were generated from 7515 nurses in four main settings (specialized palliative care unit, home, nursing home, and acute hospital) from seven countries (Belgium, Canada, Japan, The Netherlands, Norway, U.K., and U.S.). On average, the quality of the evidence was good; hence, we analyzed all selected studies. Based on the findings from a previous review, we categorized the emerging themes into: 1) important factors leading to the patient receiving palliative sedation (PS), 2) nurses' attitudes toward PS, and 3) nurses' experience of PS at the end of a patient's life. In general, nurses had a positive but cautious attitude toward the practice of PS. Most saw it as a last resort treatment for relieving suffering and refractory symptoms, and its practice was often influenced by their level of education, expertise, and the roles they played per setting. CONCLUSION Most nurses administered sedation until death only within the given circumstances because of the anticipatory benefits in controlling refractory symptoms and suffering. Some of them experienced burdens during PS delivery; these could be supported by operational guidelines and task-related training.
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Affiliation(s)
- Ebun A Abarshi
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom.
| | | | - Nancy Preston
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom
| | - Jayne Brown
- Centre for the Promotion of Excellence in Palliative Care, De Montfort University, Leicester, United Kingdom
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom
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Raus K, Brown J, Seale C, Rietjens JAC, Janssens R, Bruinsma S, Mortier F, Payne S, Sterckx S. Continuous sedation until death: the everyday moral reasoning of physicians, nurses and family caregivers in the UK, The Netherlands and Belgium. BMC Med Ethics 2014; 15:14. [PMID: 24555871 PMCID: PMC3942295 DOI: 10.1186/1472-6939-15-14] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 01/30/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Continuous sedation is increasingly used as a way to relieve symptoms at the end of life. Current research indicates that some physicians, nurses, and relatives involved in this practice experience emotional and/or moral distress. This study aims to provide insight into what may influence how professional and/or family carers cope with such distress. METHODS This study is an international qualitative interview study involving interviews with physicians, nurses, and relatives of deceased patients in the UK, The Netherlands and Belgium (the UNBIASED study) about a case of continuous sedation at the end of life they were recently involved in. All interviews were transcribed verbatim and analysed by staying close to the data using open coding. Next, codes were combined into larger themes and categories of codes resulting in a four point scheme that captured all of the data. Finally, our findings were compared with others and explored in relation to theories in ethics and sociology. RESULTS The participants' responses can be captured as different dimensions of 'closeness', i.e. the degree to which one feels connected or 'close' to a certain decision or event. We distinguished four types of 'closeness', namely emotional, physical, decisional, and causal. Using these four dimensions of 'closeness' it became possible to describe how physicians, nurses, and relatives experience their involvement in cases of continuous sedation until death. More specifically, it shined a light on the everyday moral reasoning employed by care providers and relatives in the context of continuous sedation, and how this affected the emotional impact of being involved in sedation, as well as the perception of their own moral responsibility. CONCLUSION Findings from this study demonstrate that various factors are reported to influence the degree of closeness to continuous sedation (and thus the extent to which carers feel morally responsible), and that some of these factors help care providers and relatives to distinguish continuous sedation from euthanasia.
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Affiliation(s)
- Kasper Raus
- Department of Philosophy and Moral Sciences, Ghent University, Blandijnberg 2, Ghent, Belgium
- End of Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels, Belgium
| | - Jayne Brown
- School of Nursing and Midwifery, De Monfort University, The Gateway, Leicester, UK
| | - Clive Seale
- Department of Sociology and Communications, Brunel University, Uxbridge, Middlesex, UK
| | - Judith AC Rietjens
- End of Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels, Belgium
- Department of Public Health, Erasmus MC, Dr. Molewaterplein 50, Rotterdam, The Netherlands
| | - Rien Janssens
- Department of Medical Humanities, VU Medical Centre, Van der Boechorststraat 7, Amsterdam, The Netherlands
| | - Sophie Bruinsma
- Department of Public Health, Erasmus MC, Dr. Molewaterplein 50, Rotterdam, The Netherlands
| | - Freddy Mortier
- Department of Philosophy and Moral Sciences, Ghent University, Blandijnberg 2, Ghent, Belgium
- End of Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels, Belgium
| | - Sheila Payne
- International Observatory on End of Life Care, Lancaster University, Furness College, Lancaster, UK
| | - Sigrid Sterckx
- Department of Philosophy and Moral Sciences, Ghent University, Blandijnberg 2, Ghent, Belgium
- End of Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels, Belgium
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Andrew EVW, Cohen J, Evans N, Meñaca A, Harding R, Higginson I, Pool R, Gysels M. Social-cultural factors in end-of-life care in Belgium: a scoping of the research literature. Palliat Med 2013; 27:131-43. [PMID: 22143040 DOI: 10.1177/0269216311429619] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND As end-of-life (EoL) care expands across Europe and the world, service developments are increasingly studied. The sociocultural context in which such changes take place, however, is often neglected in research. AIM To explore sociocultural factors in EoL care in Belgium as represented by the literature. DESIGN A scoping of the empirical research literature following a systematic search procedure with a focus on thematic analysis based on the literature findings. DATA SOURCES Searches were carried out in eight electronic databases, five journals, reference lists, and grey literature (through September 2010). Articles informing about sociocultural issues in EoL care were included. RESULTS One hundred and fifteen original studies met the inclusion criteria, the majority (107) published between 2000 and 2010. Four major themes were: Setting; Caregivers; Communication; and Medical EoL Decisions (the largest category). Minority Ethnic Groups was an emerging theme. Gaps included: research in Wallonia and Brussels; the role and experiences of informal caregivers; issues of access to palliative care; and experiences of minority ethnic groups. There was a paucity of in-depth qualitative studies. CONCLUSIONS Various sociocultural factors influence the provision of EoL care in Belgium. This country provides a unique opportunity to witness how euthanasia is put into practice when legalized, in a context where palliative care is also highly developed and where many health care institutions have Catholic affiliation, providing an important example to others. Attention to how the sociocultural context affects EoL care adds to the current evidence base of service provision, which is essential in the further development of EoL care.
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Affiliation(s)
- Erin V W Andrew
- Barcelona Centre for International Health Research (CRESIB, Hospital Clínic - Universitat de Barcelona), Barcelona, Spain.
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Bruinsma SM, Rietjens JAC, Seymour JE, Anquinet L, van der Heide A. The experiences of relatives with the practice of palliative sedation: a systematic review. J Pain Symptom Manage 2012; 44:431-45. [PMID: 22658470 DOI: 10.1016/j.jpainsymman.2011.09.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 09/14/2011] [Accepted: 09/15/2011] [Indexed: 01/03/2023]
Abstract
CONTEXT Guidelines about palliative sedation typically include recommendations to protect the well-being of relatives. OBJECTIVES The aim of this study was to systematically review evidence on the experiences of relatives with the practice of palliative sedation. METHODS PubMed, Embase, Web of Science, PsycINFO, and CINAHL were searched for empirical studies on relatives' experiences with palliative sedation. We investigated relatives' involvement in the decision-making and sedation processes, whether they received adequate information and support, and relatives' emotions. RESULTS Of the 564 studies identified, 39 were included. The studies (30 quantitative, six qualitative, and three mixed methods) were conducted in 16 countries; three studies were based on relatives' reports, 26 on physicians' and nurses' proxy reports, seven on medical records, and three combined different sources. The 39 studies yielded a combined total of 8791 respondents or studied cases. Caregivers involved relatives in the decision making in 69%-100% of all cases (19 quantitative studies), and in 60%-100% of all cases, relatives were reported to have received adequate information (five quantitative studies). Only two quantitative studies reported on relatives' involvement in the provision of sedation. Despite the fact that the majority of relatives were reported to be comfortable with the use of palliative sedation (seven quantitative studies, four qualitative studies), several studies found that relatives were distressed by the use of sedation (five quantitative studies, five qualitative studies). No studies reported specifically about the support provided to the relatives. CONCLUSION Relatives' experiences with palliative sedation are mainly studied from the perspective of proxies, mostly professional caregivers. The majority of relatives seems to be comfortable with the use of palliative sedation; however, they may experience substantial distress by the use of sedation.
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Affiliation(s)
- Sophie M Bruinsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
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Anquinet L, Rietjens JAC, Seale C, Seymour J, Deliens L, van der Heide A. The practice of continuous deep sedation until death in Flanders (Belgium), the Netherlands, and the U.K.: a comparative study. J Pain Symptom Manage 2012; 44:33-43. [PMID: 22652134 DOI: 10.1016/j.jpainsymman.2011.07.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 07/11/2011] [Accepted: 07/20/2011] [Indexed: 11/20/2022]
Abstract
CONTEXT Existing empirical evidence shows that continuous deep sedation until death is given in about 15% of all deaths in Flanders, Belgium (BE), 8% in The Netherlands (NL), and 17% in the U.K. OBJECTIVES This study compares characteristics of continuous deep sedation to explain these varying frequencies. METHODS In Flanders, BE (2007) and NL (2005), death certificate studies were conducted. Questionnaires about continuous deep sedation and other decisions were sent to the certifying physicians of each death from a stratified sample (Flanders, BE: n=6927; NL: n=6860). In the U.K. in 2007-2008, questionnaires were sent to 8857 randomly sampled physicians asking them about the last death attended. RESULTS The total number of deaths studied was 11,704 of which 1517 involved continuous deep sedation. In Dutch hospitals, continuous deep sedation was significantly less often provided (11%) compared with hospitals in Flanders, BE (20%) and the U.K. (17%). In U.K. home settings, continuous deep sedation was more common (19%) than in Flanders, BE (10%) or NL (8%). In NL in both settings, continuous deep sedation more often involved benzodiazepines and lasted less than 24 hours. Physicians in Flanders combined continuous deep sedation with a decision to provide physician-assisted death more often. Overall, men, younger patients, and patients with malignancies were more likely to receive continuous deep sedation, although this was not always significant within each country. CONCLUSION Differences in the prevalence of continuous deep sedation appear to reflect complex legal, cultural, and organizational factors more than differences in patients' characteristics or clinical profiles. Further in-depth studies should explore whether these differences also reflect differences between countries in the quality of end-of-life care.
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Affiliation(s)
- Livia Anquinet
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium.
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Gysels M, Evans N, Meñaca A, Andrew E, Toscani F, Finetti S, Pasman HR, Higginson I, Harding R, Pool R. Culture and end of life care: a scoping exercise in seven European countries. PLoS One 2012; 7:e34188. [PMID: 22509278 PMCID: PMC3317929 DOI: 10.1371/journal.pone.0034188] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 02/28/2012] [Indexed: 11/18/2022] Open
Abstract
AIM Culture is becoming increasingly important in relation to end of life (EoL) care in a context of globalization, migration and European integration. We explore and compare socio-cultural issues that shape EoL care in seven European countries and critically appraise the existing research evidence on cultural issues in EoL care generated in the different countries. METHODS We scoped the literature for Germany, Norway, Belgium, The Netherlands, Spain, Italy and Portugal, carrying out electronic searches in 16 international and country-specific databases and handsearches in 17 journals, bibliographies of relevant papers and webpages. We analysed the literature which was unearthed, in its entirety and by type (reviews, original studies, opinion pieces) and conducted quantitative analyses for each country and across countries. Qualitative techniques generated themes and sub-themes. RESULTS A total of 868 papers were reviewed. The following themes facilitated cross-country comparison: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The frequencies of themes varied considerably between countries. Sub-themes reflected issues characteristic for specific countries (e.g. culture-specific disclosure in the southern European countries). The work from the seven European countries concentrates on cultural traditions and identities, and there was almost no evidence on ethnic minorities. CONCLUSION This scoping review is the first comparative exploration of the cultural differences in the understanding of EoL care in these countries. The diverse body of evidence that was identified on socio-cultural issues in EoL care, reflects clearly distinguishable national cultures of EoL care, with differences in meaning, priorities, and expertise in each country. The diverse ways that EoL care is understood and practised forms a necessary part of what constitutes best evidence for the improvement of EoL care in the future.
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Affiliation(s)
- Marjolein Gysels
- Barcelona Centre for International Health Research, Universitat de Barcelona, Barcelona, Spain.
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Seymour J. Looking back, looking forward: the evolution of palliative and end-of-life care in England. ACTA ACUST UNITED AC 2012. [DOI: 10.1080/13576275.2012.651843] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Raus K, Sterckx S, Mortier F. Is continuous sedation at the end of life an ethically preferable alternative to physician-assisted suicide? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2011; 11:32-40. [PMID: 21678215 DOI: 10.1080/15265161.2011.577510] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The relatively new practice of continuous sedation at the end of life (CS) is increasingly being debated in the clinical and ethical literature. This practice received much attention when a U.S. Supreme Court ruling noted that the availability of CS made legalization of physician-assisted suicide (PAS) unnecessary, as CS could alleviate even the most severe suffering. This view has been widely adopted. In this article, we perform an in-depth analysis of four versions of this "argument of preferable alternative." Our goal is to determine the extent to which CS can be considered to be an alternative to PAS and to identify the grounds, if any, on which CS may be ethically preferable to PAS.
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Bruce A, Boston P. Relieving existential suffering through palliative sedation: discussion of an uneasy practice. J Adv Nurs 2011; 67:2732-40. [DOI: 10.1111/j.1365-2648.2011.05711.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Considerable controversy surrounds the issue of care at the end of life (EOL) for older adults. Technological advances and the legal, ethical, clinical, religious, cultural, personal, and fiscal considerations in the provision of artificial hydration and nutrition support to older adults near death are presented in this comprehensive review.
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Affiliation(s)
- Roschelle A Heuberger
- Department of Human Environmental Studies, Central Michigan University, Mt. Pleasant, Michigan 48859, USA.
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Seymour J, Rietjens J, Brown J, van der Heide A, Sterckx S, Deliens L. The perspectives of clinical staff and bereaved informal care-givers on the use of continuous sedation until death for cancer patients: The study protocol of the UNBIASED study. BMC Palliat Care 2011; 10:5. [PMID: 21375747 PMCID: PMC3056823 DOI: 10.1186/1472-684x-10-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 03/04/2011] [Indexed: 11/29/2022] Open
Abstract
Background A significant minority of dying people experience refractory symptoms or extreme distress unresponsive to conventional therapies. In such circumstances, sedation may be used to decrease or remove consciousness until death occurs. This practice is described in a variety of ways, including: 'palliative sedation', 'terminal sedation', 'continuous deep sedation until death', 'proportionate sedation' or 'palliative sedation to unconsciousness'. Surveys show large unexplained variation in incidence of sedation at the end of life across countries and care settings and there are ethical concerns about the use, intentions, risks and significance of the practice in palliative care. There are also questions about how to explain international variation in the use of the practice. This protocol relates to the UNBIASED study (UK Netherlands Belgium International Sedation Study), which comprises three linked studies with separate funding sources in the UK, Belgium and the Netherlands. The aims of the study are to explore decision-making surrounding the application of continuous sedation until death in contemporary clinical practice, and to understand the experiences of clinical staff and decedents' informal care-givers of the use of continuous sedation until death and their perceptions of its contribution to the dying process. The UNBIASED study is part of the European Association for Palliative Care Research Network. Methods/Design To realize the study aims, a two-phase study has been designed. The study settings include: the domestic home, hospital and expert palliative care sites. Phase 1 consists of: a) focus groups with health care staff and bereaved informal care-givers; and b) a preliminary case notes review to study the range of sedation therapy provided at the end of life to cancer patients who died within a 12 week period. Phase 2 employs qualitative methods to develop 30 patient-centred case studies in each country. These involve interviews with staff and informal care-givers closely involved in the care of cancer patients who received continuous sedation until death. Discussion To our knowledge, this is one of the few studies which seek to take a qualitative perspective on clinical decision making surrounding the use of continuous sedation until death and the only one which includes the perspectives of nurses, physicians, as well as bereaved informal care-givers. It has several potential strengths, weaknesses, opportunities and threats associated with the specific design of the study, as well as with the sensitive nature of the topic and the different frameworks for ethical review in the participating countries.
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Affiliation(s)
- Jane Seymour
- School of Nursing, Midwifery and Physiotherapy, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.
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Boston P, Bruce A, Schreiber R. Existential suffering in the palliative care setting: an integrated literature review. J Pain Symptom Manage 2011; 41:604-18. [PMID: 21145202 DOI: 10.1016/j.jpainsymman.2010.05.010] [Citation(s) in RCA: 208] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 05/26/2010] [Accepted: 05/28/2010] [Indexed: 11/29/2022]
Abstract
CONTEXT Existential and spiritual concerns in relation to palliative end-of-life care have received increasing attention over the past decade. OBJECTIVES To review the literature specifically related to existential suffering in palliative care in terms of the significance of existential suffering in end-of-life care, definitions, conceptual frameworks, and interventions. METHODS A systematic approach was undertaken with the aim of identifying emerging themes in the literature. Databases using CINAHL (1980-2009), MEDLINE (1970-2009), and PsychINFO (1980-2009) and the search engine of Google Scholar were searched under the key words existential suffering, existential distress, existential pain, palliative and end of life care. RESULTS The search yielded a total of 156 articles; 32% were peer-reviewed empirical research articles, 28% were peer-reviewed theoretical articles, and 14% were reviews or opinion-based articles. After manually searching bibliographies and related reference lists, 64 articles were considered relevant and are discussed in this review. Overall analysis identifies knowledge of the following: 1) emerging themes related to existential suffering, 2) critical review of those identified themes, 3) current gaps in the research literature, and 4) recommendations for future research. Findings from this comprehensive review reveal that existential suffering and deep personal anguish at the end of life are some of the most debilitating conditions that occur in patients who are dying, and yet the way such suffering is treated in the last days is not well understood. CONCLUSION Given the broad range of definitions attributed to existential suffering, palliative care clinicians may need to be mindful of their own choices and consider treatment options from a critical perspective.
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Affiliation(s)
- Patricia Boston
- Division of Palliative Care, Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada.
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Lindblad A, Juth N, Fürst CJ, Lynöe N. Continuous deep sedation, physician-assisted suicide, and euthanasia in Huntington's disorder. Int J Palliat Nurs 2011; 16:527-33. [PMID: 21135785 DOI: 10.12968/ijpn.2010.16.11.80019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To investigate the attitudes among Swedish physicians and the general public towards continuous deep sedation (CDS) as an alternative treatment for a competent, not imminently dying patient with Huntington's disorder requesting physician-assisted suicide (PAS) and euthanasia. DESIGN A questionnaire was distributed to 1200 physicians in Sweden and 1201 individuals in Stockholm. It consisted of three parts: 1) A vignette about a competent patient with Huntington's disease requesting PAS. When no longer competent, relatives request euthanasia on behalf of the patient. Responders were asked about their attitudes towards these requests and whether CDS would be an acceptable alternative. 2) General questions about PAS and euthanasia. 3) Background variables. RESULTS The response rate was 56% (physicians) and 52% (general public). The majority of the general public and a fairly large proportion of physicians reported more liberal views on CDS than are expressed in current Swedish and international recommendations. CONCLUSION In light of the results, we suggest that there is a need for a broader discussion about the recommendations for CDS, with a special focus on the needs of patients with progressive neurodegenerative disorders.
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Affiliation(s)
- Anna Lindblad
- Stockholm Centre for Healthcare Ethics, Karolinska Institutet, Stockholm, Sweden
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Sedierung in der Palliativmedizin*: Leitlinie für den Einsatz sedierender Maßnahmen in der Palliativversorgung. Schmerz 2010; 24:342-54. [DOI: 10.1007/s00482-010-0948-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fondras JC, Rameix S. Questions éthiques associées à la pratique de la sédation en phase terminale. MEDECINE PALLIATIVE 2010. [DOI: 10.1016/j.medpal.2010.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Seale C. Continuous deep sedation in medical practice: a descriptive study. J Pain Symptom Manage 2010; 39:44-53. [PMID: 19854611 DOI: 10.1016/j.jpainsymman.2009.06.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Revised: 06/20/2009] [Accepted: 06/22/2009] [Indexed: 11/24/2022]
Abstract
CONTEXT Continuous deep sedation (CDS) until death can form an effective part of palliative care. In The Netherlands and Belgium, CDS is sometimes regarded as an alternative to euthanasia, and the involvement of palliative care specialists is low. Provision of CDS through opioids alone is not recommended. OBJECTIVES This study investigates the use of CDS in the United Kingdom. METHODS A survey of 8,857 doctors, of whom 3,733 (42%) replied, with 2,923 reporting on their last patient who died. RESULTS In total, 18.7% (17.3-20.1) of the doctors attending a dying patient reported the use of CDS. CDS was more likely when patients were younger or were dying of cancer. Specialists in care of the elderly were least likely to report the use of CDS; doctors in other hospital specialties were most likely to report its use. CDS was associated with a higher rate of requests from patients or relatives for a hastened death and with a greater incidence of other end-of-life decisions containing some intent to end life by the doctor. Doctors supporting legalization of euthanasia or physician-assisted suicide, or who were nonreligious, were more likely to report using CDS. There was palliative care team involvement in half of all CDS cases, and prescription of opioids alone for sedation occurred in one-fifth of the cases but was not reported by specialists in palliative care. CONCLUSION This study provides baseline data for monitoring future trends in the United Kingdom and highlights the need for a fuller understanding of the circumstances in which CDS occurs in particular care settings.
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Affiliation(s)
- Clive Seale
- Centre for Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, United Kingdom.
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Cherny NI, Radbruch L. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009; 23:581-93. [PMID: 19858355 DOI: 10.1177/0269216309107024] [Citation(s) in RCA: 402] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review.
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Affiliation(s)
- Nathan I Cherny
- Shaare Zedek Medical Center, Department of Oncology, Jerusalem, Israel.
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Attitudes of nurses towards euthanasia and towards their role in euthanasia: A nationwide study in Flanders, Belgium. Int J Nurs Stud 2009; 46:1209-18. [DOI: 10.1016/j.ijnurstu.2009.02.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 02/18/2009] [Accepted: 02/22/2009] [Indexed: 11/19/2022]
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Venke Gran S, Miller J. Norwegian nurses’ thoughts and feelings regarding the ethics of palliative sedation. Int J Palliat Nurs 2008; 14:532-8. [DOI: 10.12968/ijpn.2008.14.11.31757] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Jean Miller
- College of Nursing University of Rhode Island, United States
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Abstract
PURPOSE OF REVIEW Palliative care is a discipline that provides satisfactory symptom relief to most patients with advanced life-threatening disease. There remain circumstances, however, in which patients experience distressing symptoms and unbearable suffering that cannot be adequately relieved. In these situations palliative sedation may be valuable as a last resort. Palliative sedation is a controversial issue and research in this area is complex for ethical and practical reasons. A review of some critical aspects, giving special attention to those areas that require further research, is therefore timely. RECENT FINDINGS There is a dearth of evidence regarding sedation in the setting of palliative care. The literature contains many expert opinions and retrospective reports, but only a few prospective studies have been published. Terminology regarding sedation is confusing, indications and outcomes do not tend to be clearly reported, and no comparative studies to test drug effectiveness have been conducted. Consensus and innovative methodologies to enhance scientific knowledge are urgently needed in this area. SUMMARY This review addresses recent literature concerning definitions of palliative sedation and intolerable/refractory suffering, indications and drug use. The current state of the art is summarized and future lines of research are proposed.
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