Sedation in terminally ill patients

Use of Opioids and Sedatives at End-of-Life

Despite their proven efficacy and safety, opioid and sedative use for palliation in patients afflicted with cancer in Singapore have been shown to be a fraction of that in other countries. This paper explores the various psychosocial and system-related factors that appear to propagate this conservative approach to care in what is largely a western-influenced care practice. A search for publications relating to sedative and opioid usage in Asia was performed on PubMed, Google, Google Scholar, World Health Organization, and Singapore's government agency websites using search terms such as "opioids," "sedatives," "palliation," "end-of-life-care," "pain management," "palliative care," "cancer pain," "Asia," "Singapore," and "morphine." Findings were classified into three broad groups - system-related, physician-related, and patient-related factors. A cautious medico-legal climate, shortage of physicians trained in palliative care, and lack of instruments for symptom assessment of patients at the end of life contribute to system-related barriers. Physician-related barriers include delayed access to palliative care due to late referrals, knowledge deficits in non-palliative medicine physicians, and sub-optimal care provided by palliative physicians. Patients' under-reporting of symptoms and fear of addiction, tolerance, and side effects of opioids and sedatives may lead to conservative opioid use in palliative care as well. System-related, physician-related, and patient-related factors play crucial roles in steering the management of palliative patients. Addressing and increasing the awareness of these factors may help ensure patients receive adequate relief and control of distressing symptoms.

Continuous sedation (CS) until death: mapping the literature by bibliometric analysis

CONTEXT

Sedation at the end of life, regardless of the nomenclature, is an increasingly debated practice at both clinical and bioethical levels. However, little is known about the characteristics and trends in scientific publications in this field of study.

OBJECTIVES

This article presents a bibliometric analysis of the scientific publications on continuous sedation until death.

METHODS

Four electronic databases (MEDLINE, PubMed, Embase, and PsycINFO®) were searched for the indexed material published between 1945 and 2011. This search resulted in bibliographic data of 273 published outputs that were analyzed using bibliometric techniques.

RESULTS

Data revealed a trend of increased scientific publication from the early 1990s. Published outputs, diverse in type (comments/letters, articles, reviews, case reports, editorials), were widely distributed across 94 journals of varying scientific disciplines (medicine, nursing, palliative care, law, ethics). Most journals (72.3%) were classified under Medical and Health Sciences, with the Journal of Pain and Symptom Management identified as the major journal in the field covering 12.1% of the total publications. Empirical research articles, mostly of a quantitative design, originated from 17 countries. Although Japan and The Netherlands were found to be the leaders in research article productivity, it was the U.K. and the U.S. that ranked top in terms of the quantity of published outputs.

CONCLUSION

This is the first bibliometric analysis on continuous sedation until death that can be used to inform future studies. Further research is needed to refine controversies on terminology and ethical acceptability of the practice, as well as conditions and modalities of its use.

The practice of continuous deep sedation until death in Flanders (Belgium), the Netherlands, and the U.K.: a comparative study

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.

Controlled sedation for refractory symptoms in dying patients

Terminally ill cancer patients near the end of life may experience intolerable suffering refractory to palliative treatment. Although sedation is considered to be an effective treatment when aggressive efforts fail to provide relief in terminally ill patients, it remains controversial. The aim of this study was to assess the need and effectiveness of sedation in dying patients with intractable symptoms, and the thoughts of relatives regarding sedation. A prospective cohort study was performed on a consecutive sample of dying patients admitted to an acute pain relief and palliative care unit within a cancer center. Indications for sedation, opioid and midazolam doses, level of delirium and sedation, nutrition, hydration, rattle, inability to cough and swallow, pharyngeal aspiration, duration of sedation and survival, and use of anticholinergics or other drugs were recorded. Family members were interviewed. Forty-two of 77 dying patients were sedated, and had a longer survival than those who were not sedated (P=0.003). Prevalent indications for sedation were dyspnea and/or delirium. Twelve patients began with an intermediate sedation, and 38 patients started with definitive sedation. The median sedation duration was 22 hours. Opioid doses did not change during sedation. Agitated delirium significantly decreased with increasing doses of midazolam, whereas the capacity to communicate concomitantly decreased. Interviewed relatives were actively involved in the process of end-of-life care, and the decision to sedate, and the efficacy of sedation, were considered appropriate by almost all relatives. Controlled sedation is successful in dying patients with untreatable symptoms, did not hasten death, and yielded satisfactory results for relatives. This study also points to the importance of palliative care and the experience of professionals skilled in both symptom control and end-of-life care.

Managing intentions: the end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia

There has been much debate regarding the 'double-effect' of sedatives and analgesics administered at the end-of-life, and the possibility that health professionals using these drugs are performing 'slow euthanasia.' On the one hand analgesics and sedatives can do much to relieve suffering in the terminally ill. On the other hand, they can hasten death. According to a standard view, the administration of analgesics and sedatives amounts to euthanasia when the drugs are given with an intention to hasten death. In this paper we report a small qualitative study based on interviews with 8 Australian general physicians regarding their understanding of intention in the context of questions about voluntary euthanasia, assisted suicide and particularly the use of analgesic and sedative infusions (including the possibility of voluntary or non-voluntary 'slow euthanasia'). We found a striking ambiguity and uncertainty regarding intentions amongst doctors interviewed. Some were explicit in describing a 'grey' area between palliation and euthanasia, or a continuum between the two. Not one of the respondents was consistent in distinguishing between a foreseen death and an intended death. A major theme was that 'slow euthanasia' may be more psychologically acceptable to doctors than active voluntary euthanasia by bolus injection, partly because the former would usually only result in a small loss of 'time' for patients already very close to death, but also because of the desirable ambiguities surrounding causation and intention when an infusion of analgesics and sedatives is used. The empirical and philosophical implications of these findings are discussed.

Palliative sedation in a southern Appalachian community

Of 1200 palliative care patients, 28 received palliative sedation. They were more likely than patients without palliative sedation to have an Eastern Cooperative Oncology Group performance status of at least 3, a cancer diagnosis, an expected survival of weeks or less, to have been monitored by the palliative care team for at least 1 week, to have delirium as the cause of decreased communication, to have dyspnea as a non-pain symptom, and to be less able to communicate symptoms. Almost 90% received palliative sedation for at least 24 hours for a median of 3 days (range, 0 to 24 days). Home patients received palliative sedation longer. Symptoms were controlled in 82% and improved in the rest. Sedation developed in 79% but was not required for symptom control in 5. Patient survival from palliative care consultation was a median of 8 days (range, 0 to 32 days).

[Symptom control and ethics in final stages of COPD]

On the basis of a case study, the complex problems of the final stages of a COPD will be demonstrated and discussed. Dyspnea and anxiousness are the primary symptoms. If they can be adequately brought under control by opiates and benzodiazepines, a palliative sedation is then not necessary. The communicative and ethical demands on the team responsible are high. It is important to be aware of the specific needs of the patient and of his/her family members, and to competently accompany the patient throughout the decision-making process--such as the decision to end respiratory therapy, for example. Clarifying the situation with the patient and finding out his/her wishes, accompanied by the corresponding documentation, is advisable.

Emotional burden of nurses in palliative sedation therapy

BACKGROUND

Palliative sedation therapy is often required in terminally ill cancer patients, and may cause emotional burden for nurses. The primary aims of this study were 1) to clarify the levels of nurses' emotional burden related to sedation, and 2) to identify the factors contributing to the burden levels.

METHODS

A questionnaire survey of 3187 nurses, with a response rate of 82%.

RESULTS

Eighty-two percent of the nurses (n = 2607) had clinical experience in continuous-deep sedation. Thirty per cent reported that they wanted to leave their current work situation due to sedation-related burden (answering occasionally, often, or always). Also, 12% of the nurses stated that being involved in sedation was a burden, 12% that they felt helpless when patients received sedation, 11% that they would avoid a situation in which they had to perform sedation if possible, and 4% that they felt what they had done was of no value when they performed sedation. The higher nurse-perceived burden was significantly associated with shorter clinical experience, nurse-perceived insufficient time in caring for patients, lack of common understanding of sedation between physicians and nurses, team conference unavailability, frequent experience of conflicting wishes for sedation between patient and family, nurse-perceived inadequate interpersonal skills, belief that it was difficult to diagnose refractory symptoms, belief that sedation would hasten death, belief that sedation was ethically indistinguishable from euthanasia, nurse-perceived inadequate coping with their own grief, and nurses' personal values contradictory to sedation therapy.

CONCLUSIONS

A significant number of nurses felt serious emotional burden related to sedation. To relieve nurses' emotional burden, we encourage 1) management efforts to reduce work overload, 2) a team approach to resolving conflicting opinions, especially between physicians and nurses, 3) co-ordination of early patient-family meetings to clarify their preferred end-of-life care, 4) education and training about sedation specifically focused on interpersonal skills, systematic approaches to diagnosing refractory symptoms, minimum life-threatening potency in sedation, and ethical principals differentiating sedation from euthanasia, and 5) exploring nurses' personal values through the patient-centered principle.

Similarity and difference among standard medical care, palliative sedation therapy, and euthanasia: a multidimensional scaling analysis on physicians' and the general population's opinions

There is a strong controversy about the differences among standard medical care, palliative sedation therapy, and euthanasia in recent medical literature. To investigate the similarities and differences among these medical treatments, a secondary analysis of two previous surveys was performed. In those surveys, Japanese physicians and the general population were asked to identify their treatment recommendations or preferences for intolerable and refractory distress in the terminal stage. The options were standard medical care without intentional sedation, mild sedation, intermittent deep sedation, continuous deep sedation, and physician-assisted suicide (PAS)/euthanasia. Multidimensional scaling analysis mapped their responses. The physician responses were clustered into 3 groups: 1) standard medical care, 2) palliative sedation therapy including mild, intermittent deep, continuous deep sedation, and 3) PAS/euthanasia. The general population's responses were classified into 3 subgroups: 1) standard medical care, 2) mild and intermittent deep sedation, and 3) a group including continuous deep sedation and PAS/euthanasia. Physicians placed continuous deep sedation closer to mild and intermittent sedation, while the general population mapped it closer to PAS/euthanasia. In conclusion, physicians and general population can generally differentiate the three approaches--standard medical care, palliative sedation therapy, and PAS/euthanasia. We recommend that mild and intermittent deep sedation should be differentiated from standard medical care, and that continuous deep sedation should be dealt with separately from other types of sedation. Clear definitions of palliative sedation therapy will contribute to quality discussion.

Definition of sedation for symptom relief: a systematic literature review and a proposal of operational criteria

Although sedation for symptom relief in terminally ill patients has been the focus of recent medical studies, the interpretation of research findings is difficult due to the confusing terminology. To clarify the agreements and inconsistencies in the definitions of sedation, a systematic review was performed. We searched the literature through MEDLINE from 1990 to July 2001. A total of 7 articles met the inclusion criteria. All studies included the use of sedative medications or the intention to reduce patient consciousness as an essential element of sedation. All but one study explicitly described that the primary aim of sedation was symptom palliation. Three definitions stated that target symptoms were severe, and 4 articles reported the refractory nature of the distress. On the other hand, there were marked inconsistencies in the definition of the degree of sedation, duration, pharmacological properties of medications used, target symptoms, and target populations. This review suggests that sedation includes two core factors: the presence of severe suffering refractory to standard palliative management, and the use of sedative medications with the primary aim to relieve distress. Thus, "palliative sedation therapy" can be defined as "the use of sedative medications to relieve intolerable and refractory distress by the reduction in patient consciousness." The marked inconsistencies in the definition of sedation should be considered to be subcategories of palliative sedation therapy, and we recommend that researchers define the degree of sedation, duration, pharmacological properties of medications, target symptoms, and target populations in future studies. This clarification of terminology will contribute to improving the accuracy and depth of sedation research.

Sedation for comfort at end of life

Treatment for patients who are dying from cancer and are suffering with physiologic and existential symptoms is an important and valuable skill for health care providers. However, the treatment for suffering at the end of life and the use of sedation for comfort often are misunderstood. The following is a discussion of the clinical skills and ethical considerations that health care providers should have when treating terminal patients with cancer.

Preferences for palliative sedation therapy in the Japanese general population

OBJECTIVES

To elucidate which types of palliative sedation therapy are preferred by the Japanese general population, what factors influence these preferences, and how the general population thinks clinicians should inform patients about sedation therapy.

METHODS

A cross-sectional questionnaire survey using a convenient sample of 457 Japanese people (effective response rate, 53.2%).

RESULTS

For refractory intractable physical distress, intermittent deep sedation was chosen as "probably want" or "strongly want" by 86% of the respondents, and mild sedation was chosen by 82%. For refractory intractable psychological distress, intermittent deep sedation was chosen as "probably want" or "strongly want" by 76%, and mild sedation was chosen by 68%. Continuous deep sedation was chosen as "absolutely not want" or "probably not want" by 72% for physical distress and 71% for psychological distress. The respondents who did not want continuous deep sedation were significantly younger, more educated, and more likely to perceive the importance of dignity and preparation for death. Eighty-five percent wanted clear information about reduction in consciousness, and 92% were positive with "in advance" information about sedation therapy. When family members did not agree with the patient's decision, 71% stated that physicians should follow the patient's wishes.

CONCLUSIONS

The Japanese general population preferred intermittent deep or mild sedation to continuous deep sedation in alleviation of intractable and refractory distress. Many required explicit information about the serious consequences of sedation and wanted physicians to respect their wishes. We recommend that clinicians recognize the importance of both symptom alleviation and maintenance of intellectual activities, and to facilitate direct patient involvement in the decision-making process.

Practical guide to palliative sedation

Terminally ill patients want assurance that their symptoms will be controlled as death approaches. Most patients can have a peaceful death with standard palliative care. Some patients approaching death, however, have refractory symptoms such as pain, dyspnea, nausea, and agitated delirium. Palliative sedation (PS), the use of medications to induce sedation in order to control refractory symptoms near death, is a therapeutic option for these patients. The reported frequency of PS use varies greatly, ranging from 5% to 52% of the terminally ill. One concern with PS is its effect on survival. Data suggest that PS does not lead to immediate death, with the median time to death after initiating PS being greater than 1 to 5 days. A number of medications have been used for PS, but midazolam is most commonly reported. PS is distinct from euthanasia because the intent of PS is relief from suffering without death as a required outcome.

Terminal restlessness in the nursing facility: assessment, palliation, and symptom management

Terminal restlessness, sometimes called agitated delirium, is a common occurrence at the end of life. This type of delirium may appear as thrashing or agitation, involuntary muscle twitching or jerks, fidgeting or tossing and turning, yelling, or moaning. Among older adults, especially those in long-term care situations, the delirium may not appear to be very different from previous episodes observed when the resident experienced an infection, exacerbation of a chronic condition, anxiety, pain, or adverse drug reactions. However, delirium at the end of life is usually multifactorial and exacerbated by the progressive shutdown of multiple body systems. Therefore, the effective management of terminal restlessness requires a different approach than the usual care of residents with delirium. For many nurses, this responsibility means adding new clinical knowledge and skills to their practice inventories. This article provides an overview of terminal restlessness, offers assessment guidelines for older adults in long-term care situations who are dying, and describes comfort and symptom management strategies for these individuals.

Opioids in cancer and chronic non-cancer pain therapy-indications and controversies

Indications for strong opioids for cancer-related pain as well as for chronic non-cancer pain are that non-opioid drugs, and other less risky therapies, fail and that the pain is opioid-sensitive. The WHO analgesic ladder principle continues to serve as an excellent educational tool in the efforts by WHO in collaboration with the World Federation of Societies of Anaesthesiologists (WFSA) and The International Association for the Study of Pain (IASP) to increase knowledge of pharmacological pain therapy and increase availability of essential opioid analgesics world-wide. Opioids differ in pharmacodynamics and pharmacokinetics, and patients have different pharmacogenetics and pain mechanisms. Sequential trials of the increasing numbers of available opioid drugs are therefore appropriate when oral morphine fails. Controversies continue concerning diagnosis and handling of opioid-insensitive pain in cancer and chronic non-cancer pain, opioid-induced neurotoxicities, risks of tolerance, addiction, pseudo-addiction, and methods for improving effectiveness and decreasing adverse effects of long-term opioid therapy, treating breakthrough pain with immediate release oral and transmucosal opioids. Consensus guidelines have recently been developed in the Nordic countries concerning the ethical practice of palliative sedation when opioids and other pain-relieving therapies fail in patients soon to die. Guidelines for long-term treatment with strong opioids of chronic non-cancer-related pain are also being developed in the Nordic countries, where very diverging traditions for the usage of such therapy still exist.