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Kauzner S, Heckel M, Ostgathe C, Schneider M, Bausewein C, Schildmann E, Kremling A, Ziegler K, Klein C. Documentation of Sedation in Palliative Care: A Scoping Review of Requirements, Recommendations, and Templates. J Palliat Med 2023; 26:1277-1284. [PMID: 37155703 DOI: 10.1089/jpm.2022.0476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Objective: To identify and describe requirements, recommendations, and templates for the documentation of sedation in adult palliative care. Introduction: International literature shows inconsistency in clinical practice regarding sedation in palliative care accompanied by legal, ethical, and medical uncertainties. Documentation in general serves as proof for previous treatments. In the context of intentional sedation to relieve suffering at the end of life, documentation provides a clear demarcation against practices of euthanasia. Inclusion Criteria: Articles with full-text version published in English or German since 2000, covering documentation requirements, recommendations, monitoring parameters or templates for sedation in adult palliative care were included. Methods: Scoping review following the JBI methodology. Search in online databases, websites of professional associations in palliative care, reference lists of relevant publications, the archive of the German "Journal of Palliative Medicine" and databases for unpublished literature were used. Search terms included "palliative care,' "sedation," and "documentation." The search was conducted from January 2022 to April 2022 with an initial hand search in November 2021. Data were screened and charted by one reviewer after conducting a pilot test of the criteria. Results: From the initial 390 articles (database search), 22 articles were included. In addition, 15 articles were integrated from the hand search. The results can be clustered in two sets of items, regarding either the documentation before or during sedation. The documentation requirements referred both to inpatient and homecare settings but in many cases, a clear assignment was missing. Conclusions: The guidelines analyzed in this study rarely cover setting-specific differences in documentation and often treat documentation as minor topic. Further research is needed addressing legal and ethical concerns of health care teams and, therefore, help to improve treatment of patients suffering from otherwise intractable burden at the end of life.
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Affiliation(s)
- Saskia Kauzner
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Maria Heckel
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Manuela Schneider
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
- Department of Hematology, Oncology and Cancer Immunology, Oncological Palliative Care and Charité Comprehensive Cancer Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander Kremling
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
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Symptomlinderung. Palliat Care 2018. [DOI: 10.1007/978-3-662-56151-5_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Janssens U. [Immediate extubation or terminal weaning in ventilated intensive care patients after therapeutic goal change]. Med Klin Intensivmed Notfmed 2017; 113:221-226. [PMID: 29147728 DOI: 10.1007/s00063-017-0382-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 10/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- U Janssens
- Klinik für Innere Medizin, St.-Antonius-Hospital, Dechant-Deckers-Str. 8, 52249, Eschweiler, Deutschland.
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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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Stiel S, Heckel M, Christensen B, Ostgathe C, Klein C. In-service documentation tools and statements on palliative sedation in Germany--do they meet the EAPC framework recommendations? A qualitative document analysis. Support Care Cancer 2015; 24:459-467. [PMID: 26268785 DOI: 10.1007/s00520-015-2889-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 08/02/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Numerous (inter-)national guidelines and frameworks have been developed to provide recommendations for the application of palliative sedation (PS). However, they are still not widely known, and large variations in PS clinical practice can be found. AIM This study aims to collect and describe contents from documents used in clinical practice and to compare to what extent they match the European Association for Palliative Care (EAPC) framework recommendations. DESIGN AND METHODS In a national survey on PS in Germany 2012, participants were asked to upload their in-service templates, assessment tools, specific protocols, and in-service statements for the application and documentation of PS. These documents are analyzed by using systematic structured content analysis. RESULTS Three hundred seven content units of 52 provided documents were coded. The analyzed templates are very heterogeneous and also contain items not mentioned in the EAPC framework. Among 11 scales for the evaluation of sedation level, the Ramsey Sedation Score (n = 5) and the Richmond-Agitation-Sedation-Scale (n = 2) were found most often. For symptom assessment, three different scales were provided one time respectively. In all six PS statements, the common core elements were possible indications for PS, instructions on dose titration, patient monitoring, and care. Wide congruency exists for physical and psychological indications. Most documents coincide on midazolam as a preferred drug and basic monitoring in regular intervals. Aspects such as pre-emptive discussion of the potential role of sedation, informational needs of relatives, and care for the medical professionals are mentioned rarely. CONCLUSIONS The analyzed templates do neglect some points of the EAPC recommendations. However, they expand the ten-point scheme of the framework in some details. The findings may facilitate the development of standardized consensus documentation and monitoring draft as an operational statement.
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Affiliation(s)
- Stephanie Stiel
- Department of Palliative Medicine, Comprehensive Cancer Center CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Maria Heckel
- Department of Palliative Medicine, Comprehensive Cancer Center CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Britta Christensen
- Department of Palliative Medicine, Comprehensive Cancer Center CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Comprehensive Cancer Center CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine, Comprehensive Cancer Center CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany.
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Bozzaro C. Der Leidensbegriff im medizinischen Kontext: Ein Problemaufriss am Beispiel der tiefen palliativen Sedierung am Lebensende. Ethik Med 2015. [DOI: 10.1007/s00481-015-0339-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Brinkkemper T, van Norel AM, Szadek KM, Loer SA, Zuurmond WWA, Perez RSGM. The use of observational scales to monitor symptom control and depth of sedation in patients requiring palliative sedation: a systematic review. Palliat Med 2013; 27:54-67. [PMID: 22045725 DOI: 10.1177/0269216311425421] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Palliative sedation is the intentional lowering of consciousness of a patient in the last phase of life to relieve suffering from refractory symptoms such as pain, delirium and dyspnoea. AIM In this systematic review, we evaluated the use of monitoring scales to assess the degree of control of refractory symptoms and/or the depth of the sedation. DESIGN A database search of PubMed and Embase was performed up to January 2010 using the search terms 'palliative sedation' OR 'terminal sedation'. DATA SOURCES Retro- and prospective studies as well as reviews and guidelines containing information about monitoring of palliative sedation, written in the English, German or Dutch language were included. RESULTS The search yielded 264 articles of which 30 were considered relevant. Most studies focused on monitoring refractory symptoms (pain, fatigue or delirium) or the level of awareness to control the level of sedation. Four prospective and one retrospective study used scales validated in other settings: the Numeric Pain Rating Scale, the Visual Analogue Scale, the Memorial Delirium Assessment Scale, the Communication Capacity Scale and Agitation Distress Scale. Only the Community Capacity Scale was partially validated for use in a palliative sedation setting. One guideline described the use of a scale validated in another setting. CONCLUSIONS A minority of studies reported the use of observational scales to monitor the effect of palliative sedation. Future studies should be focused on establishing proper instruments, most adequate frequency and timing of assessment, and interdisciplinary evaluation of sedation depth and symptom control for palliative sedation.
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Affiliation(s)
- Tijn Brinkkemper
- Department of Anaesthesiology, VU University Medical Centre, Amsterdam, The Netherlands.
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Jaspers B, Nauck F, Lindena G, Elsner F, Ostgathe C, Radbruch L. Palliative Sedation in Germany: How Much Do We Know? A Prospective Survey. J Palliat Med 2012; 15:672-80. [DOI: 10.1089/jpm.2011.0395] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Birgit Jaspers
- Department of Palliative Medicine, University of Bonn, Germany
- Department of Palliative Medicine, University Medical Center, Göttingen, Germany
| | - Friedemann Nauck
- Department of Palliative Medicine, University Medical Center, Göttingen, Germany
| | - Gabriele Lindena
- Department of Palliative Medicine, University Medical Center, Göttingen, Germany
- CLARA Clinical Research, Kleinmachnow, Germany
| | - Frank Elsner
- Department of Palliative Medicine, RWTH Aachen University, Germany
| | | | - Lukas Radbruch
- Department of Palliative Medicine, University of Bonn, Germany
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Einführung eines ethischen Basis-Assessments in der Spezialisierten Ambulanten Palliativversorgung in Augsburg. Ethik Med 2011. [DOI: 10.1007/s00481-011-0165-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Radbruch L, Nauck F. [To sedate or not to sedate-that is the question here : Palliative sedation between standard care and flexibility]. Schmerz 2010; 24:313-4. [PMID: 20665221 DOI: 10.1007/s00482-010-0947-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schippinger W, Weixler D, Müller-Busch C. Palliative Sedierung zur Symptomkontrolle massiver Dyspnoe. Wien Med Wochenschr 2010; 160:338-42. [DOI: 10.1007/s10354-009-0735-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 09/11/2009] [Indexed: 10/19/2022]
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Palliative Sedierungstherapie in der Pädiatrie. Wien Med Wochenschr 2008; 158:659-63. [DOI: 10.1007/s10354-008-0617-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Accepted: 10/28/2008] [Indexed: 11/26/2022]
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Abstract
Terminal illnesses can cause distressing symptoms such as severe pain, mental confusions, feelings of suffocation, and agitation. Despite skilled palliative care in some cases these symptoms may not respond to standard interventions. After all other means to provide comfort and relief to a dying patient have been tried and are unsuccessful, clinical caregivers and patients can consider palliative sedation. Sedation in the context of palliative medicine is the monitored use of medications to induce varying degrees of unconsciousness to bring about a state of decreased or absent awareness in order to relieve the burden of otherwise refractory suffering. Palliative sedation is not intended to cause death or shorten life. The patient and family should agree with plans for palliative sedation. Because cases involving palliative sedation are emotionally stressful, the patient, family, and health care workers can all benefit from talking about the complex medical, ethical, and emotional issues they raise.
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Affiliation(s)
- K Sauer
- Kliniken Essen-Mitte, Henricistrasse 92, 45136, Essen, Deutschland.
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