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Huang HL, Chen PJ, Mori M, Suh SY, Wu CY, Peng JK, Shih CY, Yao CA, Tsai JS, Chiu TY, Hiratsuka Y, Kim SH, Morita T, Yamaguchi T, Tsuneto S, Hui D, Cheng SY. Improved Symptom Change Enhances Quality of Dying in Patients With Advanced Cancer: An East Asian Cross-Cultural Study. Oncologist 2024; 29:e553-e560. [PMID: 37758042 PMCID: PMC10994251 DOI: 10.1093/oncolo/oyad269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/20/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Symptom burdens tend to increase for patients with cancer and their families over the disease trajectory. There is still a lack of evidence on the associations between symptom changes and the quality of dying and death. In this context, this research investigated how symptom changes influence the quality of dying and death. METHODS This international prospective cohort study (the East Asian Collaborative Cross-Cultural Study to Elucidate the Dying Process (EASED), 2017-2019) included 22, 11, and 4 palliative care units across Japan, South Korea, and Taiwan. Eligible participants were adults (Japan and Korea, ≥18 years; Taiwan, ≥20 years) with locally advanced or metastatic cancer. Physical and psychological symptoms were assessed by physicians upon admission and within 3 days before death. Death quality was assessed using the Good Death Scale (GDS), developed in Taiwan. Univariate and multivariate regression analyses were used to identify correlations between symptom severity changes and GDS scores. RESULTS Among 998 patients (542 [54.3%] men and 456 [45.7%] women; mean [SD] age = 70.1 [± 12.5] years), persistent dyspnea was associated with lower GDS scores when compared to stable dyspnea (β = -0.427, 95% CI = -0.783 to -0.071). Worsened (-1.381, -1.932 to -0.831) and persistent (-1.680, -2.701 to -0.659) delirium were also significantly associated with lower GDS scores. CONCLUSIONS Better quality of dying and death was associated with improved symptom control, especially for dyspnea and delirium. Integrating an outcome measurement for the quality of dying and death is important in the management of symptoms across the disease trajectory in a goal-concordant manner.
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Affiliation(s)
- Hsien-Liang Huang
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Republic of China
| | - Ping-Jen Chen
- Department of Family Medicine and Division of Geriatrics and Gerontology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Republic of China
- Department of Family Medicine, School of Medicine, Kaohsiung Medical University, Kaohsiung, Republic of China
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Sang-Yeon Suh
- Department of Family Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
- Department of Medicine, School of Medicine, Dongguk University, Seoul, South Korea
| | - Chien-Yi Wu
- Department of Family Medicine and Division of Geriatrics and Gerontology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Republic of China
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung, Republic of China
| | - Jen-Kuei Peng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Republic of China
| | - Chih-Yuan Shih
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Republic of China
| | - Chien-An Yao
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Republic of China
| | - Jaw-Shiun Tsai
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Republic of China
| | - Tai-Yuan Chiu
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Republic of China
| | - Yusuke Hiratsuka
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Miyagi Prefecture, Japan
| | - Sun-Hyun Kim
- Department of Family Medicine, School of Medicine, Catholic Kwandong University, International St. Mary's Hospital, Incheon, South Korea
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takashi Yamaguchi
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto Prefecture, Japan
| | - David Hui
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, USA
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Republic of China
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Shevchenko S, Zhavoronkov A. The Role of Exceptionalism in the Evolution of Bioethical Regulation. Camb Q Healthc Ethics 2024; 33:185-197. [PMID: 37288492 DOI: 10.1017/s0963180123000336] [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: 06/09/2023]
Abstract
The paper aims to present a critical analysis of the phenomenon and notion of exceptionalism in bioethics. The authors demonstrate that exceptionalism pertains to phenomena that are not (yet) entirely familiar to us and could potentially bear risks regarding their regulation. After an overview of the state of the art, we briefly describe the origins and evolution of the concept, compared to exception and exclusion. In the second step, they look at the overall development debates on genetic exceptionalism, compared to other bioethical debates on exceptionalism, before presenting a detailed analysis of a specific case of early regulation of genetic screening. In the last part, the authors explain the historical background behind the connection between exceptionalism and exclusion in these debates. Their main conclusion is that while the initial stage of the discussion is shaped by the concept of exceptionalism and awareness of risks of exclusion, the later development centers around exceptions that are needed in detailed regulatory procedures.
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Affiliation(s)
| | - Alexey Zhavoronkov
- Institut für Philosophie, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
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Farrelly-Jackson S. Intentions at the End of Life: Continuous Deep Sedation and France's Claeys-Leonetti law. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2024; 49:43-57. [PMID: 37804077 DOI: 10.1093/jmp/jhad040] [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: 10/08/2023] Open
Abstract
In 2016, France passed a major law that is unique in giving terminally ill and suffering patients the right to the controversial procedure of continuous deep sedation until death (CDS). In so doing, the law identifies CDS as a sui generis clinical practice, distinct from other forms of palliative sedation therapy, as well as from euthanasia. As such, it reconfigures the ethical debate over CDS in interesting ways. This paper addresses one aspect of this reconfiguration and its implications for the intentions at work in this complex time at the end of life. The concept of intention is often considered central to the ethics of end-of-life care, but its role is recognized to be problematic, with charges of elusiveness and ambiguity. I aim to show that consideration of the French law affords a new understanding of the intentionality of CDS, and that in addition to the obvious importance of this for clarifying the ethics of the practice, it may suggest new ways of addressing the wider problem of ambiguous clinical intentions at end of life.
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Tomczyk M, Andorno R, Jox RJ. Should continuous deep sedation until death be legally regulated in Switzerland? An exploratory study with palliative care physicians. Palliat Care Soc Pract 2023; 17:26323524231219509. [PMID: 38152555 PMCID: PMC10752051 DOI: 10.1177/26323524231219509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023] Open
Abstract
Background In Switzerland, continuous deep sedation until death (CDSUD) is not legally regulated and the current clinical practice guidelines on palliative sedation from 2005 do not refer to it. In contrast, in France, a neighbouring country, CDSUD is regulated by a specific law and professional guidelines. International studies show that in culturally polymorphic countries, there are variations in the end-of-life practices between linguistic regions and that a linguistic region shares many cultural characteristics with the neighbouring country. Objectives This study aimed to explore the attitudes of palliative care physicians from the French-speaking part of Switzerland on the question of whether CDSUD should be legally regulated in the country, and to identify their arguments. Our study also aimed to assess whether a hypothetical Swiss law on CDSUD should be similar to the current legal regulation of this practice in France. Design We conducted a multicentre exploratory qualitative study based on face-to-face interviews with palliative care physicians in the French-speaking part of Switzerland. Methods We analysed the interview transcripts using thematic analysis, combining deductive and inductive coding. Results Most of the participants were opposed to having specific legal regulation of CDSUD in Switzerland. Their arguments were diverse: some focused on medical and epistemological aspects of CDSUD, whereas others emphasized the legal inconvenience of having such regulation. None had the opinion that, if CDSUD were legally regulated in Switzerland, the regulation should be similar to that in France. Conclusion This study allows to better understand why palliative care physicians in French-speaking Switzerland may be reluctant to have legal regulation of CDSUD. Further studies covering the whole country would be needed to gain a more complete picture of Swiss palliative care physicians on this question.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Av. de Provence 82, Lausanne CH-1007, Switzerland
| | - Roberto Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Ralf J. Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Palliative & Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Le Dorze M, Barthélémy R, Giabicani M, Audibert G, Cousin F, Gakuba C, Robert R, Chousterman B, Perrigault PF. Continuous and deep sedation until death after a decision to withdraw life-sustaining therapies in intensive care units: A national survey. Palliat Med 2023; 37:1202-1209. [PMID: 37306034 DOI: 10.1177/02692163231180656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Continuous and deep sedation until death is a much highly debated end-of-life practice. France is unique in having a regulatory framework for it. However, there are no data on its practice in intensive care units (ICUs). AIM The aim is to describe continuous and deep sedation in relation to the framework in the specific context of withdrawal of life-sustaining therapies in ICUs, that is, its decision-making process and its practice compared to other end-of-life practices in this setting. DESIGN AND SETTING French multicenter observational study. Consecutive ICU patients who died after a decision to withdraw life-sustaining therapies. RESULTS A total of 343 patients in 57 ICUs, 208 (60%) with continuous and deep sedation. A formalized procedure for continuous and deep sedation was available in 32% of the ICUs. Continuous and deep sedation was not the result of a collegial decision-making process in 17% of cases, and did not involve consultation with an external physician in 29% of cases. The most commonly used sedative medicines were midazolam (10 [5-18] mg h-1) and propofol (200 [120-250] mg h -1). The Richmond Agitation Sedation Scale (RASS) was -5 in 60% of cases. Analgesia was associated with sedation in 94% of cases. Compared with other end-of-life sedative practices (n = 98), medicines doses were higher with no difference in the depth of sedation. CONCLUSIONS This study shows a poor compliance with the framework for continuous and deep sedation. It highlights the need to formalize it to improve the decision-making process and the match between the intent, the practice and the actual effect.
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Affiliation(s)
- Matthieu Le Dorze
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université Paris-Saclay, CESP U1018, Inserm, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Romain Barthélémy
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Mikhael Giabicani
- Department of Anaesthesia and Critical Care, AP-HP, Beaujon Hospital, Paris, France
- Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, Laboratoire ETREs, Paris, France
| | - Gérard Audibert
- Department of Anaesthesia and Critical Care Medicine, CHRU Nancy, Université de Lorraine, Nancy, France
| | - François Cousin
- Centre national des soins palliatifs et de la fin de vie (CNSPFV), Paris, France
| | - Clément Gakuba
- Department of Anesthesia and Critical Care Medicine, Caen, France
| | - René Robert
- Médecine Intensive Réanimation, CHU Poitiers, F-86000, Poitiers, France
- Université de Poitiers, CIC Inserm ALIVE, F-86000, Poitiers, France
| | - Benjamin Chousterman
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Pierre-François Perrigault
- Department of Anesthesia and Critical Care Medicine, Gui de Chauliac University Hospital, Université de Montpellier, Montpellier, France
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Fasse L, Roche N, Flahault C, Garrouste-Orgeas M, Ximenes M, Pages A, Evin A, Dauchy S, Scotte F, Le Provost JB, Blot F, Mateus C. The APSY-SED study: protocol of an observational, longitudinal, mixed methods and multicenter study exploring the psychological adjustment of relatives and healthcare providers of patients with cancer with continuous deep sedation until death. Palliat Care 2022; 21:217. [PMID: 36464684 PMCID: PMC9720978 DOI: 10.1186/s12904-022-01106-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Since 2016, France is the only country in the World where continuous deep sedation until death (CDSUD) is regulated by law. CDSUD serves as a response to refractory suffering in palliative situations where the patients' death is expected to occur in the following hours or days. Little is known on the psychological adjustment surrounding a CDSUD procedure for healthcare providers (HCPs) and relatives. Our study aims to gather qualitative and quantitative data on the specific processes behind the psychological adjustment of both relatives and HCPs, after the administration of CDSUD for patients with cancer. METHODS The APSY-SED study is a prospective, longitudinal, mixed-methods and multicenter study. Recruitment will involve any French-speaking adult cancer patient for who a CDSUD is discussed, their relatives and HCPs. We plan to include 150 patients, 150 relatives, and 50 HCPs. The evaluation criteria of this research are: 1/ Primary criterion: Psychological adjustment of relatives and HCPs 6 and 13 months after the death of the patient with cancer (psychological adjustment = intensity of anxiety, depression and grief reactions, CDSUD-related distress, job satisfaction, Professional Stress and Professional experience). Secondary criteria: a)occurrence of wish for a CDSUD in patients in palliative phase; b)occurrence of wish for hastened death in patients in palliative phase; c)potential predictors of adjustment assessed after the discussion concerning CDSUD as an option and before the setting of the CDSUD; d) Thematic analysis and narrative account of meaning-making process concerning the grief experience. DISCUSSION The APSY-SED study will be the first to investigate the psychological adjustment of HCPs and relatives in the context of a CDSUD procedure implemented according to French law. Gathering data on the grief process for relatives can help understand bereavement after CDSUD, and participate in the elaboration of specific tailored interventions to support HCPs and relatives. Empirical findings on CDSUD among patients with cancer in France could be compared with existing data in other countries and with results related to other medical fields where CDSUD is also conducted. TRIAL REGISTRATION This protocol received the National Registration Number: ID-RCB2021-A03042-39 on 14/12/2021.
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Affiliation(s)
- L. Fasse
- grid.14925.3b0000 0001 2284 9388DIOPP, Gustave Roussy Hospital, Villejuif, France ,grid.508487.60000 0004 7885 7602Institut de Psychologie Laboratoire de Psychopathologie et Processus de Santé, Université Paris Cité, 71 avenue E. Vaillant, F-92100 Boulogne- Billancourt, France
| | - N. Roche
- grid.14925.3b0000 0001 2284 9388DIOPP, Gustave Roussy Hospital, Villejuif, France
| | - C. Flahault
- grid.14925.3b0000 0001 2284 9388DIOPP, Gustave Roussy Hospital, Villejuif, France ,grid.508487.60000 0004 7885 7602Institut de Psychologie Laboratoire de Psychopathologie et Processus de Santé, Université Paris Cité, 71 avenue E. Vaillant, F-92100 Boulogne- Billancourt, France
| | - M. Garrouste-Orgeas
- grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, F-75018 Paris, France ,Palliative Care unit, Reuilly Diaconesses Fondation, Rueil Malmaison, France ,Medical unit, French British Hospital, Levallois-Perret, France
| | - M. Ximenes
- Maison Médicale Marie Galène, Bordeaux, France
| | - A. Pages
- grid.14925.3b0000 0001 2284 9388Biostatistical Unit, Gustave Roussy Hospital, Villejuif, France
| | - A. Evin
- grid.277151.70000 0004 0472 0371Palliative Care unit, CHU, Nantes, France
| | - S. Dauchy
- grid.508487.60000 0004 7885 7602DMU Psychiatry and Addictology, AP-HP.Centre, Université de Paris, Paris, France
| | - F. Scotte
- grid.14925.3b0000 0001 2284 9388DIOPP, Gustave Roussy Hospital, Villejuif, France
| | - JB. Le Provost
- grid.14925.3b0000 0001 2284 9388DIOPP, Gustave Roussy Hospital, Villejuif, France
| | - F. Blot
- grid.14925.3b0000 0001 2284 9388DIOPP, Gustave Roussy Hospital, Villejuif, France
| | - C. Mateus
- grid.14925.3b0000 0001 2284 9388DIOPP, Gustave Roussy Hospital, Villejuif, France
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Mentzelopoulos SD, Couper K, Raffay V, Djakow J, Bossaert L. Evolution of European Resuscitation and End-of-Life Practices from 2015 to 2019: A Survey-Based Comparative Evaluation. J Clin Med 2022; 11:jcm11144005. [PMID: 35887769 PMCID: PMC9316602 DOI: 10.3390/jcm11144005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 01/27/2023] Open
Abstract
Background: In concordance with the results of large, observational studies, a 2015 European survey suggested variation in resuscitation/end-of-life practices and emergency care organization across 31 countries. The current survey-based study aimed to comparatively assess the evolution of practices from 2015 to 2019, especially in countries with “low” (i.e., average or lower) 2015 questionnaire domain scores. Methods: The 2015 questionnaire with additional consensus-based questions was used. The 2019 questionnaire covered practices/decisions related to end-of-life care (domain A); determinants of access to resuscitation/post-resuscitation care (domain B); diagnosis of death/organ donation (domain C); and emergency care organization (domain D). Responses from 25 countries were analyzed. Positive or negative responses were graded by 1 or 0, respectively. Domain scores were calculated by summation of practice-specific response grades. Results: Domain A and B scores for 2015 and 2019 were similar. Domain C score decreased by 1 point [95% confidence interval (CI): 1–3; p = 0.02]. Domain D score increased by 2.6 points (95% CI: 0.2–5.0; p = 0.035); this improvement was driven by countries with “low” 2015 domain D scores. In countries with “low” 2015 domain A scores, domain A score increased by 5.5 points (95% CI: 0.4–10.6; p = 0.047). Conclusions: In 2019, improvements in emergency care organization and an increasing frequency of end-of-life practices were observed primarily in countries with previously “low” scores in the corresponding domains of the 2015 questionnaire.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675 Athens, Greece
- Correspondence: or ; Tel.: +30-697-530-4909; Fax: +30-213-204-3307
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham, NHS Foundation Trust, Birmingham B15 2TH, UK;
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus;
- Serbian Resuscitation Council, 21102 Novi Sad, Serbia
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, 26801 Hořovice, Czech Republic;
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic
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Anand A, Saigal S, Kodamanchili S, Panda R, Nair RR. Quality of last journey. Intensive Care Med 2022; 48:1101. [PMID: 35593937 DOI: 10.1007/s00134-022-06736-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Abhijeet Anand
- India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India.
| | - Saurabh Saigal
- India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | | | - Rajesh Panda
- India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Rohini R Nair
- India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Bretonniere S, Fournier V. Continuous Deep Sedation Until Death: First National Survey in France after the 2016 Law Promulgating It. J Pain Symptom Manage 2021; 62:e13-e19. [PMID: 33819514 DOI: 10.1016/j.jpainsymman.2021.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT The French parliament passed a groundbreaking law in 2016, opening a right for patients to access continuous and deep sedation until death (CDS) at the end of life, under conditions. Parliamentarians' goal was to consolidate patients' rights whilst avoiding legislating on medical aid in dying. OBJECTIVES To conduct a first national retrospective survey on CDS to evaluate the number of CDS requested, proposed and performed in 2017 and to elicit qualitative data from physicians on the practice and on the terms used by patients to refer to CDS. METHODS Early 2018, an online survey was sent to all French hospitals, nursing homes, hospital at homes services and general practitioners (GPs). Descriptive statistics and qualitative inductive content analysis were used to analyze the data and comments of respondents. RESULTS The qualitative data show that respondents generally approve the law on CDS as it sets a legal framework; nonetheless, there is a persistent controversy about CDS vs. euthanasia for some physicians in all settings. GPs reported limited access to midazolam and the difficulty in organizing multidisciplinary procedures as major constraints. In hospital settings in particular, differentiating CDS from other sedation practices is uneasy. All physicians reported patients use multiple elements of language to request CDS. CONCLUSION After the law was passed in France, CDS were requested, proposed and performed in all medical settings, in nursing homes, at home. The qualitative data presented here show the relevance of exploring physicians' reflexive stances on this practice in different settings and within the context of a patient-physician relationship marked by a new patient's right. The study highlights the wide range of elements of language used by patients at the end of life, as understood by respondent physicians to mean a request for CDS and underscores the polymorphous meaning of CDS.
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Affiliation(s)
- Sandrine Bretonniere
- Centre national des soins palliatifs et de la fin de vie (S.B.), Paris Cedex 19, France.
| | - Veronique Fournier
- Centre national des soins palliatifs et de la fin de vie, Centre d'éthique clinique, Assistance publique-Hôpitaux de Paris (V.F.), Paris, France
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Refractory psycho-existential distress and continuous deep sedation until death in palliative care: The French perspective. Palliat Support Care 2021; 18:486-494. [PMID: 31551106 DOI: 10.1017/s1478951519000816] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Since February 2016, French Claeys-Leonetti law has recognized patients' right to confront incurable diseases with short-term prognosis and refractory physical or psychological or existential symptoms by requesting continuous deep sedation until death (CDSUD). Determining when psychological or existential distress is refractory and unbearable remains complex and controversial.This review provides a comprehensive thought on CDSUD for advanced incurable patients with refractory psychological and/or existential distress in palliative care settings. It offers guidance on psychiatric or psychological diagnosis for explaining patients' requests for CDSUD. METHOD A narrative literature review (2000-2019) was conducted on the MedLine search about the use of palliative sedation in cases of refractory psychological and/or existential distress. RESULTS (1) Definitions of "refractory symptom," "refractory psychological distress," and "refractory existential distress" are inconsistent; (2) alternative diagnoses might obscure or be obscured by psycho-existential distress; and (3) criteria on meanings, reasons for requests, decision-making processes, and functions are evolving in practice. SIGNIFICANCE OF RESULTS Before implementing CDSUD, palliative healthcare professionals should seek input from psycho-oncologists in palliative care. Mental health professionals should analyze and assess the reasons for psychological and/or existential distress, consider the intentionality processes of requests, and explore alternative diagnoses, such as depressive or adjustment disorders, demoralization syndrome, desire to hasten death, and desire for euthanasia. Therapeutic responses (e.g., pharmacological and psychotherapeutic) should be implemented before deciding that psycho-existential distress is refractory.
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11
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Vieille M, Dany L, Coz PL, Avon S, Keraval C, Salas S, Bernard C. Perception, Beliefs, and Attitudes Regarding Sedation Practices among Palliative Care Nurses and Physicians: A Qualitative Study. Palliat Med Rep 2021; 2:160-167. [PMID: 34223516 PMCID: PMC8241398 DOI: 10.1089/pmr.2021.0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Palliative care teams face complex medical situations on a daily basis. These situations require joint reflection and decision making to propose appropriate patient care. Sometimes, sedation is one of the options to be considered. In addition to medical and technical criteria justifying the use of sedation, multiple psychosocial criteria impact the decision making of palliative care teams and guide, give sense to, and legitimize professional practices. Objective: The main goal of this study was to explore perceptions, experiences, and beliefs of palliative care teams about sedation practices in a legislative context (Claeys–Leonetti law, 2016; France), which authorizes continuous deep sedation (CDS) until death. Methods: This is a qualitative study using 28 semistructured interviews with physicians and nurses working in a palliative care team in France (PACA region). All verbal productions produced during interviews were fully transcribed and the contents analyzed. Findings: Content analysis revealed four themes: (1) sedation as a “good death,” (2) emotional experiences of sedations, (3) the practice of CDS, and (4) the ambiguous relationship with the Claeys–Leonetti law. Conclusions: This qualitative study provides evidence of a form of “naturalization” of the practice of sedation. However, the Claeys–Leonetti law exacerbates differences of opinion between palliative caregivers on sedation and questions the interest of this law for society and palliative care practices. clinicalTrials.gov identifier: NCT04016038.
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Affiliation(s)
| | - Lionel Dany
- Aix-Marseille Université, LPS, Aix-en-Provence, France.,APHM, Timone, Service d'Oncologie Médicale, Marseille, France
| | - Pierre Le Coz
- Aix Marseille Université, CNRS, EFS, ADES, Marseille, France
| | - Sophie Avon
- Aix-Marseille Université, LPS, Aix-en-Provence, France
| | | | - Sébastien Salas
- APHM, Timone, Service d'Oncologie Médicale, Marseille, France.,Aix Marseille Université, CRO2, Marseille, France
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12
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Tomczyk M, Dieudonné-Rahm N, Jox RJ. A qualitative study on continuous deep sedation until death as an alternative to assisted suicide in Switzerland. BMC Palliat Care 2021; 20:67. [PMID: 33990204 PMCID: PMC8122537 DOI: 10.1186/s12904-021-00761-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/16/2021] [Indexed: 12/24/2022] Open
Abstract
Background According to the European Association for Palliative Care, decisions regarding palliative sedation should not be made in response to requests for assisted dying, such as euthanasia or assisted suicide. However, several studies show that continuous deep sedation until death (CDSUD) – a particular form of sedation – has been considered as an alternative to these practices in some countries. In Switzerland, where assisted suicide is decriminalized and CDSUD is not legally regulated, no studies have comprehensively investigated their relation. Our study aimed to identify and describe the experience among palliative care physicians of CDSUD as a potential alternative to assisted suicide in the French-speaking part of Switzerland. Methods We performed an exploratory multicentre qualitative study based on interviews with palliative care physicians in the French-speaking part of Switzerland and conducted linguistic and thematic analysis of all interview transcripts. The study is described in accordance with COREQ guidelines. Results We included 10 interviews conducted in four palliative care units. Our linguistic analysis shows four main types of sedation, which we called ‘rapid CDSUD’, ‘gradual CDSUD’, ‘temporary sedation’ and ‘intermittent sedation’. CDSUD (rapid or gradual) was not considered an alternative to assisted suicide, even if a single situation has been reported. In contrast, ‘temporary’ or ‘intermittent sedation’, although not medically indicated, was sometimes introduced in response to a request for assisted suicide. This was the fact when there were barriers to an assisted suicide at home (e.g., when transfer home was impossible or the patient wished not to burden the family). Conclusion These preliminary results can guide clinical, ethical, linguistic and legal reflection in this field and be used to explore this question more deeply at the national and international levels in a comparative, interdisciplinary and multiprofessional approach. They can also be useful to update Swiss clinical guidelines on palliative sedation in order to include specific frameworks on various sedation protocols and sedation as an alternative to assisted suicide. Potential negative impacts of considering palliative sedation as an alternative to assisted suicide should be nuanced by open and honest societal debate.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland.
| | - Nathalie Dieudonné-Rahm
- Palliative Care Unit, Geneva University Hospitals, Chemin de la Savonnière 11, 1245 Collonge Bellerive, Geneva, Switzerland
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland.,Palliative & Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital & University of Lausanne, Av. Pierre-Decker 5, CH-1011, Lausanne, Switzerland
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13
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Takla A, Savulescu J, Wilkinson DJC, Pandit JJ. General anaesthesia in end-of-life care: extending the indications for anaesthesia beyond surgery. Anaesthesia 2021; 76:1308-1315. [PMID: 33878803 PMCID: PMC8581983 DOI: 10.1111/anae.15459] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 01/08/2023]
Abstract
In this article, we describe an extension of general anaesthesia – beyond facilitating surgery – to the relief of suffering during dying. Some refractory symptoms at the end of life (pain, delirium, distress, dyspnoea) might be managed by analgesia, but in high doses, adverse effects (e.g. respiratory depression) can hasten death. Sedation may be needed for agitation or distress and can be administered as continuous deep sedation (also referred to as terminal or palliative sedation) generally using benzodiazepines. However, for some patients these interventions are not enough, and others may express a clear desire to be completely unconscious as they die. We summarise the historical background of an established practice that we refer to as ‘general anaesthesia in end‐of‐life care’. We discuss its contexts and some ethical and legal issues that it raises, arguing that these are largely similar issues to those already raised by continuous deep sedation. To be a valid option, general anaesthesia in end‐of‐life care will require a clear multidisciplinary framework and consensus practice guidelines. We see these as an impending development for which the specialty should prepare. General anaesthesia in end‐of‐life care raises an important debate about the possible role of anaesthesia in the relief of suffering beyond the context of surgical/diagnostic interventions.
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Affiliation(s)
- A Takla
- Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
| | - J Savulescu
- Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - D J C Wilkinson
- Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia.,Department of Neonatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
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14
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Wilkinson D, Savulescu J. Current controversies and irresolvable disagreement: the case of Vincent Lambert and the role of 'dissensus'. JOURNAL OF MEDICAL ETHICS 2019; 45:631-635. [PMID: 31395693 PMCID: PMC6855788 DOI: 10.1136/medethics-2019-105622] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/10/2019] [Accepted: 07/12/2019] [Indexed: 06/10/2023]
Abstract
Controversial cases in medical ethics are, by their very nature, divisive. There are disagreements that revolve around questions of fact or of value. Ethical debate may help in resolving those disagreements. However, sometimes in such cases, there are opposing reasonable views arising from deep-seated differences in ethical values. It is unclear that agreement and consensus will ever be possible. In this paper, we discuss the recent controversial case of Vincent Lambert, a French man, diagnosed with a vegetative state, for whom there were multiple court hearings over a number of years. Both family and health professionals were divided about whether artificial nutrition and hydration should be withdrawn and Lambert allowed to die. We apply a 'dissensus' approach to his case and argue that the ethical issue most in need of scrutiny (resource allocation) is different from the one that was the focus of attention.
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Affiliation(s)
- Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- John Radcliffe Hospital, Oxford, UK
- Murdoch Children’s Research Institute, Melbourne, Australia
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Murdoch Children’s Research Institute, Melbourne, Australia
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15
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Emmerich N, Gordijn B. Ethics of crisis sedation: questions of performance and consent. JOURNAL OF MEDICAL ETHICS 2019; 45:339-345. [PMID: 31005858 DOI: 10.1136/medethics-2018-105285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 03/06/2019] [Accepted: 03/11/2019] [Indexed: 06/09/2023]
Abstract
This paper focuses on the practice of injecting patients who are dying with a relatively high dose of sedatives in response to a catastrophic event that will shortly precipitate death, something that we term 'crisis sedation.' We first present a confabulated case that illustrates the kind of events we have in mind, before offering a more detailed account of the practice. We then comment on some of the ethical issues that crisis sedation might raise. We identify the primary value of crisis sedation as allowing healthcare professionals to provide some degree of reassurance to patients, their families and the professionals who are caring for them. Next we focus on the issue of informed consent. Finally, we ask whether continuous deep sedation might be preferable to crisis sedation in scenarios where potential catastrophic events can be anticipated.
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Affiliation(s)
- Nathan Emmerich
- School of Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
- Institute of Ethics, Dublin City University, Dublin, Ireland
| | - Bert Gordijn
- Institute of Ethics, Dublin City University, Dublin, Ireland
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16
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Sinmyee S, Pandit VJ, Pascual JM, Dahan A, Heidegger T, Kreienbühl G, Lubarsky DA, Pandit JJ. Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying. Anaesthesia 2019; 74:630-637. [PMID: 30786320 DOI: 10.1111/anae.14532] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2018] [Indexed: 01/15/2023]
Abstract
A decision by a society to sanction assisted dying in any form should logically go hand-in-hand with defining the acceptable method(s). Assisted dying is legal in several countries and we have reviewed the methods commonly used, contrasting these with an analysis of capital punishment in the USA. We expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used. However, the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined. In voluntary assisted dying (in some US states and European countries), the common method to induce unconsciousness appears to be self-administered barbiturate ingestion, with death resulting slowly from asphyxia due to cardiorespiratory depression. Physician-administered injections (a combination of general anaesthetic and neuromuscular blockade) are an option in Dutch guidelines. Hypoxic methods involving helium rebreathing have also been reported. The method of capital punishment (USA) resembles the Dutch injection technique, but specific drugs, doses and monitoring employed vary. However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane, and we have used lessons from the most recent studies of accidental awareness during anaesthesia to describe an optimal means that could better achieve unconsciousness. We found that the very act of defining an 'optimum' itself has important implications for ethics and the law.
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Affiliation(s)
- S Sinmyee
- Department of Anaesthesia, Northwick Park Hospital, London North West Healthcare NHS Trust, London, UK
| | - V J Pandit
- University of Kent, UK.,l'Aix-Marseille Université, Marseille, France
| | - J M Pascual
- Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - A Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - T Heidegger
- Department of Anaesthesia, Intensive Care and Resuscitation Spitalregion Rheintal Werdenberg Sarganserland, Grabs, Switzerland.,University of Bern, Bern, Switzerland
| | - G Kreienbühl
- Kantonsspital St. Gallen and Former Head of Research Ethics Committee, Kanton St Gallen, Switzerland
| | - D A Lubarsky
- Human Health Sciences and Chief Executive Officer, University of California, UC Davis Health, USA
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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17
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Jouffre S, Ghazal J, Robert R, Reignier J, Albarracín D. Personalizing Patients' Advance Directives Decreases the Willingness of Intensive Care Unit Residents to Stop Treatment: A Randomized Study. J Palliat Med 2018; 21:1157-1160. [PMID: 29461907 DOI: 10.1089/jpm.2017.0502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND While following patients' advance directives (ADs) is legally binding, French physicians in Intensive Care Unit (ICU) perceive them as complicating their decision. Decision making and ICU residents benefit from personalizing the dying process. In France, ADs can include personal information. OBJECTIVE Whether personalizing ADs affects ICU residents' decisions and perception of the patient. SUBJECTS AND DESIGN Sixty-six ICU residents assigned to three experimental groups and presented with a case file for an ICU patient. The files were identical except for the patient's AD, which was manipulated to give three conditions: No Personal Information, Sociodemographic Information, and Agency Information (ability to plan and act upon the world). MEASUREMENTS Residents evaluated the relevance of the AD, assessed its influence on medical decisions, and decided whether to stop treatment, postpone the decision, or consult the family. Finally, they evaluated the patient with respect to two dimensions of personhood (agency and experience). RESULTS Residents in all conditions considered the AD to be highly relevant and influential. Residents in both Information conditions perceived the patient as having more capacities for agency and for experience than those in the No Information condition. They were also less likely to stop treatment and more likely to postpone their decision. Consulting the family was not sensitive to the information condition. CONCLUSION Personalizing ADs of an unknown patient leads ICU residents to be less prone to follow them, but does not affect whether or not they decide to consult the patient's family. Hence, promoting shared decision making by including the incapacitated patients' families in treatment decisions is a major challenge, especially in countries such as France, where ADs are legally binding.
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Affiliation(s)
- Stéphane Jouffre
- 1 Centre de Recherches sur la Cognition et l'Apprentissage (UMR CNRS 7295), Centre National de la Recherche Scientifique, Université de Poitiers, Université François Rabelais de Tours , Poitiers, France
| | - Joanne Ghazal
- 1 Centre de Recherches sur la Cognition et l'Apprentissage (UMR CNRS 7295), Centre National de la Recherche Scientifique, Université de Poitiers, Université François Rabelais de Tours , Poitiers, France
| | - René Robert
- 2 Centre d'Investigation Clinique (Inserm CIC 1402), Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire de Poitiers, Université de Poitiers , Poitiers, France
| | - Jean Reignier
- 3 Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Dolores Albarracín
- 4 Clinique de l'Acte et Psycho-Sexualité (EA 4050), Université de Poitiers , Poitiers, France
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