1
|
Guité-Verret A, Boivin J, Hanna AMR, Downar J, Bush SH, Marcoux I, Guay D, Tapp D, Lapenskie J, Gagnon B. Continuous palliative sedation until death: a qualitative study of palliative care clinicians' experiences. BMC Palliat Care 2024; 23:104. [PMID: 38637812 PMCID: PMC11027280 DOI: 10.1186/s12904-024-01426-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 04/02/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The practice of continuous palliative sedation until death is the subject of much medical and ethical debate, which is reflected in the inconsistency that persists in the literature regarding the definition and indications of palliative sedation. AIM This study aims to gain a better understanding of palliative care clinicians' experiences with continuous palliative sedation. DESIGN We conducted a qualitative study based on focus group discussions. SETTING/PARTICIPANTS We conducted six focus groups with a total of 28 palliative care clinicians (i.e., 15 nurses, 12 physicians, and 1 end-of-life doula) from diverse care settings across Canada, where assisted dying has recently been legalized. RESULTS An interpretative phenomenological analysis was used to consolidate the data into six key themes: responding to suffering; grappling with uncertainty; adapting care to ensure ongoing quality; grounding clinical practice in ethics; combining medical expertise, relational tact, and reflexivity; and offering an alternative to assisted death. CONCLUSIONS Interaction with the patient's family, uncertainty about the patient's prognosis, the concurrent practice of assisted dying, and the treatment of existential suffering influence the quality of sedation and indicate a lack of clear palliative care guidelines. Nevertheless, clinicians exhibit a reflective and adaptive capacity that can facilitate good practice.
Collapse
Affiliation(s)
- Alexandra Guité-Verret
- Department of Psychology, Université du Québec à Montréal, Montréal, Canada
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
| | - Jessica Boivin
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, Canada
- CHU Québec-Université Laval Research Centre, Québec, Canada
| | | | - James Downar
- Bruyère Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Shirley H Bush
- Bruyère Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Isabelle Marcoux
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Diane Guay
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Québec, Canada
| | - Diane Tapp
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- CHU Québec-Université Laval Research Centre, Québec, Canada
- Faculty of Nursing, Université Laval, Québec, Canada
| | - Julie Lapenskie
- Bruyère Research Institute, Ottawa, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Bruno Gagnon
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada.
- CHU Québec-Université Laval Research Centre, Québec, Canada.
- Bruyère Research Institute, Ottawa, Canada.
- Department of Family and Emergency Medicine, Université Laval, Québec, Canada.
| |
Collapse
|
2
|
Surges SM, Brunsch H, Jaspers B, Apostolidis K, Cardone A, Centeno C, Cherny N, Csikós À, Fainsinger R, Garralda E, Ling J, Menten J, Mercadante S, Mosoiu D, Payne S, Preston N, Van den Block L, Hasselaar J, Radbruch L. Revised European Association for Palliative Care (EAPC) recommended framework on palliative sedation: An international Delphi study. Palliat Med 2024; 38:213-228. [PMID: 38297460 PMCID: PMC10865771 DOI: 10.1177/02692163231220225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability. AIM To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers. DESIGN Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure. SETTING European. PARTICIPANTS International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation. RESULTS A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms suffering used to encompass distressing physical and psychological symptoms as well as existential suffering and refractory to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided. CONCLUSIONS This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals.
Collapse
Affiliation(s)
- Séverine M Surges
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Holger Brunsch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Birgit Jaspers
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Department of Palliative Medicine, University Medicine Goettingen, Goettingen, Germany
| | | | - Antonella Cardone
- Cancer Patients Europe, Brussels, Belgium
- Pancreatic Cancer Europe, Brussels, Belgium
| | - Carlos Centeno
- ATLANTES Global Observatory of Palliative Care, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Nathan Cherny
- Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Àgnes Csikós
- Department of Primary Health Care, Department of Hospice-Palliative Care, University of Pecs Medical School, Pecs, Hungary
| | | | - Eduardo Garralda
- ATLANTES Global Observatory of Palliative Care, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Julie Ling
- European Association for Palliative Care, Vilvoorde, Belgium
| | - Johan Menten
- Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Sebastiano Mercadante
- Main Regional Centre for Pain Relief and Palliative/Supportive Care, La Maddalena Cancer Centre, Palermo, Italy
| | - Daniela Mosoiu
- Medical Faculty, Transilvania University, Brasov, Romania
- Education and National Development Department, Hospice Casa Sperantei, Brasov, Romania
| | - Sheila Payne
- International Observatory on End-of-Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Nancy Preston
- International Observatory on End-of-Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Lieve Van den Block
- VUB-UGhent End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jeroen Hasselaar
- Department of Primary Care, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
- Task Force on Palliative Sedation of the European Association for Palliative Care, Brussels, Belgium
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Task Force on Palliative Sedation of the European Association for Palliative Care, Brussels, Belgium
| |
Collapse
|
3
|
Tomczyk M, Jaques C, Jox RJ. Palliative sedation: ethics in clinical practice guidelines - systematic review. BMJ Support Palliat Care 2024; 13:e651-e663. [PMID: 37567756 DOI: 10.1136/spcare-2023-004266] [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] [Received: 03/10/2023] [Accepted: 07/11/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVES The objective of our study was to determine whether, and to what degree, the ethical dimension was present in clinical practice guidelines (CPGs) on palliative sedation, and to identify the ethical issues with respect to the different forms of this practice. The purpose was purely to be descriptive; our aim was not to make any kind of normative judgements on these ethical issues or to develop our own ethical recommendations. METHODS We performed a systematic review of CPGs on the palliative sedation of adults, focusing our analysis on the ethical dimension of these texts and the ethical issues of this practice. The study protocol is registered on PROSPERO. RESULTS In total, 36 current CPGs from four continents (and 14 countries) were included in our analysis. Generally, ethics was rarely referred to or absent from the CPGs. Only six texts contained a specific section explicitly related to ethics. Ethical issues were named, conceptualised and presented in heterogeneous, often confusing ways. It was impossible to identify the ethical issues of each form of palliative sedation. Ethics expertise was not involved in the development of most of the CPGs and, if it was, this did not always correlate with the ethical dimension of the document. CONCLUSIONS Effective cooperation between palliative care clinicians and ethicists should be encouraged, in order to integrate in particular the crucial ethical issues of continuous deep sedation until death when developing or updating CPGs on palliative sedation.
Collapse
Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Cécile Jaques
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, 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
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Sarmet M, Kabani A, Coelho L, Dos Reis SS, Zeredo JL, Mehta AK. The use of natural language processing in palliative care research: A scoping review. Palliat Med 2023; 37:275-290. [PMID: 36495082 DOI: 10.1177/02692163221141969] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Natural language processing has been increasingly used in palliative care research over the last 5 years for its versatility and accuracy. AIM To evaluate and characterize natural language processing use in palliative care research, including the most commonly used natural language processing software and computational methods, data sources, trends in natural language processing use over time, and palliative care topics addressed. DESIGN A scoping review using the framework by Arksey and O'Malley and the updated recommendations proposed by Levac et al. was conducted. SOURCES PubMed, Web of Science, Embase, Scopus, and IEEE Xplore databases were searched for palliative care studies that utilized natural language processing tools. Data on study characteristics and natural language processing instruments used were collected and relevant palliative care topics were identified. RESULTS 197 relevant references were identified. Of these, 82 were included after full-text review. Studies were published in 48 different journals from 2007 to 2022. The average sample size was 21,541 (median 435). Thirty-two different natural language processing software and 33 machine-learning methods were identified. Nine main sources for data processing and 15 main palliative care topics across the included studies were identified. The most frequent topic was mortality and prognosis prediction. We also identified a trend where natural language processing was frequently used in analyzing clinical serious illness conversations extracted from audio recordings. CONCLUSIONS We found 82 papers on palliative care using natural language processing methods for a wide-range of topics and sources of data that could expand the use of this methodology. We encourage researchers to consider incorporating this cutting-edge research methodology in future studies to improve published palliative care data.
Collapse
Affiliation(s)
- Max Sarmet
- Tertiary Referral Center of Neuromuscular Diseases, Hospital de Apoio de Brasília, Brazil.,Graduate Department of Health Science and Technology, University of Brasília, Brazil
| | - Aamna Kabani
- Johns Hopkins University, School of Medicine, USA
| | - Luis Coelho
- Center of Innovation in Engineering and Industrial Technology, Polytechnic of Porto - School of Engineering (ISEP), Portugal
| | - Sara Seabra Dos Reis
- Center of Innovation in Engineering and Industrial Technology, Polytechnic of Porto - School of Engineering (ISEP), Portugal
| | - Jorge L Zeredo
- Graduate Department of Health Science and Technology, University of Brasília, Brazil
| | - Ambereen K Mehta
- Palliative Care Program, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University, School of Medicine, USA
| |
Collapse
|
6
|
Van der Elst M, Payne S, Arantzamendi M, Preston N, Hasselaar J, Centeno C, Belar A, Jaspers B, Brunsch H, Surges S, Adile C, Menten J. An analysis of the experiences of bereaved relatives and health care providers following palliative sedation: a study protocol for a qualitative international multicenter case study. BMC Palliat Care 2022; 21:227. [PMID: 36550539 PMCID: PMC9783747 DOI: 10.1186/s12904-022-01117-w] [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: 07/06/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients at the end-of-life may experience refractory symptoms of which pain, delirium, vomiting and dyspnea are the most frequent. Palliative sedation can be considered a last resort option to alleviate one or more refractory symptoms. There are only a limited number of (qualitative) studies exploring the experiences of relatives of sedated patients and their health care professionals (HCPs). The aims of this study protocol are: 1) to elicit the experiences of bereaved relatives and health care professionals of patients treated with palliative sedation and 2) to explore the understanding of the decision-making process to start palliative sedation across care settings in 5 European countries. METHODS This study protocol is part of the larger HORIZON 2020 Palliative Sedation project. Organisational case study methodology will be used to guide the study design. In total, 50 cases will be conducted in five European countries (10 per country). A case involves a semi-structured interview with a relative and an HCP closely involved in the care of a deceased patient who received some type of palliative sedation at the end-of-life. Relatives and health care professionals of deceased patients participating in a linked observational cohort study of sedated patients cared for in hospital wards, palliative care units and hospices will be recruited. The data will be analyzed using a framework analysis approach. The first full case will be analyzed by all researchers after being translated into English using a pre-prepared code book. Afterwards, bimonthly meetings will be organized to coordinate the data analysis. DISCUSSION The study aims to have a better understanding of the experiences of relatives and professional caregivers regarding palliative sedation and this within different settings and countries. Some limitations are: 1) the sensitivity of the topic may deter some relatives from participation, 2) since the data collection and analysis will be performed by at least 5 different researchers in 5 countries, some differences may occur which possibly makes it difficult to compare cases, but using a rigorous methodology will minimize this risk.
Collapse
Affiliation(s)
- M. Van der Elst
- grid.5596.f0000 0001 0668 7884Department of Oncology, Laboratory of Experimental Radiotherapy, Katholieke Universiteit Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - S. Payne
- grid.9835.70000 0000 8190 6402International Observatory On End of Life Care, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4AT UK
| | - M. Arantzamendi
- grid.5924.a0000000419370271Institute for Culture and Society-ATLANTES, Universidad de Navarra, Calle Universidad 6, Navarra 31009 Pamplona, Spain ,grid.508840.10000 0004 7662 6114IdISNA- Instituto de Investigación Sanitaria de Navarra. Palliative Medicine, Pamplona, Spain
| | - N. Preston
- grid.9835.70000 0000 8190 6402International Observatory On End of Life Care, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4AT UK
| | - J. Hasselaar
- grid.5590.90000000122931605Department of Anesthesiology, Pain and Palliative Medicine, Radboud University and Radboudumc, Geert Grote Plein 10, HB6500 Nijmegen, Netherlands
| | - C. Centeno
- grid.5924.a0000000419370271Institute for Culture and Society-ATLANTES, Universidad de Navarra, Calle Universidad 6, Navarra 31009 Pamplona, Spain ,grid.508840.10000 0004 7662 6114IdISNA- Instituto de Investigación Sanitaria de Navarra. Palliative Medicine, Pamplona, Spain ,grid.411730.00000 0001 2191 685XClínica Universidad de Navarra, Palliative Medicine Department, Pamplona, Spain
| | - A. Belar
- grid.5924.a0000000419370271Institute for Culture and Society-ATLANTES, Universidad de Navarra, Calle Universidad 6, Navarra 31009 Pamplona, Spain ,grid.508840.10000 0004 7662 6114IdISNA- Instituto de Investigación Sanitaria de Navarra. Palliative Medicine, Pamplona, Spain
| | - B. Jaspers
- grid.15090.3d0000 0000 8786 803XDepartment of Palliative Medicine, Universitätsklinikum Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - H. Brunsch
- grid.15090.3d0000 0000 8786 803XDepartment of Palliative Medicine, Universitätsklinikum Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - S. Surges
- grid.15090.3d0000 0000 8786 803XDepartment of Palliative Medicine, Universitätsklinikum Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - C. Adile
- grid.10776.370000 0004 1762 5517La Maddalena Cancer Center, Via San Lorenzo 312, 90146 Palermo, Italy
| | - J. Menten
- grid.5596.f0000 0001 0668 7884Department of Oncology, Laboratory of Experimental Radiotherapy, Katholieke Universiteit Leuven, Herestraat 49, 3000 Leuven, Belgium
| |
Collapse
|
7
|
Tomczyk M, Jaques C, Jox RJ. Clinical Practice Guidelines on Palliative Sedation Around the World: A Systematic Review. J Palliat Care 2022:8258597221138674. [PMID: 36437779 DOI: 10.1177/08258597221138674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective: The principal aim of this study was to identify, systematically and transparently, clinical practice guidelines (CPGs) on palliative sedation from around the world. Methods: A systematic search was performed using 5 databases, grey literature search tools, citation tracking, and contact with palliative care experts across the world. Current CPGs accredited by an international, national, or regional authority, published in English, German, French, or Italian, were subjected to content analysis. Results: In total, 35 CPGs from 14 countries and 1 international CPG were included in the analysis. The CPGs had diverse formal characteristics. Their thematic scope was difficult to analyze and compare because of differences in the terms and definitions of palliative sedation in those texts. We identified 3 main situations: (1) CPGs with a fully explicit thematic scope; (2) CPGs with a partially explicit thematic scope; and (3) CPGs without an explicit thematic scope. Several CPGs explicitly stated what forms of sedation were excluded from the text. However, this presentation was often confusing. Conclusion: Our review provides several pieces of information that could guide international reflections in this field, and be used to develop or update CPGs at all levels. Efforts should be made to clarify the thematic scope of each CPG on palliative sedation, in order to generate an understanding of the forms of this therapy addressed in the text.
Collapse
Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Cécile Jaques
- Medical Library, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ralf J Jox
- Institute of Humanities in Medicine, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Palliative & Supportive Care Service, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
8
|
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.
Collapse
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
| | | |
Collapse
|
9
|
Physicians’ Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095472. [PMID: 35564867 PMCID: PMC9104501 DOI: 10.3390/ijerph19095472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 02/05/2023]
Abstract
As previous research has paid little attention to environmental factors affecting the practice of continuous deep sedation until death (CDS), we aimed to explore these using physicians’ experiences and perceptions. We performed an interpretative thematic analysis of primary data from a qualitative interview study conducted from February to May 2019 in Belgium with 47 physicians. Structural factors were identified: the lack of professional and/or technical support in monitoring sedated patients; the use of guidelines in team contexts; the time constraints for treating individual patients and work pressure; the structural knowledge gap in medical education; the legal context for assisted dying; and the lack of a clear legal context for CDS. Cultural factors were identified: the moral reservations of care teams and/or institutions towards CDS; the presence of a palliative care culture within care teams and institutions; the culture of fear of making clinical errors regarding CDS among a group of physicians; the professional stigma of performing assisted dying among some of the physician population; the different understandings of CDS in medical and policy fields; and the societal taboo around suffering at the end of life and natural death. To conclude, improving CDS practice requires a whole-system approach considering environmental factors.
Collapse
|
10
|
Meesters S, Grüne B, Bausewein C, Schildmann E. "We don't want to sedate him" - A qualitative interview study on intentions when administering sedative drugs at the end of life in nursing homes and hospitals. BMC Palliat Care 2021; 20:141. [PMID: 34517847 PMCID: PMC8439055 DOI: 10.1186/s12904-021-00832-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous data indicate major differences between countries and settings regarding the intention when administering sedative drugs at the end of life and the perception, which drugs are sedating. Therefore, we aimed to explore the concept of 'sedative drugs' and the intentions of German healthcare professionals in general palliative care when administering sedative drugs at the end of life. METHODS Semi-structured qualitative interviews with physicians and nurses (n = 49). Recruitment took place via contact persons in five hospital departments (haematology/oncology (n = 2), neurology, geriatrics, gynaecology) and five nursing homes. We thematically analysed the transcripts by the Framework approach, using MAXQDA version 2018.2. RESULTS Most interviewees referred to benzodiazepines, opioids, and antipsychotics. Some subsumed all into sedative drugs, others differentiated between sedative drugs, anxiolytics, and analgesics. In explaining their intention, interviewees particularly emphasized what they want to avoid when administering sedative drugs. We identified three main themes regarding (excluded) intentions: (1) use of sedative drugs to relieve the patient's suffering with reduction of consciousness as side effect, (2) use of sedative drugs to relieve the situation for the team and/or the family, (3) distinction between intention and expectation regarding hastening death. Interviewees often equated the term 'sedation' with inducing a state of unconsciousness, which should be avoided. CONCLUSION German healthcare professionals in general palliative care seem to negatively connote the term 'sedation'. Moreover, they see themselves in a more passive role by accepting a side effect rather than performing an intentional act. Critical reflection of indications and intentions in accordance with respective guidelines is needed.
Collapse
Affiliation(s)
- Sophie Meesters
- Department of Palliative Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Bettina Grüne
- Department of Palliative Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| |
Collapse
|
11
|
Tomczyk M, Viallard ML, Beloucif S. « Sédation » ou « pratiques sédatives à visée palliative en fin de vie » ? Une étude linguistique des recommandations francophones en matière de sédation en soins palliatifs chez l’adulte. Rech Soins Infirm 2021:106-117. [PMID: 33485279 DOI: 10.3917/rsi.143.0106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Introduction : Despite the number and importance of French-language guidelines related to palliative sedation for adults, these texts have never been the subject of a linguistic analysis.Objectives : This study aimed to explore and analyze the terms used for sedation and their definitions in Belgian, French, Quebec, and Swiss guidelines.Methods : Current documents were subjected to textual, terminological, and conceptual analysis.Results : Belgian, Quebec, and Swiss guidelines use the same term to refer to sedation, without, however, conceptualizing it in a consistent way. By contrast, guidelines developed in France use various terms but define sedation in a similar (but not identical) way. Cultural specificities linked to end-of-life legislation in those countries and region were identified as a potential causal factor.Discussion and conclusion : The diversity of terms and definitions inevitably reinforces the imprecision of the medical language, and the terminology in particular. This is likely to have a negative impact on communication between healthcare professionals, patients, and their families. Efforts should be made to homogenize the terminology and definitions used in guidelines.
Collapse
|
12
|
Koksvik GH, Richards N, Gerson SM, Materstvedt LJ, Clark D. Medicalisation, suffering and control at the end of life: The interplay of deep continuous palliative sedation and assisted dying. Health (London) 2020; 26:512-531. [PMID: 33307828 PMCID: PMC9163770 DOI: 10.1177/1363459320976746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Medicalisation is a pervasive feature of contemporary end of life and dying in Western Europe and North America. In this article, we focus on the relationship between two specific aspects of the medicalisation of dying: deep continuous palliative sedation until death and assisted dying. We draw upon a qualitative interview study with 29 health professionals from three jurisdictions where assisted dying is lawful: Flanders, Belgium; Oregon, USA; and Quebec, Canada. Our findings demonstrate that the relationship between palliative sedation and assisted dying is often perceived as fluid and complex. This is inconsistent with current laws as well as with ethical and clinical guidelines according to which the two are categorically distinct. The article contributes to the literature examining health professionals’ opinions and experiences. Moreover, our findings inform a discussion about emergent themes: suffering, timing, autonomy and control – which appear central in the wider discourse in which both palliative sedation and assisted dying are situated, and which in turn relate to the wider ideas about what constitutes a ‘good death’.
Collapse
|
13
|
Thomas HL. Demedicalisation: radically reframing the assisted dying debate-an essay by Lucy Thomas. BMJ 2020; 371:m2919. [PMID: 32998910 DOI: 10.1136/bmj.m2919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
14
|
Abstract
'Palliation sedation' is a widely used term to describe the intentional administration of sedatives to reduce a dying person's consciousness to relieve intolerable suffering from refractory symptoms. Research studies generally focus on either 'continuous sedation until death' or 'continuous deep sedation'. It is not always clear whether instances of secondary sedation (i.e. caused by specific symptom management) have been excluded. Continuous deep sedation is controversial because it ends a person's 'biographical life' (the ability to interact meaningfully with other people) and shortens 'biological life'. Ethically, continuous deep sedation is an exceptional last resort measure. Studies suggest that continuous deep sedation has become 'normalized' in some countries and some palliative care services. Of concern is the dissonance between guidelines and practice. At the extreme, there are reports of continuous deep sedation which are best described as non-voluntary (unrequested) euthanasia. Other major concerns relate to its use for solely non-physical (existential) reasons, the under-diagnosis of delirium and its mistreatment, and not appreciating that unresponsiveness is not the same as unconsciousness (unawareness). Ideally, a multiprofessional palliative care team should be involved before proceeding to continuous deep sedation. Good palliative care greatly reduces the need for continuous deep sedation.
Collapse
|
15
|
Robijn L, Seymour J, Deliens L, Korfage I, Brown J, Pype P, Van Der Heide A, Chambaere K, Rietjens J. The involvement of cancer patients in the four stages of decision-making preceding continuous sedation until death: A qualitative study. Palliat Med 2018; 32:1198-1207. [PMID: 29667509 DOI: 10.1177/0269216318770342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Involving patients in decision-making is considered to be particularly appropriate towards the end of life. Professional guidelines emphasize that the decision to initiate continuous sedation should be made in accordance with the wishes of the dying person and be preceded by their consent. AIM To describe the decision-making process preceding continuous sedation until death with particular attention to the involvement of the person who is dying. DESIGN Qualitative case studies using interviews. SETTING/PARTICIPANTS Interviews with 26 physicians, 30 nurses and 24 relatives caring for 24 patients with cancer who received continuous sedation until death in Belgium, the United Kingdom and the Netherlands. RESULTS We distinguished four stages of decision-making: initiation, information exchange, deliberation and the decision to start continuous sedation until death. There was wide variation in the role the patient had in the decision-making process. At one end of the spectrum (mostly in the United Kingdom), the physician discussed the possible use of sedation with the patient, but took the decision themselves. At the other end (mostly in Belgium and the Netherlands), the patient initiated the conversation and the physician's role was largely limited to evaluating if and when the medical criteria were met. CONCLUSION Decision-making about continuous sedation until death goes through four stages and the involvement of the patient in the decision-making varies. Acknowledging the potential sensitivity of raising the issue of end-of-life sedation, we recommend building into clinical practice regular opportunities to discuss the goals and preferences of the person who is dying for their future medical treatment and care.
Collapse
Affiliation(s)
- Lenzo Robijn
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Jane Seymour
- 3 The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Luc Deliens
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Ida Korfage
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
| | - Jayne Brown
- 5 School of Nursing and Midwifery, De Montfort University, Leicester, UK.,6 Centre for the Promotion of Excellence in Palliative Care, De Montfort University, Leicester, UK
| | - Peter Pype
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,7 Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Agnes Van Der Heide
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
| | - Kenneth Chambaere
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Judith Rietjens
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
| | | |
Collapse
|
16
|
Rodrigues P, Crokaert J, Gastmans C. Palliative Sedation for Existential Suffering: A Systematic Review of Argument-Based Ethics Literature. J Pain Symptom Manage 2018; 55:1577-1590. [PMID: 29382541 DOI: 10.1016/j.jpainsymman.2018.01.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
CONTEXT Although unanimity exists on using palliative sedation (PS) for controlling refractory physical suffering in end-of-life situations, using it for controlling refractory existential suffering (PS-ES) is controversial. Complicating the debate is that definitions and terminology for existential suffering are unclear, ambiguous, and imprecise, leading to a lack of consensus for clinical practice. OBJECTIVES To systematically identify, describe, analyze, and discuss ethical arguments and concepts underpinning the argument-based bioethics literature on PS-ES. METHODS We conducted a systematic search of the argument-based bioethics literature in PubMed, CINAHL, Embase®, The Philosopher's Index, PsycINFO®, PsycARTICLES®, Scopus, ScienceDirect, Web of Science, Pascal-Francis, and Cairn. We included articles published in peer-reviewed journals till December 31, 2016, written in English or French, which focused on ethical arguments related to PS-ES. We used Peer Review of Electronic Search Strategies protocol, Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and The Qualitative Analysis Guide of Leuven for data extraction and synthesis of themes. RESULTS We identified 18 articles that met the inclusion criteria. Our analysis revealed mind-body dualism, existential suffering, refractoriness, terminal condition, and imminent death as relevant concepts in the ethical debate on PS-ES. The ethical principles of double effect, proportionality, and the four principles of biomedical ethics were used in argumentations in the PS-ES debate. CONCLUSION There is a clear need to better define the terminology used in discussions of PS-ES and to ground ethical arguments in a more effective way. Anthropological presuppositions such as mind-body dualism underpin the debate and need to be more clearly elucidated using an interdisciplinary approach.
Collapse
Affiliation(s)
- Paulo Rodrigues
- Université Catholique de Lille, ETHICS EA7446, Centre for Medical Ethics, Lille, France; Katholieke Universiteit Leuven, Centre for Biomedical Ethics and Law, Faculty of Medicine, Leuven, Belgium; Université Catholique de Louvain, Research Institute Religions, Spirituality, Cultures, Societies (RSCS), Louvain-la-Neuve, Belgium.
| | - Jasper Crokaert
- Université Catholique de Louvain, Faculty of Medicine, Louvain-la-Neuve, Belgium
| | - Chris Gastmans
- Katholieke Universiteit Leuven, Centre for Biomedical Ethics and Law, Faculty of Medicine, Leuven, Belgium
| |
Collapse
|
17
|
Zimmerman S, van der Steen JT. It's Not a Small World After All. J Am Med Dir Assoc 2018; 19:187-189. [PMID: 29477772 DOI: 10.1016/j.jamda.2018.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 01/08/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC; Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Jenny T van der Steen
- Leiden University Medical Center, Department of Public Health and Primary Care, Leiden, The Netherlands; Radboud University Medical Center, Department of Primary and Community Care, Nijmegen, The Netherlands
| |
Collapse
|
18
|
Lokker ME, Swart SJ, Rietjens JAC, van Zuylen L, Perez RSGM, van der Heide A. Palliative sedation and moral distress: A qualitative study of nurses. Appl Nurs Res 2018; 40:157-161. [PMID: 29579492 DOI: 10.1016/j.apnr.2018.02.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/06/2018] [Accepted: 02/12/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clinical nursing practice may involve moral distress, which has been reported to occur frequently when nurses care for dying patients. Palliative sedation is a practice that is used to alleviate unbearable and refractory suffering in the last phase of life and has been linked to distress in nurses. AIM The aim of this study was to explore nurses' reports on the practice of palliative sedation focusing on their experiences with pressure, dilemmas and morally distressing situations. METHODS In-depth interviews with 36 nurses working in hospital, nursing home or primary care. RESULTS Several nurses described situations in which they felt that administration of palliative sedation was in the patient's best interest, but where they were constrained from taking action. Nurses also reported on situations where they experienced pressure to be actively involved in the provision of palliative sedation, while they felt this was not in the patient's best interest. The latter situation related to (1) starting palliative sedation when the nurse felt not all options to relieve suffering had been explored yet; (2) family requesting an increase of the sedation level where the nurse felt that this may involve unjustified hastening of death; (3) a decision by the physician to start palliative sedation where the patient had previously expressed an explicit wish for euthanasia. CONCLUSIONS Nurses experienced moral distress in situations where they were not able to act in what they believed is the patient's best interest. Situations involving moral distress require nurses to be well informed and able to adequately communicate with suffering patients, distressed family and physicians.
Collapse
Affiliation(s)
- M E Lokker
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands; Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands.
| | - S J Swart
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - J A C Rietjens
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - L van Zuylen
- Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands
| | - R S G M Perez
- Department of Anesthesiology, VUmc, Amsterdam, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| |
Collapse
|
19
|
|
20
|
Palliative sedation challenging the professional competency of health care providers and staff: a qualitative focus group and personal written narrative study. BMC Palliat Care 2017; 16:25. [PMID: 28399846 PMCID: PMC5387333 DOI: 10.1186/s12904-017-0198-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 04/04/2017] [Indexed: 11/18/2022] Open
Abstract
Background Despite recent advances in palliative medicine, sedating a terminally ill patient is regarded as an indispensable treatment to manage unbearable suffering. With the prospect of widespread use of palliative sedation, the feelings and representations of health care providers and staff (carers) regarding sedation must be carefully explored if we are to gain a better understanding of its impact and potential pitfalls. The objective of the study was to provide a comprehensive description of the opinions of carers about the use of sedation practices in palliative care units (PCU), which have become a focus of public attention following changes in legislation. Methods Data were collected using a qualitative study involving multi-professional focus groups with health care providers and staff as well as personal narratives written by physicians and paramedical staff. A total of 35 medical and paramedical providers volunteered to participate in focus group discussions in three Palliative Care Units in two French hospitals and to write personal narratives. Results Health care provider and staff opinions had to do with their professional stance and competencies when using midazolam and practicing sedation in palliative care. They expressed uncertainty regarding three aspects of the comprehensive care: biomedical rigour of diagnosis and therapeutics, quality of the patient/provider relationship and care to be provided. Focusing on the sedative effect of midazolam and continuous sedation until death, the interviewed health care providers examined the basics of their professional competency as well as the key role played by the health care team in terms of providing support and minimizing workplace suffering. Nurses were subject to the greatest misgivings about their work when they were called upon to sedate patients. Conclusions The uncertainty experienced by the carers with regard to the medical, psychosocial and ethical justification for sedation is a source of psychological burden and moral distress, and it has proved to be a major source of suffering in the workplace. Lastly, the study shows the uncertainty can have the positive effect of prompting the care team to devise ways to deal with it.
Collapse
|
21
|
|
22
|
Robijn L, Cohen J, Rietjens J, Deliens L, Chambaere K. Trends in Continuous Deep Sedation until Death between 2007 and 2013: A Repeated Nationwide Survey. PLoS One 2016; 11:e0158188. [PMID: 27337064 PMCID: PMC4918927 DOI: 10.1371/journal.pone.0158188] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 06/10/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuous deep sedation until death is a highly debated medical practice, particularly regarding its potential to hasten death and its proper use in end-of-life care. A thorough analysis of important trends in this practice is needed to identify potentially problematic developments. This study aims to examine trends in the prevalence and practice characteristics of continuous deep sedation until death in Flanders, Belgium between 2007 and 2013, and to study variation on physicians' degree of palliative training. METHODS Population-based death certificate study in 2007 and 2013 in Flanders, Belgium. Reporting physicians received questionnaires about medical practices preceding the patient's death. Patient characteristics, clinical characteristics (drugs used, duration, artificial nutrition/hydration, intention and consent), and palliative care training of attending physician were recorded. We posed the following question regarding continuous deep sedation: 'Was the patient continuously and deeply sedated or kept in a coma until death by the use of one or more drugs'. RESULTS After the initial rise of continuous deep sedation to 14.5% in 2007 (95%CI 13.1%-15.9%), its use decreased to 12.0% in 2013 (95%CI 10.9%-13.2%). Compared with 2007, in 2013 opioids were less often used as sole drug and the decision to use continuous deep sedation was more often preceded by patient request. Compared to non-experts, palliative care experts more often used benzodiazepines and less often opioids, withheld artificial nutrition/hydration more often and performed sedation more often after a request from or with the consent of the patient or family. CONCLUSION Worldwide, this study is the first to show a decrease in the prevalence of continuous deep sedation. Despite positive changes in performance and decision-making towards more compliance with due care requirements, there is still room for improvement in the use of recommended drugs and in the involvement of patients and relatives in the decision-making process.
Collapse
Affiliation(s)
- Lenzo Robijn
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Judith Rietjens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
23
|
Raus K, Sterckx S. How defining clinical practices may influence their evaluation: the case of continuous sedation at the end of life. J Eval Clin Pract 2016; 22:425-32. [PMID: 26711308 DOI: 10.1111/jep.12503] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2015] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Continuous sedation at the end of life is an end-of-life practice that has gained considerable attention in the international literature. Nevertheless, significant confusion persists, even on how to label or define the practice. Several different terms and definitions exist, and these are often non-neutral and indicative of one's normative position on sedation at the end of life. This is problematic for two reasons. First, the use of such value-laden terms or definitions of continuous sedation may make it difficult, if not impossible, to agree on the facts surrounding continuous sedation. Second, including normative criteria in a definition can lead one to make disguised circular or tautological statements. METHODS This paper identifies commonly used terms and definitions and demonstrates how particular elements present in these are value-laden and can influence the ethical evaluation of continuous sedation at the end of life. RESULTS Two commonly used terms, 'palliative sedation' and 'terminal sedation', have been strongly criticized. We propose to use another, more descriptive term, namely 'continuous sedation at the end of life'. As regards the different definitions of sedation, some are general, but most contain very specific elements, thereby clearly limiting the number of cases that are covered by the definition. Some definitions of sedation include the intention one should (not) have, the possible indications for the practice, and the type of patients the practice should be reserved for. CONCLUSION Including value-laden elements in the very definition of a clinical practice runs the risk of pre-empting a proper normative debate about the practice. We explain why this is the case and why it is problematic, and we propose an alternative, descriptive, definition that seeks to avoid these problems.
Collapse
Affiliation(s)
- Kasper Raus
- Ghent University, Bioethics Institute Ghent, Ghent, Belgium
| | - Sigrid Sterckx
- Ghent University, Bioethics Institute Ghent, Ghent, Belgium
| |
Collapse
|
24
|
No Negative Impact of Palliative Sedation on Relatives' Experience of the Dying Phase and Their Wellbeing after the Patient's Death: An Observational Study. PLoS One 2016; 11:e0149250. [PMID: 26871717 PMCID: PMC4752210 DOI: 10.1371/journal.pone.0149250] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 01/28/2016] [Indexed: 11/19/2022] Open
Abstract
Background Palliative sedation is the widely-used intervention of administering sedating agents to induce a state of unconsciousness to take away a dying patient’s perception of otherwise irrelievable symptoms. However, it remains questionable whether this ethically complex intervention is beneficial for patients and whether the associated lack of communication in the last phase of life has a negative impact on relatives’ wellbeing. Methods An observational questionnaire study was conducted among relatives of a consecutive sample of patients who died a non-sudden death in the Erasmus MC Cancer Institute or in the hospice ‘Laurens Cadenza’ (both in Rotterdam) between 2010 and 2013. Results Relatives filled in questionnaires regarding 151 patients who had been sedated and 90 patients who had not been sedated. The median time since all patients had passed away was 21 (IQR 14–32) months. No significant differences were found in relatives´ assessments of the quality of end-of-life care, patients´ quality of life in the last week before death and their quality of dying, between patients who did and did not receive sedation, or in relatives’ satisfaction with their own life, their general health and their mental wellbeing after the patient’s death. Conclusions The use of sedation in these patients appears to have no negative effect on bereaved relatives’ evaluation of the patient’s dying phase, or on their own wellbeing after the patient’s death.
Collapse
|
25
|
Affiliation(s)
- Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola, Italy
| | | |
Collapse
|