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Ostgathe C, Bausewein C, Schildmann E, Bazata J, Heckel M, Kauzner S, Klein C, Krauss SH, Kremling A, Schneider M, Seifert A, Ziegler K, Jäger C, Schildmann J. Use of sedative drugs in specialist palliative care (iSedPall): a multi-modal intervention pilot study protocol. Pilot Feasibility Stud 2025; 11:45. [PMID: 40211291 PMCID: PMC11984285 DOI: 10.1186/s40814-025-01627-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/24/2025] [Indexed: 04/14/2025] Open
Abstract
BACKGROUND The use of sedative drugs in specialist palliative care is common but presents challenges due to specific medical, ethical, and legal considerations. There is little to no assistance for administering adequate sedative drug doses, ensuring accurate documentation before and during sedation, or managing ethically and legally challenging situations. In 2021, the SedPall study group published recommendations on the use of sedative drugs in palliative care. The German Association for Palliative Medicine endorsed the dissemination of the recommendations nationwide. However, disseminating recommendations alone does not necessarily lead to changes in clinical practice. In the project "Development and piloting of a multi-modal intervention for the use of sedative drugs in specialist palliative care (iSedPall)", we will develop a multi-modal intervention that implements these national recommendations into practical tools for healthcare professionals in specialist inpatient and home care settings. In the pilot study described below, we aim to test the feasibility of the multi-modal intervention, its appropriateness, and acceptability as primary feasibility outcomes of the multi-modal intervention. Additionally, we aim to assess the feasibility of measuring healthcare professionals´ confidence in using sedative drugs as an outcome indicator for a possible subsequent study. METHODS AND ANALYSIS We will use a mixed-methods approach to develop and pilot a multi-modal intervention. The primary feasibility outcomes and formative evaluation of the implementation process will be explored using quantitative (retrospective cohort study, survey) and qualitative elements (focus groups, interviews). Additionally, we will pilot the measurement of healthcare professionals´ confidence in using sedative drugs as an outcome indicator through a pre-post survey. Four specialist palliative care services will pilot the complex intervention for nine months. Due to the complexity of the intervention, we will follow the principles of the MRC framework for complex interventions and will apply a Theory of Change approach. The intervention will include different elements to be used throughout the patients' treatment in inpatient and home specialist palliative care considering medical, ethical, and legal aspects for the use of sedative drugs and intentional sedation. The evaluation of the overall feasibility and the decision about proceeding to an implementation study will be based on the integration of quantitative and qualitative data, according to our mixed-methods approach. DISCUSSION This project is the first attempt to translate national recommendations on best practices for sedative drug use into a multi-modal intervention and tests its feasibility. The study group identified potential risks and challenges related to the intervention´s feasibility, acceptability, and appropriateness in advance. To mitigate these risks, the study protocol is based on a theoretical framework, developed through a Theory of Change approach. Participatory elements and the involvement of different stakeholders are expected to enhance user acceptance and feasibility, potentially improving the development of supporting materials for sedative drug use in specialist palliative care while considering the interests of non-professionals. TRIAL REGISTRATION Registered in the German Clinical Trials Register, DRKS-ID: DRKS00027241; Registered: 10/12/2021; https://www.drks.de/drks_web/setLocale_EN.do .
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Affiliation(s)
- Christoph Ostgathe
- Department of Palliative Medicine, CCC Erlangen - EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Jeremias Bazata
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Maria Heckel
- Department of Palliative Medicine, CCC Erlangen - EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Saskia Kauzner
- Department of Palliative Medicine, CCC Erlangen - EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen - EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sabine H Krauss
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Alexander Kremling
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Manuela Schneider
- Department of Palliative Medicine, CCC Erlangen - EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Andreas Seifert
- Paderborn Centre for Educational Research and Teacher Education - PLAZ Professional School, Paderborn University, Paderborn, Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christian Jäger
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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Kremling A, Bausewein C, Klein C, Nadolny S, Ostgathe C, Schildmann E, Ziegler K, Schildmann J. Terminological Confusion About Sedation in Palliative Care: Results of an International Online Vignette Survey. J Palliat Med 2024; 27:487-494. [PMID: 38330403 PMCID: PMC10998700 DOI: 10.1089/jpm.2023.0159] [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] [Accepted: 11/08/2023] [Indexed: 02/10/2024] Open
Abstract
Background: Terminological problems concerning sedation in palliative care and consequences for research and clinical decision making have been reported frequently. Objectives: To gather data on the application of definitions of sedation practices in palliative care to clinical cases and to analyze implications for high-quality definitions. Design: We conducted an online survey with a convenience sample of international experts involved in the development of guidelines on sedation in palliative care and members of the European Association for Palliative Care (EAPC). Participants were asked to apply four published definitions to four case vignettes. Data were analyzed using descriptive statistics. Results: A total of 32 experts and 271 EAPC members completed the survey. The definitions were applied correctly in n = 2200/4848 cases (45.4%). The mean number of correct applications of the definitions (4 points max.) was 2.2 ± 1.14 for the definition of the SedPall study group, 1.8 ± 1.03 for the EAPC definition, 1.7 ± 0.98 for the definition of the Norwegian Medical Association, and 1.6 ± 1.01 for the definition of the Japanese Society of Palliative Medicine. The rate of correct applications for the 16 vignette-definition pairs varied between 70/303 (23.1%) and 227/303 (74.9%). The content of definitions and vignettes together with free-text comments explains participants' decisions and misunderstandings. Conclusions: Definitions of sedation in palliative care are frequently incorrectly applied to clinical case scenarios under simplified conditions. This suggests that clinical communication and research might be negatively influenced by misunderstandings and inconsistent labeling or reporting of data. Clinical Trial Registration Number: DRKS00015047.
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Affiliation(s)
- Alexander Kremling
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, Ludwig Maximilian University München, Comprehensive Cancer Centre Munich (CCCM), Germany
| | - Carsten Klein
- Department of Palliative Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Stephan Nadolny
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
- Institute for Educational and Health-Care Research in the Health Sector, Hochschule Bielefeld—University of Applied Sciences and Arts, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, LMU University Hospital, Ludwig Maximilian University München, Comprehensive Cancer Centre Munich (CCCM), Germany
- Palliative Medicine, Faculty of Medicine, University of Augsburg, Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jan Schildmann
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
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Shah K, Geller DA, Tohme S, Antoni M, Kallem CJ, Vodovotz Y, Ramanathan R, Naveen R, Geroni M, Devine L, Amin A, Kiefer GJ, Zandberg DP, Reyes V, Steel JL. Predictors and Consequences of Cancer and Non-Cancer-Related Pain in Those Diagnosed with Primary and Metastatic Cancers. Curr Oncol 2023; 30:8826-8840. [PMID: 37887537 PMCID: PMC10605887 DOI: 10.3390/curroncol30100637] [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: 08/11/2023] [Revised: 09/08/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVES The aims of the study were to (1) describe types of pain in cancer patients, (2) examine the predictors and consequences of pain, (3) investigate the association between type of pain and survival, and (4) examine potential biological mediators of pain and survival. METHODS This was a secondary analysis of baseline data from patients diagnosed with cancer. Patients answered questionnaires that assessed sociodemographic characteristics, pain, depression, sleep, and fatigue. Blood was collected and cytokine assays were performed. Analysis of variance, Kaplan-Meier, and Cox regression survival analyses were used to test the aims. RESULTS Of the 779 patients diagnosed with cancer, the mean age was 63.5 years, 57.8% male, and 90.6% White. Of those who reported pain (total 70.3%), 46.5% stated their pain was cancer-related while 53.5% stated their pain was non-cancer-related. While both cancer and non-cancer-related pain was associated with depressive symptoms, fatigue, and sleep duration, those with cancer-related pain had significantly higher rates of depressive symptoms (F(1,516) = 21.217, p < 0.001) and fatigue (F(1,516) = 30.973, p < 0.001) but not poorer sleep (F(1,497) = 0.597, p = 0.440). After adjusting for sociodemographic, disease-related characteristics, depression, sleep duration, and morphine milligram equivalent, patient reports of cancer-related pain were significantly associated with poorer survival (HR = 0.646, 95% CI = 0.459-0.910, p = 0.012) compared to those with non-cancer-related pain, which was not associated with survival (HR = 1.022, 95% CI = 0.737-1.418, p = 0.896). Cytokines did not significantly mediate the link between pain and survival. CONCLUSION While nearly half of the pain reported was cancer-related, both types of pain resulted in greater symptom burden, but only cancer-related pain was associated with survival.
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Affiliation(s)
- Kriti Shah
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (K.S.); (D.A.G.); (S.T.); (C.J.K.); (Y.V.); (R.R.); (R.N.); (M.G.); (L.D.); (A.A.)
| | - David A. Geller
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (K.S.); (D.A.G.); (S.T.); (C.J.K.); (Y.V.); (R.R.); (R.N.); (M.G.); (L.D.); (A.A.)
| | - Samer Tohme
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (K.S.); (D.A.G.); (S.T.); (C.J.K.); (Y.V.); (R.R.); (R.N.); (M.G.); (L.D.); (A.A.)
| | - Michael Antoni
- Department of Psychology, University of Miami, Coral Gables, FL 33124, USA;
| | - Cramer J. Kallem
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (K.S.); (D.A.G.); (S.T.); (C.J.K.); (Y.V.); (R.R.); (R.N.); (M.G.); (L.D.); (A.A.)
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (K.S.); (D.A.G.); (S.T.); (C.J.K.); (Y.V.); (R.R.); (R.N.); (M.G.); (L.D.); (A.A.)
| | - Rekha Ramanathan
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (K.S.); (D.A.G.); (S.T.); (C.J.K.); (Y.V.); (R.R.); (R.N.); (M.G.); (L.D.); (A.A.)
| | - Raam Naveen
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (K.S.); (D.A.G.); (S.T.); (C.J.K.); (Y.V.); (R.R.); (R.N.); (M.G.); (L.D.); (A.A.)
| | - MacKenzie Geroni
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (K.S.); (D.A.G.); (S.T.); (C.J.K.); (Y.V.); (R.R.); (R.N.); (M.G.); (L.D.); (A.A.)
| | - LaNita Devine
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (K.S.); (D.A.G.); (S.T.); (C.J.K.); (Y.V.); (R.R.); (R.N.); (M.G.); (L.D.); (A.A.)
| | - Aarshati Amin
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (K.S.); (D.A.G.); (S.T.); (C.J.K.); (Y.V.); (R.R.); (R.N.); (M.G.); (L.D.); (A.A.)
| | - Gauri J. Kiefer
- UPMC Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (G.J.K.); (D.P.Z.); (V.R.)
| | - Dan P. Zandberg
- UPMC Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (G.J.K.); (D.P.Z.); (V.R.)
| | - Vincent Reyes
- UPMC Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (G.J.K.); (D.P.Z.); (V.R.)
| | - Jennifer L. Steel
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA; (K.S.); (D.A.G.); (S.T.); (C.J.K.); (Y.V.); (R.R.); (R.N.); (M.G.); (L.D.); (A.A.)
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Schildmann E, Meesters S, Bausewein C, Grüne B, Sophie Licher A, Bolzani A, Remi C, Nübling G, Benedikt Westphalen C, Drey M, Harbeck N, Hentrich M, Grüne B. Sedatives and Sedation at the End of Life in the Hospital. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:373-379. [PMID: 35440363 PMCID: PMC9487710 DOI: 10.3238/arztebl.m2022.0194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 07/10/2021] [Accepted: 04/05/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Data on sedation at the end of life (eol) in different medical disciplines are scarce and mostly based on subjective reports. We aimed to assess the use of sedatives with continuous effect in the last week of life and associated factors in different hospital departments, with the aid of objectifiable criteria. METHODS We conducted a retrospective cohort study based on the medical records of patients who died in one of five clinical departments of German hospitals between January 2015 and December 2017 (hematology/oncology [two different departments], neurology, geriatrics, and gynecology). The use of sedatives that are recommended in guidelines for palliative sedation was analyzed, irrespective of indication and treatment intent, with the aid of published definitions of continuous effect and of at least moderately sedating doses. The analysis consisted of descriptive statistics and multivariate logistic regression analysis. RESULTS 260/517 (50%) of the patients who died were given sedatives with continuous effect in the last week of life, 53/517 (10%) in at least moderately sedating doses. For 76/260 (29%) patients, no indication was noted. The term "sedation" was used in the medical records of 20/260 (8%) patients. The use of sedatives with continuous effect was significantly associated with the department in which the patient was treated (hematology/oncology II: OR 0.32, 95% CI [0.16: 0.63]; geriatrics: OR 0.23, 95% CI [0.10:0.50]; reference, hematology/oncology I). CONCLUSION It was not possible to draw a clear distinction between the use of sedatives for symptom control, without sedating effect or intent to sedate, and intentional sedation to relieve suffering. The observed differences between hospital departments and deviations from recommended practice, e.g. lack of documentation of the indication, warrant further exploration. Moreover, context-specific supportive measures for the use of sedatives and sedation at the end of life should be developed.
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Affiliation(s)
- Eva Schildmann
- Department of Palliative Medicine, University Hospital, LMU Munich,Oncological Palliative Care, Department of Hematology, Oncology and Cancer Immunology & Charité Comprehensive Cancer Center, Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin,*Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie Onkologische Palliativmedizin Hindenburgdamm 30, 12203 Berlin, Germany
| | - Sophie Meesters
- Department of Palliative Medicine, University Hospital, LMU Munich
| | | | - Bettina Grüne
- Department of Palliative Medicine, University Hospital, LMU Munich
| | | | - Anna Bolzani
- Department of Palliative Medicine, University Hospital, LMU Munich
| | - Constanze Remi
- Department of Palliative Medicine, University Hospital, LMU Munich
| | - Georg Nübling
- Department of Neurologiy, University Hospital, LMU Munich
| | - C. Benedikt Westphalen
- Medizinische Klinik und Poliklinik III, University Hospital, LMU Munich & Comprehensive Cancer Center Munich
| | - Michael Drey
- Department of Internal Medicine IV, Geriatrics, University Hospital, LMU Munich
| | - Nadia Harbeck
- Breast Center, Department of Obstetrics and Gynecology, University Hospital, LMU Munich & Comprehensive Cancer Center Munich
| | - Marcus Hentrich
- Department of Hematology and Oncology, Red Cross Hospital, Munich
| | - Bettina Grüne
- Department of Youth and Youth Services, German Youth Institute (DJI), Munich
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Grüne B, Meesters S, Bausewein C, Schildmann E. Challenges and Strategies Regarding Sedation at the End of Life in Hospitals and Nursing Homes. J Pain Symptom Manage 2022; 63:530-538. [PMID: 34921935 DOI: 10.1016/j.jpainsymman.2021.12.012] [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: 07/16/2021] [Revised: 11/26/2021] [Accepted: 12/07/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT Sedation is an accepted, but controversially discussed and challenging measure to treat suffering at the end of life. Although most people die in hospitals or nursing homes, little is known how professionals in these settings deal with sedatives and sedation at the end of life. OBJECTIVES To explore 1) challenges regarding use of sedatives and sedation at the end of life in hospitals and nursing homes, and 2) strategies, and supportive measures to meet these challenges, as perceived by nurses and physicians. METHODS Multicenter qualitative interview study. Forty-nine participants: 12 general practitioners and 12 nurses from five nursing homes, 12 physicians, and 13 nurses from five hospital departments (hematology/oncology (n = 2), neurology, geriatrics, gynecology). Semi-structured qualitative interviews. Data analysis guided by framework approach. RESULTS Perceived challenges relate to three levels of the care situation: individual, interaction with others, and work environment. The main challenge was defining the adequate timing and/or dose. Other challenges, e.g., disagreements regarding indication or legal uncertainties, were highly interrelated, and strongly associated with this major challenge. Reported strategies and supportive measures to address challenges also corresponded to the three interrelated levels. Major named strategies were education and training, joint decision-making within the team and regular discussion with the patient and family. On the level work environment, no implemented strategies, but wishes for change were identified. CONCLUSION To meet the identified challenges in a sustainable way and enable continuous improvement of quality of care, best practice recommendations, and other supportive measures have to address all identified levels of challenges.
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Affiliation(s)
- Bettina Grüne
- Department of Palliative Medicine (B.G., S.M., C.B., E.S.), University Hospital, LMU Munich, Germany; German Youth Institute (DJI), Department of Youth and Youth Services (B.G.), Munich, Germany.
| | - Sophie Meesters
- Department of Palliative Medicine (B.G., S.M., C.B., E.S.), University Hospital, LMU Munich, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine (B.G., S.M., C.B., E.S.), University Hospital, LMU Munich, Germany
| | - Eva Schildmann
- Department of Palliative Medicine (B.G., S.M., C.B., E.S.), University Hospital, LMU Munich, Germany
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