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Srifuengfung M, Pennington BRT, Lenze EJ. Optimizing treatment for older adults with depression. Ther Adv Psychopharmacol 2023; 13:20451253231212327. [PMID: 38022834 PMCID: PMC10657532 DOI: 10.1177/20451253231212327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
This review presents a comprehensive guide for optimizing medication management in older adults with depression within an outpatient setting. Medication optimization involves tailoring the antidepressant strategy to the individual, ensuring the administration of appropriate medications at optimal dosages. In the case of older adults, this process necessitates not only adjusting or changing antidepressants but also addressing the concurrent use of inappropriate medications, many of which have cognitive side effects. This review outlines various strategies for medication optimization in late-life depression: (1) Utilizing the full dose range of a medication to maximize therapeutic benefits and strive for remission. (2) Transitioning to alternative classes (such as a serotonin and norepinephrine reuptake inhibitor [SNRI], bupropion, or mirtazapine) when first-line treatment with selective serotonin reuptake inhibitors [SSRIs] proves inadequate. (3) Exploring augmentation strategies like aripiprazole for treatment-resistant depression. (4) Implementing measurement-based care to help adjust treatment. (5) Sustaining an effective antidepressant strategy for at least 1 year following depression remission, with longer durations for recurrent episodes or severe presentations. (6) Safely discontinuing anticholinergic medications and benzodiazepines by employing a tapering method when necessary, coupled with counseling about the benefits of stopping them. Additionally, this article explores favorable medications for depression, as well as alternatives for managing anxiety, insomnia, allergy, overactive bladder, psychosis, and muscle spasm in order to avoid potent anticholinergics and benzodiazepines.
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Affiliation(s)
- Maytinee Srifuengfung
- Department of Psychiatry, Washington University School of Medicine, 660 S Euclid Avenue, PO Box 8134, St. Louis, MO 63110, USA
- Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
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Garcia ACM, Isidoro GM, Paiva EMDC, Silva AE, Costa ICP, Bornemann-Cimenti H. Palliative Sedation at Home: A Scoping Review. Am J Hosp Palliat Care 2023; 40:173-182. [PMID: 35466700 DOI: 10.1177/10499091221096412] [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: 01/19/2023] Open
Abstract
Palliative Sedation (PS) is an effective measure for the relief of refractory symptoms in end-of-life patients. This intervention can be performed at home, respecting the patients' and their families' decisions. A scoping review was performed to map the available evidence in the literature on the performance of PS at home. This review included 23 studies. Most were conducted in European countries with adult cancer patients. Patients, family members and healthcare providers participated in the decision making regarding the use of PS at home. PS was used primarily to manage refractory symptoms (pain, delirium, dyspnea, and others), and in 1 of the studies PS was mentioned as a possible intervention for shortening life. The most commonly used medication was midazolam and the average duration ranged from 4 h to 7 days. There are few reports on adverse events related to PS. This intervention seems to be a feasible possibility for the management of refractory symptoms in patients at the end of life, despite the fact that it can represent specific challenges for healthcare providers, patients and families. However, the literature is limited regarding PS in children and in people with diseases other than cancer, as well as on the evaluation of possible adverse effects related to this intervention. Furthermore, it is essential to have a broad ethical, clinical and legal debate on whether to consider the use of PS for the purpose of shortening life in specific cases.
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Affiliation(s)
| | | | | | - Alexandre E Silva
- Nursing Department - Campus Centro-Oeste Dona Lindu, 74383Federal University of São João del-Rei, Divinópolis, Brazil
| | | | - Helmar Bornemann-Cimenti
- Departement of Anesthesiology and Intensive Care Medicine, 31475Medical University of Graz, Graz, Austria
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Ijaopo EO, Zaw KM, Ijaopo RO, Khawand-Azoulai M. A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness. Gerontol Geriatr Med 2023; 9:23337214231183243. [PMID: 37426771 PMCID: PMC10327414 DOI: 10.1177/23337214231183243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/23/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Background: World population is not only aging but suffering from serious chronic illnesses, requiring an increasing need for end-of-life care. However, studies show that many healthcare providers involved in the care of dying patients sometimes express challenges in knowing when to stop non-beneficial investigations and futile treatments that tend to prolong undue suffering for the dying person. Objective: To evaluate the clinical signs and symptoms that show end-of-life is imminent in individuals with advanced illness. Design: Narrative review. Methods: Computerized databases, including PubMed, Embase, Medline,CINAHL, PsycInfo, and Google Scholar were searched from 1992 to 2022 for relevant original papers written in or translated into English language that investigated clinical signs and symptoms of imminent death in individuals with advanced illness. Results: 185 articles identified were carefully reviewed and only those that met the inclusion criteria were included for review. Conclusion: While it is often difficult to predict the timing of death, the ability of healthcare providers to recognize the clinical signs and symptoms of imminent death in terminally-ill individuals may lead to earlier anticipation of care needs and better planning to provide care that is tailored to individual's needs, and ultimately results in better end-of-life care, as well as a better bereavement adjustment experience for the families.
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Affiliation(s)
| | - Khin Maung Zaw
- University of Miami Miller School of Medicine, FL, USA
- Miami VA Medical Center, FL, USA
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HarnEnz Z, Vermilion P, Foster-Barber A, Treat L. Pediatric neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:157-184. [PMID: 36599507 DOI: 10.1016/b978-0-12-824535-4.00015-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.
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Affiliation(s)
- Zoe HarnEnz
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Paul Vermilion
- Department of Medicine, University of Rochester, Rochester, NY, United States
| | - Audrey Foster-Barber
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Lauren Treat
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States.
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Willard EG, Wiencek C. Palliative Sedation Therapy: A Case Report. Crit Care Nurse 2022; 42:47-52. [DOI: 10.4037/ccn2022377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Introduction
Despite repeated exposure to dying patients, critical care providers and nurses may not be familiar with palliative sedation. This case report describes a scenario in which palliative sedation therapy was considered for a patient dying in the intensive care unit.
Clinical Findings
A 72-year-old woman was transferred from an outside hospital for management of severe acute respiratory distress syndrome. After her transfer, she experienced cardiac arrest and was resuscitated.
Diagnosis
The patient was diagnosed with pneumonia related to COVID-19. Arterial blood gas values showed her ratio of partial pressure of oxygen to fraction of inspired oxygen to be less than 200, consistent with acute respiratory distress syndrome.
Interventions
The patient was intubated and started on a ventilator protocol for acute respiratory distress syndrome. After her cardiac arrest, she required a continuous epinephrine infusion.
Outcomes
The patient’s family was notified of the severity of her clinical status, and the critical care team began to plan the transition from aggressive to comfort care. A provider suggested that the patient should receive continuous intravenous propofol after extubation to manage dyspnea during the dying process.
Conclusion
Palliative sedation therapy may be needed for dying patients, such as those with severe acute respiratory distress syndrome. The transition from curative to palliative measures often occurs in intensive care units but the ethical principles behind palliative sedation are not well understood by those providing care in these settings. It is vital that critical care nurses and providers be informed about available treatments for symptoms of dying patients, including palliative sedation.
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Affiliation(s)
- Emily G. Willard
- Emily G. Willard is a staff nurse and education coordinator in the medical-respiratory intensive care unit, VCU Health, in Richmond, Virginia. She is a graduate student at the University of Virginia School of Nursing, Charlottesville, Virginia
| | - Clareen Wiencek
- Clareen Wiencek is a palliative care nurse practitioner and a professor of nursing at the University of Virginia
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Wibisono S, Minto K, Lizzio-Wilson M, Thomas EF, Crane M, Molenberghs P, Kho M, Amiot CE, Decety J, Breen LJ, Noonan K, Forbat L, Louis W. Attitudes Toward and Experience With Assisted-Death Services and Psychological Implications for Health Practitioners: A Narrative Systematic Review. OMEGA-JOURNAL OF DEATH AND DYING 2022:302228221138997. [PMID: 36357863 DOI: 10.1177/00302228221138997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
A narrative systematic review was conducted to review studies that examine mental health implications of involvement in assisted-death services among health practitioners. Qualitative and quantitative studies were included to understand health practitioners' attitudes and experiences with assisted dying services, as well as to identify the mental health consequences. We identified 18 articles from 1591 articles drawn from seven major scientific databases (i.e., PubMed, MEDLINE, CINAHL, PsycINFO, Embase, Web of Science, and Scopus). Two raters independently evaluated the exclusion and inclusion decisions of the articles and examined methodological flaws in the selected articles. We found that engagement in assisted death services were not reliably associated with mental health outcomes such as anxiety and moral distress. Both positive and negative outcomes were reported, and psychological outcomes for practitioners were shown to vary based on factors including social support for health practitioners' views; their perceived capacity to care for the patients; and legislation.
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Affiliation(s)
- Susilo Wibisono
- School of Psychology, University of Queensland, Brisbane, QLD, Australia
- Department of Psychology, Universitas Islam Indonesia, Yogyakarta, Indonesia
| | - Kiara Minto
- School of Historical and Philosophical Inquiry, University of Queensland, Brisbane, QLD, Australia
| | - Morgana Lizzio-Wilson
- College of Education, Psychology, and Social Work, Flinders University, Adelaide, SA, Australia
| | - Emma F Thomas
- College of Education, Psychology, and Social Work, Flinders University, Adelaide, SA, Australia
| | - Monique Crane
- School of Psychological Sciences, Macquarie University, Sydney, NSW, Australia
| | | | - Madison Kho
- School of Psychological Sciences, Macquarie University, Sydney, NSW, Australia
| | - Catherine E Amiot
- Department of Psychology, The Universite du Quebec a Montreal, Montreal, QC, Canada
| | - Jean Decety
- Department of Psychology, The University of Chicago, Chicago, IL, USA
| | - Lauren J Breen
- Curtin School of Population Health and Enable Institute, Curtin University, Perth, WA, Australia
| | - Kerrie Noonan
- School of Social Sciences, Western Sydney University, Kingswood, Australia
| | - Liz Forbat
- Faculty of Social Science, University of Stirling, Stirling, UK
| | - Winnifred Louis
- School of Psychology, University of Queensland, Brisbane, QLD, Australia
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Kwon S, Kim M, Choi S. Ethical dilemmas and care actions in nurses providing palliative sedation. Nurs Ethics 2022; 29:1220-1230. [PMID: 35728273 DOI: 10.1177/09697330221105639] [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: 11/16/2022]
Abstract
BACKGROUND Recently, palliative care is increasingly important, with an emphasis on the process of dying with dignity. However, nurses who care for such patients experience the associated ethical dilemmas. OBJECTIVE To explore the meaning of nurses' experiences in dealing with ethical dilemmas in relation to palliative sedation. RESEARCH DESIGN A qualitative research design was employed with a thematic analysis approach. PARTICIPANTS AND RESEARCH CONTEXT Using purposive sampling, 15 nurses, working at palliative care units for at least 1 year, were recruited as participants. Data were collected using unstructured in-depth interviews, and data collection and analysis was performed simultaneously. ETHICAL CONSIDERATIONS Ethical approval was obtained from the authors' institutional review board. All participants provided informed consent. For the face-to-face interview, the South Korean standard COVID-19 quarantine guidelines, such as mandatory masking and social distancing, were followed. RESULTS Dilemmas raised by patients, were related to concerns about appropriate drug dose; dilemmas raised by nurses, were related to passive care, sense of guilt for failure to predict death, and colleague's disrespectful attitudes toward patients; dilemmas from patients' families were related to demands for palliative sedation and reversal of those demands. Care actions to deal with ethical dilemmas comprised evidence-based care, person-centered thinking, reflecting on the death situation, compassion, providing explanation and help to family members. CONCLUSION Nurses' ethical dilemmas were pre-dominantly influenced by themselves, rather than by the patients or their families, especially if they felt they could not do their best for patients. The core concept of care actions to deal with the ethical dilemmas, was person-centered care and compassion. Then, how patients and their family members perceive person-centered care and compassion, should be further explored to improve palliative sedation.
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Affiliation(s)
- Sinyoung Kwon
- Department of Nursing, 250458Gangdong University, Eumseong-gun, Chungcheongbuk-do, Korea
| | | | - Sujin Choi
- 35031Woosuk University, Wanju, Jeollabuk-do, Korea
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Rivas García F. Sedación paliativa en el final de la vida. REVISTA IBEROAMERICANA DE BIOÉTICA 2022. [DOI: 10.14422/rib.i18.y2022.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
La sedación paliativa es una práctica clínica ampliamente asumida y aplicada en situaciones que anticipan el final de la vida. No obstante, a pesar de sus beneficios cuando los síntomas refractarios no tienen otra alternativa, en algunas ocasiones la sedación puede ser fuente de numerosos dilemas bioéticos relacionados con el principio de doble efecto que actúa como una de las herramientas base, en el ámbito de la bioética, sobre las que puede sustentarse la licitud de la sedación en el final de la vida.
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Heino L, Stolt M, Haavisto E. The practices and attitudes of nurses regarding palliative sedation: A scoping review. Int J Nurs Stud 2020; 117:103859. [PMID: 33545642 DOI: 10.1016/j.ijnurstu.2020.103859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/12/2020] [Accepted: 12/20/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Palliative sedation is used as a last-resort option to treat refractory symptoms of dying patients. Nurses are important participants in the process of sedation. However, little is known about palliative sedation from a nursing perspective. OBJECTIVES To analyze the practices and attitudes of nurses concerning palliative sedation. DATA SOURCES AND REVIEW METHODS A scoping review guided by Arksey and O`Malley`s methodological framework was used to analyze existing peer-reviewed empirical research on the topic of the practices and attitudes of nurses related to the palliative sedation of patients aged 18 years and older. Of the 316 publications identified from the PubMed, CINAHL and Cochrane Library, 17 full-text articles were included in this review. The data of the included articles were charted (author(s), year of publication, country, objectives, study design, data collection, setting, respondents, definition of palliative sedation, focus of the study and key findings), and the results were summarized with inductive content analysis. The PRISMA-ScR checklist was used as a guideline for the reporting in this review. RESULTS During the decision-making concerning the start of palliative sedation, nurses usually have an advocatory and supportive role, although the role varies between different countries. This role then changes to a relatively independent performance of sedation; including administration of the medication, monitoring the effectiveness of sedation, and in some cases taking decisions concerning the medication and dosage policy. Further, nurses provide information and compassionate care to both the patient and the family during the process of palliative sedation. Most nurses view palliative sedation as a positive and sometimes necessary last resort therapy to relieve refractory suffering of dying patients. However, sedation poses ethical problems for many nurses. These problems especially concern the essential elements of deciding to use palliative sedation, the depth of sedation, the potential for shortening life, and the loss of social interaction. CONCLUSIONS Nurses play a key role in palliative sedation, as they often perform sedation independently and have important information about the needs and wishes of both patients and their families due to their unique position at the bedside of the patient. Although nurses generally see palliative sedation as a positive practice for selected patients, many of them feel it is ethically controversial. This scoping review reveals a great need for further research and discussion on the practices and attitudes of nurses regarding palliative sedation.
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Affiliation(s)
- Linda Heino
- Bachelor of Health Sciences, Department of Nursing Science, University of Turku, Turku, Finland.
| | - Minna Stolt
- Department of Nursing Science, University of Turku, Turku and Turku University Hospital, Turku, Finland
| | - Elina Haavisto
- Department of Nursing Science, University of Turku, Turku and Satakunta Central Hospital, Pori, Finland
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