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Thornton JD, Varisco T, Patel H, Shrestha M, Wanat M, Schaefer E, Leslie D, Zhao H, Saadi RA, Shen C. Characterising incident opioid use among incident users of prescription sedative hypnotics: A national cohort study. BMJ Open 2024; 14:e082339. [PMID: 38816043 DOI: 10.1136/bmjopen-2023-082339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVE To evaluate co-prescribing of sedatives hypnotics and opioids. DESIGN Retrospective study evaluating the association of patient characteristics and comorbidities with coprescribing. SETTING AND PARTICIPANTS Using the national Merative MarketScan Database between 2005 and 2018, we identified patients who received an incident sedative prescription with or without subsequent, incident opioid prescriptions within a year of the sedative prescription in the USA. OUTCOME MEASURES Coprescription of sedative-hypnotics and opioids. RESULTS A total of 2 632 622 patients (mean (SD) age, 43.2 (12.34) years; 1 297 356 (62.5%) female) received incident prescriptions for sedatives over the course of the study period. The largest proportion of sedative prescribing included benzodiazepines (71.1%); however, z-drugs (19.9%) and barbiturates (9%) were also common. About 557 845 (21.2%) patients with incident sedatives also received incident opioid prescriptions. About 59.2% of these coprescribed patients received opioids coprescription on the same day. Multivariate logistic regression findings showed that individuals with a comorbidity index score of 1, 2 or ≥3 (aOR 1.19 (95% CI 1.17 to 1.21), 1.17 (95% C 1.14 to 1.19) and 1.25 (95% C 1.2 to 1.31)) and substance use disorder (1.21 (95% C 1.19 to 1.23)) were more likely to be coprescribed opioids and sedatives. The likelihood of receiving both opioid and sedative prescriptions was lower for female patients (aOR 0.93; 95% CI 0.92 to 0.94), and those receiving a barbiturate (aOR 0.3; 95% CI 0.29 to 0.31) or z-drugs (aOR 0.67; 95% CI 0.66 to 0.68) prescriptions at the index date. CONCLUSIONS Coprescription of sedatives with opioids was associated with the presence of comorbidities and substance use disorder, gender and types of sedatives prescribed at the index date. Additionally, more than half of the coprescribing occurred on the same day which warrants further evaluation of current prescribing and dispensing best practice guidelines.
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Affiliation(s)
- James Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas, USA
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Tyler Varisco
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas, USA
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Harshil Patel
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Mina Shrestha
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Matthew Wanat
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Eric Schaefer
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Douglas Leslie
- Center for Applied Studies in Health Economics, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Randa Al Saadi
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Chan Shen
- Division of Outcomes Research and Quality, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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Ajdžanović VZ, Šošić-Jurjević BT, Ranin JT, Filipović BR. Biologia Futura: does the aging process contribute to the relativity of time? Biol Futur 2023:10.1007/s42977-023-00167-2. [PMID: 37213056 DOI: 10.1007/s42977-023-00167-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/01/2023] [Indexed: 05/23/2023]
Abstract
In his Theory of relativity, Einstein determined that the time is relative to the reference frame of the observer. Under specific conditions, there is a difference in the elapsed time between two clocks, known as time dilation. A similar relativistic effect could be attributed to the brain operating at different frequencies, e.g., while it is slow and during the thought process. Time flow and the aging process are causally linked. Herein, we introduce physical relativity into the mind/thought context and elaborate changed perception of the time flow (the impression of the time acceleration) with aging. The phenomenology of time is observed in the context of physical and biological clock, as well as by introducing the category of 'mind time.' Mental processing impairment is crucial for the "aging-caused relativity of time," while adjusting of its' perception seems to be a matter of body/mind rest, mental hygiene and physical activity of the aging subject. We also provide a brief overview of the perception of time flow in some disease states that coincide with aging. Our main idea has a perspective for future development in the interdisciplinary synergy of philosophy, physical-mathematical elaboration, experimental biology and clinical investigations.
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Affiliation(s)
- Vladimir Z Ajdžanović
- Department of Cytology, Institute for Biological Research "Siniša Stanković"-National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia.
| | - Branka T Šošić-Jurjević
- Department of Cytology, Institute for Biological Research "Siniša Stanković"-National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Jovan T Ranin
- Clinic for Infectious and Tropical Diseases, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko R Filipović
- Department of Cytology, Institute for Biological Research "Siniša Stanković"-National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia
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Miele E, Mastronuzzi A, Cefalo MG, Del Bufalo F, De Pasquale MD, Serra A, Spinelli GP, De Sio L. Propofol-based palliative sedation in terminally ill children with solid tumors: A case series. Medicine (Baltimore) 2019; 98:e15615. [PMID: 31124940 PMCID: PMC6571440 DOI: 10.1097/md.0000000000015615] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE The palliative sedation therapy is defined as the intentional reduction of the alert state, using pharmacological tools. Propofol is a short-acting general anesthetic agent, widely used for induction and maintenance of general anesthesia and rarely employed in palliative care. PATIENT CONCERNS AND DIAGNOSES This case series describes 5 pediatric oncology inpatients affected by relapsed/refractory solid tumors received palliative sedation using propofol alone or in combination with opioids and benzodiazepines. INTERVENTIONS AND OUTCOMES Five terminally ill children affected by solid tumors received propofol-based palliative sedation. All patients were previously treated with opioids and some of them reduced the consumption of these drugs after propofol starting. In all cases the progressive increase of the level of sedation until the death has been the only effective measure of control of refractory symptoms related todisease progression and psychological suffering. LESSONS We evaluated the quality of propofol-based palliative sedation in a series of pediatric oncology patients with solid tumors at the end of their life. We concluded that propofol represents an effective and tolerable adjuvant drug for the management of intractable suffering and a practicable strategy for palliative sedation in pediatric oncology patients at the end of their life.
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Affiliation(s)
- Evelina Miele
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - Angela Mastronuzzi
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - M. Giuseppina Cefalo
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - Francesca Del Bufalo
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - M. Debora De Pasquale
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - Annalisa Serra
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
| | - Gian Paolo Spinelli
- Unità Operativa Complessa Oncology, University of Rome “Sapienza”, Azienda Sanitaria Locale Latina District 1, Aprilia (LT), Rome, Italy
| | - Luigi De Sio
- Department of Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)
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O'Donnell SB, Nicholson MK, Boland JW. The Association Between Benzodiazepines and Survival in Patients With Cancer: A Systematic Review. J Pain Symptom Manage 2019; 57:999-1008.e11. [PMID: 30708126 DOI: 10.1016/j.jpainsymman.2019.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 01/19/2019] [Accepted: 01/22/2019] [Indexed: 01/25/2023]
Abstract
CONTEXT Patients with cancer often experience distressing symptoms such as anxiety or dyspnea, which can be managed with benzodiazepines; however, concerns regarding the impact of these drugs on survival may dissuade prescribing and compliance. OBJECTIVES We aimed to identify and appraise studies examining benzodiazepine use and survival in adults with cancer, to investigate the relationship and context of use. METHODS Systematic review of the international literature prepared according to preferred reporting items for systematic reviews. Comprehensive searches of the MEDLINE, Embase, PsycINFO, Cochrane Library, and AMED databases using medical subject heading and free-text search combinations with no date or language restrictions were undertook. Handsearching of references was conducted. Risk of bias of the included studies was assessed using Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS Two thousand two hundred fifty-seven unique records were identified, with 18 meeting inclusion criteria, representing 4117 patients. All studies were very low quality. No study found an increase in mortality in association with benzodiazepine use, whereas two demonstrated an increase. CONCLUSION Existing evidence shows no association between benzodiazepine use in patients with cancer and decreased survival. None of the studies evaluated the association between benzodiazepine use and survival in earlier stages of cancer, and the quality of studies retrieved signifies a need for further robust studies to draw more definitive conclusions. Further investigation in patients with cancer using well-designed, high-quality research with survival as a primary outcome should be conducted.
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Affiliation(s)
- Sean B O'Donnell
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | | | - Jason W Boland
- Hull York Medical School, University of Hull, Hull, United Kingdom
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Ingravallo F, de Nooijer K, Pucci V, Casini C, Miccinesi G, Rietjens JAC, Morino P. Discussions about palliative sedation in hospice: Frequency, timing and factors associated with patient involvement. Eur J Cancer Care (Engl) 2019; 28:e13019. [DOI: 10.1111/ecc.13019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 12/04/2018] [Accepted: 01/17/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Francesca Ingravallo
- Department of Medical and Surgical Sciences (DIMEC)University of Bologna Bologna Italy
| | - Kim de Nooijer
- Department of Public HealthErasmus University Medical Center Rotterdam the Netherlands
| | - Valentina Pucci
- Department of Medical and Surgical Sciences (DIMEC)University of Bologna Bologna Italy
| | - Cinzia Casini
- Palliative Care Coordination, Toscana Centrale Local Health TrustHospice Convento delle Oblate Florence Italy
| | - Guido Miccinesi
- Clinical Epidemiology UnitOncological network, prevention and research Institute (ISPRO) Florence Italy
| | - Judith A. C. Rietjens
- Department of Public HealthErasmus University Medical Center Rotterdam the Netherlands
| | - Piero Morino
- Palliative Care Coordination, Toscana Centrale Local Health TrustHospice Convento delle Oblate Florence Italy
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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.
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Franken LG, de Winter BCM, Masman AD, van Dijk M, Baar FPM, Tibboel D, Koch BCP, van Gelder T, Mathot RAA. Population pharmacodynamic modelling of midazolam induced sedation in terminally ill adult patients. Br J Clin Pharmacol 2017; 84:320-330. [PMID: 28960387 PMCID: PMC5777431 DOI: 10.1111/bcp.13442] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 09/11/2017] [Accepted: 09/13/2017] [Indexed: 12/24/2022] Open
Abstract
Aims Midazolam is the drug of choice for palliative sedation and is titrated to achieve the desired level of sedation. A previous pharmacokinetic (PK) study showed that variability between patients could be partly explained by renal function and inflammatory status. The goal of this study was to combine this PK information with pharmacodynamic (PD) data, to evaluate the variability in response to midazolam and to find clinically relevant covariates that may predict PD response. Method A population PD analysis using nonlinear mixed effect models was performed with data from 43 terminally ill patients. PK profiles were predicted by a previously described PK model and depth of sedation was measured using the Ramsay sedation score. Patient and disease characteristics were evaluated as possible covariates. The final model was evaluated using a visual predictive check. Results The effect of midazolam on the sedation level was best described by a differential odds model including a baseline probability, Emax model and interindividual variability on the overall effect. The EC50 value was 68.7 μg l–1 for a Ramsay score of 3–5 and 117.1 μg l–1 for a Ramsay score of 6. Comedication with haloperidol was the only significant covariate. The visual predictive check of the final model showed good model predictability. Conclusion We were able to describe the clinical response to midazolam accurately. As expected, there was large variability in response to midazolam. The use of haloperidol was associated with a lower probability of sedation. This may be a result of confounding by indication, as haloperidol was used to treat delirium, and deliria has been linked to a more difficult sedation procedure.
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Affiliation(s)
- Linda G Franken
- Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Anniek D Masman
- Palliative Care Centre, Laurens Cadenza, Rotterdam, The Netherlands.,Intensive Care, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Monique van Dijk
- Intensive Care, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Frans P M Baar
- Palliative Care Centre, Laurens Cadenza, Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Ron A A Mathot
- Hospital Pharmacy - Clinical Pharmacology, Academic Medical Centre, Amsterdam, The Netherlands
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9
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Cristina E, Carlo S, Gabriella D, Mirella P. Factors associated with the decision-making process in palliative sedation therapy. The experience of an Italian hospice struggling with balancing various individual autonomies. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1290307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Endrizzi Cristina
- Hospice Il Gelso, Local Health Alessandria (ASL AL), Via San Pio V, 41, Alessandria, Italy
| | - Senore Carlo
- The Reference Centre for Epidemiology and Cancer Prevention, Regional Hospitals of City of Science and Health “AOU Città della Salute e della Scienza”, Turin, Italy
| | - D’Amico Gabriella
- Hospice Il Gelso, Local Health Alessandria (ASL AL), Via San Pio V, 41, Alessandria, Italy
| | - Palella Mirella
- Hospice Il Gelso, Local Health Alessandria (ASL AL), Via San Pio V, 41, Alessandria, Italy
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10
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Is regular systemic opioid analgesia associated with shorter survival in adult patients with cancer? A systematic literature review. Pain 2015. [DOI: 10.1097/j.pain.0000000000000306] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Gu X, Cheng W, Chen M, Liu M, Zhang Z. Palliative sedation for terminally ill cancer patients in a tertiary cancer center in Shanghai, China. BMC Palliat Care 2015; 14:5. [PMID: 25810691 PMCID: PMC4373517 DOI: 10.1186/s12904-015-0002-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 02/20/2015] [Indexed: 11/28/2022] Open
Abstract
Background There are a number of studies dedicated to characteristics of sedation, but these studies are mostly bound to western country practices. The aim of this study is to describe the characteristics of patients who suffered from cancer and who had been sedated until their death in Shanghai, China. Methods Retrospective medical data of 244 terminally ill cancer patients including 82 sedated patients were collected. Data collected included demographic characteristics, disease-related characteristics and details of the sedation. Results In sedated cases, patients and/or caregivers gave the consent to start palliative sedation due to unmanageable symptoms. On average, sedation was performed 24.65(±1.78)hours before death. Agitated delirium and dyspnea were the most frequent indications for palliative sedation. There was no significant difference in survival time from admission till death between sedated and non-sedated patients (p > 0.05). Conclusions Palliative sedation is effective for reducing terminally ill cancer patients’ suffering without hastening death. Prospective research is needed to determine the optimal conditions for Chinese patients including indications, decision making process, informed consent, cultural and ethical issues, type of sedation and drugs.
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Affiliation(s)
- Xiaoli Gu
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, #270, Dong'An Road, Shanghai, 200032 People's Republic of China ; Department of Oncology, Shanghai Medical College, Fudan University, #270, Dong'An Road, Shanghai, 200032 China
| | - Wenwu Cheng
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, #270, Dong'An Road, Shanghai, 200032 People's Republic of China ; Department of Oncology, Shanghai Medical College, Fudan University, #270, Dong'An Road, Shanghai, 200032 China
| | - Menglei Chen
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, #270, Dong'An Road, Shanghai, 200032 People's Republic of China ; Department of Oncology, Shanghai Medical College, Fudan University, #270, Dong'An Road, Shanghai, 200032 China
| | - Minghui Liu
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, #270, Dong'An Road, Shanghai, 200032 People's Republic of China ; Department of Oncology, Shanghai Medical College, Fudan University, #270, Dong'An Road, Shanghai, 200032 China
| | - Zhe Zhang
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, #270, Dong'An Road, Shanghai, 200032 People's Republic of China ; Department of Oncology, Shanghai Medical College, Fudan University, #270, Dong'An Road, Shanghai, 200032 China
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Hui D, Li Z, Chisholm GB, Didwaniya N, Bruera E. Changes in medication profile among patients with advanced cancer admitted to an acute palliative care unit. Support Care Cancer 2015; 23:427-32. [PMID: 25123192 DOI: 10.1007/s00520-014-2390-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The decision-making process for medication use in the last weeks of life is complex because of patient frailty and poor prognosis. Limited literature is available on medication use in the palliative care setting, particularly in acute palliative care units (APCUs). We examined the changes in medication profile among hospitalized patients with advanced cancer before their palliative care inpatient consultation team referral, after palliative care consultation, at the time of APCU admission, and at APCU discharge or death. METHODS We included consecutive patients with advanced cancer who were first seen by our inpatient palliative care consultation team and subsequently admitted to the APCU. We retrieved data on all scheduled medications at the prespecified time points. RESULTS Among the 100 patients, the median duration of hospitalization was 10.5 days (interquartile range 8-15 days), and the median APCU stay was 5 days (interquartile range 3-7 days). The average number of medications before palliative care inpatient consultation team referral, after palliative care consultation, at APCU admission and at APCU discharge/death was 9.2 (standard deviation [SD] 4.5), 9.9 (SD 4.2), 10.3 (SD 3.8), and 10.1 (SD 3.8), respectively (P = 0.03). An increasing proportion of patients received medications for symptom control over their course of hospitalization, including systemic corticosteroids, laxatives, neuroleptics, and antiulcer agents (P < 0.05). In contrast, the frequency of several classes of medications such as antihypertensives, antilipemics, and anticonvulsants decreased over time (P < 0.05). CONCLUSIONS Palliative care involvement was associated with an increase in symptom control medications and decrease in medications for comorbid conditions over time.
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Affiliation(s)
- David Hui
- Department of Palliative Care & Rehabilitation Medicine Unit 1414, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA,
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Beller EM, van Driel ML, McGregor L, Truong S, Mitchell G. Palliative pharmacological sedation for terminally ill adults. Cochrane Database Syst Rev 2015; 1:CD010206. [PMID: 25879099 PMCID: PMC6464857 DOI: 10.1002/14651858.cd010206.pub2] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Terminally ill people experience a variety of symptoms in the last hours and days of life, including delirium, agitation, anxiety, terminal restlessness, dyspnoea, pain, vomiting, and psychological and physical distress. In the terminal phase of life, these symptoms may become refractory, and unable to be controlled by supportive and palliative therapies specifically targeted to these symptoms. Palliative sedation therapy is one potential solution to providing relief from these refractory symptoms. Sedation in terminally ill people is intended to provide relief from refractory symptoms that are not controlled by other methods. Sedative drugs such as benzodiazepines are titrated to achieve the desired level of sedation; the level of sedation can be easily maintained and the effect is reversible. OBJECTIVES To assess the evidence for the benefit of palliative pharmacological sedation on quality of life, survival, and specific refractory symptoms in terminally ill adults during their last few days of life. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 11), MEDLINE (1946 to November 2014), and EMBASE (1974 to December 2014), using search terms representing the sedative drug names and classes, disease stage, and study designs. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, non-RCTs, and observational studies (e.g. before-and-after, interrupted-time-series) with quantitative outcomes. We excluded studies with only qualitative outcomes or that had no comparison (i.e. no control group or no within-group comparison) (e.g. single arm case series). DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts of citations, and full text of potentially eligible studies. Two review authors independently carried out data extraction using standard data extraction forms. A third review author acted as arbiter for both stages. We carried out no meta-analyses due to insufficient data for pooling on any outcome; therefore, we reported outcomes narratively. MAIN RESULTS The searches resulted in 14 included studies, involving 4167 adults, of whom 1137 received palliative sedation. More than 95% of people had cancer. No studies were randomised or quasi-randomised. All were consecutive case series, with only three having prospective data collection. Risk of bias was high, due to lack of randomisation. No studies measured quality of life or participant well-being, which was the primary outcome of the review. Five studies measured symptom control, using four different methods, so pooling was not possible. The results demonstrated that despite sedation, delirium and dyspnoea were still troublesome symptoms in these people in the last few days of life. Control of other symptoms appeared to be similar in sedated and non-sedated people. Only one study measured unintended adverse effects of sedative drugs and found no major events; however, four of 70 participants appeared to have drug-induced delirium. The study noticed no respiratory suppression. Thirteen of the 14 studies measured survival time from admission or referral to death, and all demonstrated no statistically significant difference between sedated and non-sedated groups. AUTHORS' CONCLUSIONS There was insufficient evidence about the efficacy of palliative sedation in terms of a person's quality of life or symptom control. There was evidence that palliative sedation did not hasten death, which has been a concern of physicians and families in prescribing this treatment. However, this evidence comes from low quality studies, so should be interpreted with caution. Further studies that specifically measure the efficacy and quality of life in sedated people, compared with non-sedated people, and quantify adverse effects are required.
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Affiliation(s)
- Elaine M Beller
- Faculty ofHealth Sciences andMedicine, Bond University, Gold Coast, Queensland, 4229, Australia.
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Cherny N. ESMO Clinical Practice Guidelines for the management of refractory symptoms at the end of life and the use of palliative sedation. Ann Oncol 2014; 25 Suppl 3:iii143-52. [DOI: 10.1093/annonc/mdu238] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kajiyama H, Utsumi F, Higashi M, Sakata J, Sekiya R, Mizuno M, Umezu T, Suzuki S, Yamamoto E, Mitsui H, Niimi K, Shibata K, Kikkawa F. Is there any association between where patients spend the end of life and survival after anticancer treatment for gynecologic malignancy? J Palliat Med 2014; 17:325-30. [PMID: 24617316 DOI: 10.1089/jpm.2013.0366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND It remains unknown whether the end-of-life (EOL) environment influences survival after anticancer treatment, particularly for gynecologic malignancy. OBJECTIVE The study's objective was to clarify whether the survival time varied depending on where patients spend the EOL. METHODS This retrospective study included patients who received initial oncologic treatment but died due to cancer recurrence and/or progression. The subjects were a cohort of 181 gynecologic malignant tumor cases in a single institution from 2002 to 2008. Measurement was of postcancer treatment survival (PCS), defined as the time interval between the last date of anticancer treatment after recurrence/progression and death from the disease, analyzed on stratification by type of supportive care or where patients spent the EOL. RESULTS The median survival time was 26.1 (1.0-306.4) months. The distribution of the carcinoma type was as follows: 28.7% of patients with cervical (N=52), 27.6% with endometrial (N=50), and 43.1% with ovarian (N=79) cancer. The median PCS was 13.3 weeks. Patients in the hospice/home care group showed a significantly more favorable PCS than those in the hospital group (log rank: P=0.029). On multivariate analysis, the age (<60 versus ≥60) and site of supportive care (hospital versus hospice/home care) retained their significance as independent prognostic factors of poor PCS (age: HR=0.679, 95% CI, 0.496-0.928, P=0.0151; site of supportive care: HR=0.704, 95% CI, 0.511-0.970, P=0.0319). CONCLUSIONS Our current data could be hypothesis generating; it is possible that the EOL environment is a crucial prognostic factor for survival after anticancer treatment.
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Affiliation(s)
- Hiroaki Kajiyama
- 1 Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine , Nagoya, Japan
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Irwin SA, Pirrello RD, Hirst JM, Buckholz GT, Ferris FD. Clarifying delirium management: practical, evidenced-based, expert recommendations for clinical practice. J Palliat Med 2013; 16:423-35. [PMID: 23480299 PMCID: PMC3612281 DOI: 10.1089/jpm.2012.0319] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2013] [Indexed: 12/30/2022] Open
Abstract
Delirium is highly prevalent in those with serious or advanced medical illnesses. It is associated with many adverse consequences, including significant patient, family, and health care provider distress. This article suggests a novel approach to delirium assessment and management and provides useful, practical guidance for clinicians based on a complete review of the existing literature and the expert clinical opinion of the authors and their colleagues, derived from over a decade of collective bedside experience. Comprehensive assessment includes careful description of observed symptoms, signs, and behaviors; and an understanding of the patient's situation, including primary diagnosis, associated comorbidities, functional status, and prognosis. The importance of incorporating goals of care for the patient and family is discussed. The concepts of potential reversibility versus irreversible delirium and delirium subtype are proffered, with a description of how diagnostic and management strategies follow from these concepts. Pharmacological interventions that provide rapid, effective, and safe relief are presented. Employing both pharmacological and nonpharmacological interventions, including patient and family education, improves symptoms and relieves patient and family distress, whether the delirium is reversible or irreversible, hyperactive or hypoactive. All interventions can be provided in any setting of care, including patients' homes.
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Affiliation(s)
- Scott A Irwin
- San Diego Hospice and The Institute for Palliative Medicine, San Diego, CA 92103, USA.
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Barathi B, Chandra PS. Palliative Sedation in Advanced Cancer Patients: Does it Shorten Survival Time? - A Systematic Review. Indian J Palliat Care 2013; 19:40-7. [PMID: 23766594 PMCID: PMC3680838 DOI: 10.4103/0973-1075.110236] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with advanced cancer often suffer from multiple refractory symptoms in the terminal phase of their life. Palliative sedation is one of the few ways to relieve this refractory suffering. OBJECTIVES This systematic review investigated the effect of palliative sedation on survival time in terminally ill cancer patients. MATERIALS AND METHODS Six electronic databases were searched for both prospective and retrospective studies which evaluated the effect of palliative sedation on survival time. Only those studies which had a comparison group that did not receive palliative sedation were selected for the review. Abstracts of all retrieved studies were screened to include the most relevant studies and only studies which met inclusion criteria were selected. References of all retrieved studies were also screened for relevant studies. Selected studies were assessed for quality and data extraction was done using the structured data extraction form. RESULTS Eleven studies including four prospective and seven retrospective studies were identified. Mean survival time (MST) was measured as the time from last admission until death. A careful analysis of the results of all the 11 studies indicated that MST of sedated and non-sedated group was not statistically different in any of the studies. CONCLUSION This systematic review supports the fact that palliative sedation does not shorten survival in terminally ill cancer patients. However, this conclusion needs to be taken with consideration of the methodology, study design, and the population studied of the included studies in this review.
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Affiliation(s)
- B Barathi
- Department of Pain and Palliative Care, St. John's Medical College Hospital, Bangalore, India
| | - Prabha S Chandra
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
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Gielen J, Van den Branden S, Van Iersel T, Broeckaert B. Flemish palliative-care nurses’ attitudes to palliative sedation. Nurs Ethics 2012; 19:692-704. [DOI: 10.1177/0969733011436026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Palliative sedation is an option of last resort to control refractory suffering. In order to better understand palliative-care nurses’ attitudes to palliative sedation, an anonymous questionnaire was sent to all nurses (589) employed in palliative care in Flanders (Belgium). In all, 70.5% of the nurses ( n = 415) responded. A large majority did not agree that euthanasia is preferable to palliative sedation, were against non-voluntary euthanasia in the case of a deeply and continuously sedated patient and considered it generally better not to administer artificial floods or fluids to such a patient. Two clusters were found: 58.5% belonged to the cluster of advocates of deep and continuous sedation and 41.5% belonged to the cluster of nurses restricting the application of deep and continuous sedation. These differences notwithstanding, overall the attitudes of the nurses are in accordance with the practice and policy of palliative sedation in Flemish palliative-care units.
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Nogueira FL, Sakata RK. Palliative Sedation of Terminally ill Patients. Braz J Anesthesiol 2012; 62:580-92. [DOI: 10.1016/s0034-7094(12)70157-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 09/05/2011] [Indexed: 10/26/2022] Open
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Maltoni M, Scarpi E, Rosati M, Derni S, Fabbri L, Martini F, Amadori D, Nanni O. Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol 2012; 30:1378-83. [PMID: 22412129 DOI: 10.1200/jco.2011.37.3795] [Citation(s) in RCA: 179] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Palliative sedation is a clinical procedure aimed at relieving refractory symptoms in patients with advanced cancer. It has been suggested that sedative drugs may shorten life, but few studies exist comparing the survival of sedated and nonsedated patients. We present a systematic review of literature on the clinical practice of palliative sedation to assess the effect, if any, on survival. METHODS A systematic review of literature published between January 1980 and December 2010 was performed using MEDLINE and EMBASE databases. Search terms included palliative sedation, terminal sedation, refractory symptoms, cancer, neoplasm, palliative care, terminally ill, end-of-life care, and survival. A manual search of the bibliographies of electronically identified articles was also performed. RESULTS Eleven published articles were identified describing 1,807 consecutive patients in 10 retrospective or prospective nonrandomized studies, 621 (34.4%) of whom were sedated. One case-control study was excluded from prevalence analysis. The most frequent reason for sedation was delirium in the terminal stages of illness (median, 57.1%; range, 13.8% to 91.3%). Benzodiazepines were the most common drug category prescribed. Comparing survival of sedated and nonsedated patients, the sedation approach was not shown to be associated with worse survival. CONCLUSION Even if there is no direct evidence from randomized clinical trials, palliative sedation, when appropriately indicated and correctly used to relieve unbearable suffering, does not seem to have any detrimental effect on survival of patients with terminal cancer. In this setting, palliative sedation is a medical intervention that must be considered as part of a continuum of palliative care.
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Affiliation(s)
- Marco Maltoni
- Istituto Scientifico Romagnolo per lo Studio e lCura dei Tumori, Meldola, Italy.
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Gielen J, Gupta H, Rajvanshi A, Bhatnagar S, Mishra S, Chaturvedi AK, den Branden SV, Broeckaert B. The Attitudes of Indian Palliative-care Nurses and Physicians to Pain Control and Palliative Sedation. Indian J Palliat Care 2011; 17:33-41. [PMID: 21633619 PMCID: PMC3098541 DOI: 10.4103/0973-1075.78447] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aim: We wanted to assess Indian palliative-care nurses and physicians’ attitudes toward pain control and palliative sedation. Materials and Methods: From May to September 2008, we interviewed 14 physicians and 13 nurses working in different palliative-care programs in New Delhi, using a semi-structured questionnaire, and following grounded-theory methodology (Glaser and Strauss). Results: The interviewees did not consider administration of painkillers in large doses an ethical problem, provided the pain killers are properly titrated. Mild palliative sedation was considered acceptable. The interviewees disagreed whether palliative sedation can also be deep and continuous. Arguments mentioned against deep continuous palliative sedation were the conviction that it may cause unacceptable side effects, and impedes basic daily activities and social contacts. A few interviewees said that palliative sedation may hasten death. Conclusion: Due to fears and doubts regarding deep continuous palliative sedation, it may sometimes be too easily discarded as a treatment option for refractory symptoms.
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Affiliation(s)
- Joris Gielen
- Interdisciplinary Centre for the Study of Religion and World View (Catholic University Leuven), Sint-Michielsstraat 4 - Bus 3101, 3000 Leuven, Belgium
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Rurup ML, Rhodius CA, Borgsteede SD, Boddaert MS, Keijser AG, Pasman HRW, Onwuteaka-Philipsen BD. The use of opioids at the end of life: the knowledge level of Dutch physicians as a potential barrier to effective pain management. BMC Palliat Care 2010; 9:23. [PMID: 21073709 PMCID: PMC3000381 DOI: 10.1186/1472-684x-9-23] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Accepted: 11/12/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is still one of the most frequently occurring symptoms at the end of life, although it can be treated satisfactorily in most cases if the physician has adequate knowledge. In the Netherlands, almost 60% of the patients with non-acute illnesses die at home where end of life care is coordinated by the general practitioner (GP); about 30% die in hospitals (cared for by clinical specialists), and about 10% in nursing homes (cared for by elderly care physicians).The research question of this study is: what is the level of knowledge of Dutch physicians concerning pain management and the use of opioids at the end of life? METHODS A written questionnaire was sent to a random sample of physicians of specialties most often involved in end of life care in the Netherlands. The questionnaire was completed by 406 physicians, response rate 41%. RESULTS Almost all physicians were aware of the most basal knowledge about opioids, e.g. that it is important for treatment purposes to distinguish nociceptive from neuropathic pain (97%). Approximately half of the physicians (46%) did not know that decreased renal function raises plasma concentration of morphine(-metabolites) and 34% of the clinical specialists erroneously thought opioids are the favoured drug for palliative sedation.Although 91% knew that opioids titrated against pain do not shorten life, 10% sometimes or often gave higher dosages than needed with the explicit aim to hasten death. About half felt sometimes or often pressured by relatives to hasten death by increasing opioiddosage.The large majority (83%) of physicians was interested in additional education about subjects related to the end of life, the most popular subject was opioid rotation (46%). CONCLUSIONS Although the basic knowledge of physicians was adequate, there seemed to be a lack of knowledge in several areas, which can be a barrier for good pain management at the end of life. From this study four areas emerge, in which it seems likely that an improvement can improve the quality of pain management at the end of life for many patients in the Netherlands: 1)palliative sedation; 2)expected effect of opioids on survival; and 3) opioid rotation.
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Affiliation(s)
- Mette L Rurup
- VU University Medical Center, EMGO Institute for Health and Care Research, Department of Public and Occupational Health, Amsterdam, The Netherlands.
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Maltoni M, Pittureri C, Scarpi E, Piccinini L, Martini F, Turci P, Montanari L, Nanni O, Amadori D. Palliative sedation therapy does not hasten death: results from a prospective multicenter study. Ann Oncol 2009; 20:1163-9. [DOI: 10.1093/annonc/mdp048] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Rurup ML, Borgsteede SD, van der Heide A, van der Maas PJ, Onwuteaka-Philipsen BD. Trends in the use of opioids at the end of life and the expected effects on hastening death. J Pain Symptom Manage 2009; 37:144-55. [PMID: 18692359 DOI: 10.1016/j.jpainsymman.2008.02.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Revised: 02/18/2008] [Accepted: 02/18/2008] [Indexed: 10/21/2022]
Abstract
The aim of our study was to describe trends in opioid use and perceptions of having hastened the end of life of a patient. In 2005, a questionnaire was sent to 6860 physicians in The Netherlands who had attended a death. The response rate was 78%. In 1995 and 2001 similar studies were done. Physicians less often administered opioids with the intention to hasten death in 2005 (3.1% of the non-sudden deaths) than in 2001 and in 1995 (7% and 10%, respectively). Physicians gave similar dosages of opioids in 2005, 2001, and 1995, but physicians in 2005 less often thought that life was actually shortened than in 2001 and 1995 (37% in 2005, 50% in 2001, and 53% in 1995). Of the physicians in 2005 who did think that the life of the patient was shortened by opioids, 94% did not give higher dosages than were, in their own opinion, required for pain and symptom management. Physicians in 2005 more often took hastening death into account when they gave higher dosages of opioids when the patient experienced more severe symptoms and with female patients. In older patients (>or=80 years), physicians took the hastening of death into account more often, but the actual dosages of opioids were lower. These data indicate that physicians in The Netherlands less often thought that death was hastened by opioids and less often gave opioids, with the intention to hasten death in 2005 than in 2001 and 1995.
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Affiliation(s)
- Mette L Rurup
- EMGO Institute, Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands.
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25
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Rurup ML, Buiting HM, Pasman HRW, van der Maas PJ, van der Heide A, Onwuteaka-Philipsen BD. The Reporting Rate of Euthanasia and Physician-Assisted Suicide. Med Care 2008; 46:1198-202. [DOI: 10.1097/mlr.0b013e31817d69e8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Claessens P, Menten J, Schotsmans P, Broeckaert B. Palliative sedation: a review of the research literature. J Pain Symptom Manage 2008; 36:310-33. [PMID: 18657380 DOI: 10.1016/j.jpainsymman.2007.10.004] [Citation(s) in RCA: 184] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Revised: 10/23/2007] [Accepted: 10/26/2007] [Indexed: 11/27/2022]
Abstract
The overall aim of this paper is to systematically review the following important aspects of palliative sedation: prevalence, indications, survival, medication, food and fluid intake, decision making, attitudes of physicians, family experiences, and efficacy and safety. A thorough search of different databases was conducted for pertinent research articles published from 1966 to June 2007. The following keywords were used: end of life, sedation, terminal sedation, palliative sedation, refractory symptoms, and palliative care. Language of the articles was limited to English, French, German, and Dutch. Papers reporting solely on the sedatives used in palliative care, without explicitly reporting the prevalence or intensity of sedation, and papers not reporting on primary research (such as reviews or theoretical articles) were excluded. Methodological quality was assessed according to the criteria of Hawker et al. (2002). The search yielded 130 articles, 33.8% of which were peer-reviewed empirical research studies. Thirty-three research papers and one thesis were included in this systematic review. This review reveals that there still are many inconsistencies with regard to the prevalence, the effect of sedation, food and fluid intake, the possible life-shortening effect, and the decision-making process. Further research to clarify all of this should be based on multicenter, prospective, longitudinal, and international studies that use a uniform definition of palliative sedation, and valid and reliable instruments. Only through such research will it be possible to resolve some of the important ethical issues related to palliative sedation.
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Affiliation(s)
- Patricia Claessens
- Centre for Biomedical Ethics and Law, Catholic University of Leuven, Drongen, Belgium.
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Relieving pain and suffering does not hasten death. Crit Care Med 2008; 36:2486-7. [DOI: 10.1097/ccm.0b013e31817c478f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
PURPOSE OF REVIEW Palliative sedation, the conscious induction of sleep in patients with a very short life expectancy who suffer intractable physical and existential distress, may offer the patient and his or her relatives a more peaceful dying. This technique is still subject to several ethical and medical controversies justifying a review of the recent literature on this subject. RECENT FINDINGS The available evidence consists of few prospective trials and mainly retrospectively collected case reports. Two guidelines are published in the period under review. The most important points stressed in these reviews are the careful information exchange with the patient, if possible, and his or her proxies, a gradually increased sedation allowing respite if possible to evaluate the effect of the sedation and the need for consultation with colleagues, preferentially physicians experienced in palliative care. Stopping artificial nutrition and hydration is a medical decision that should be taken after evaluation of the potential side effects and consultation with the patient and relatives. SUMMARY Palliative sedation may be considered for terminally ill patients who suffer intractable symptoms. Ideally it should be included in the patient's trajectory that has been described and discussed earlier when the disease was judged to be incurable. The main goal is to offer comfort.
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Affiliation(s)
- Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University, Nijmegen, The Netherlands.
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Connor SR, Pyenson B, Fitch K, Spence C, Iwasaki K. Comparing hospice and nonhospice patient survival among patients who die within a three-year window. J Pain Symptom Manage 2007; 33:238-46. [PMID: 17349493 DOI: 10.1016/j.jpainsymman.2006.10.010] [Citation(s) in RCA: 271] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2006] [Revised: 10/11/2006] [Accepted: 10/13/2006] [Indexed: 11/30/2022]
Abstract
There is a widespread belief by some health care providers and the wider community that medications used to alleviate symptoms may hasten death in hospice patients. Conversely, there is a clinical impression among hospice providers that hospice might extend some patients' lives. We studied the difference of survival periods of terminally ill patients between those using hospices and not using hospices. We performed retrospective statistical analysis on selected cohorts from large paid claim databases of Medicare beneficiaries for five types of cancer and congestive heart failure (CHF) patients. We analyzed the survival of 4493 patients from a sample of 5% of the entire Medicare beneficiary population for 1998-2002 associated with six narrowly defined indicative markers. For the six patient populations combined, the mean survival was 29 days longer for hospice patients than for nonhospice patients. The mean survival period was also significantly longer for the hospice patients with CHF, lung cancer, pancreatic cancer, and marginally significant for colon cancer (P=0.08). Mean survival was not significantly different (statistically) for hospice vs. nonhospice patients with breast or prostate cancer. Across groups studied, hospice enrollment is not significantly associated with shorter survival, but for certain terminally ill patients, hospice is associated with longer survival times. The claims-based method used death within three years as a surrogate for a clinical judgment to recommend hospice, which means our findings apply to cases where a clinician is very sure the patient will die within three years, and it points to the need to validate these findings.
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Affiliation(s)
- Stephen R Connor
- National Hospice and Palliative Care Organization, Alexandria, Virginia 22314, USA.
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de Graeff A, Dean M. Palliative Sedation Therapy in the Last Weeks of Life: A Literature Review and Recommendations for Standards. J Palliat Med 2007; 10:67-85. [PMID: 17298256 DOI: 10.1089/jpm.2006.0139] [Citation(s) in RCA: 237] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
PURPOSE Palliative sedation therapy (PST) is a controversial issue. There is a need for internationally accepted definitions and standards. METHODS A systematic review of the literature was performed by an international panel of 29 palliative care experts. Draft papers were written on various topics concerning PST. This paper is a summary of the individual papers, written after two meetings and extensive e-mail discussions. RESULTS PST is defined as the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness, using appropriate drugs carefully titrated to the cessation of symptoms. The initial dose of sedatives should usually be small enough to maintain the patients' ability to communicate periodically. The team looking after the patient should have enough expertise and experience to judge the symptom as refractory. Advice from palliative care specialists is strongly recommended before initiating PST. In the case of continuous and deep PST, the disease should be irreversible and advanced, with death expected within hours to days. Midazolam should be considered first-line choice. The decision whether or not to withhold or withdraw hydration should be discussed separately. Hydration should be offered only if it is considered likely that the benefit will outweigh the harm. PST is distinct from euthanasia because (1) it has the intent to provide symptom relief, (2) it is a proportionate intervention, and (3) the death of the patient is not a criterion for success. PST and its outcome should be carefully monitored and documented. CONCLUSION When other treatments fail to relieve suffering in the imminently dying patient, PST is a valid palliative care option.
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Affiliation(s)
- Alexander de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, F.02.126 Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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