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Miranda R, Raemdonck E, Deliens L, Kaasa S, Zimmermann C, Rodin G, Robijn L, Lundeby T, Houbracken I, Beernaert K. Do cancer centres and palliative care wards routinely measure patients' quality of life? An international cross-sectional survey study. Support Care Cancer 2023; 31:499. [PMID: 37523097 DOI: 10.1007/s00520-023-07964-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE Routinely assessing quality of life (QoL) of patients with cancer is crucial for improving patient-centred cancer care. However, little is known about whether or how cancer centres assess QoL for clinical practice or for research purposes. Therefore, our study aimed to investigate if QoL data is collected and if so, how and for what purposes. METHOD We conducted a cross-sectional survey study among 32 cancer centres in Europe and Canada. Centre representatives identified persons who they judged to have sufficient insight into QoL data collections in their wards to complete the survey. Descriptive statistics were used to summarise the information on QoL assessment and documentation. RESULTS There were 20 (62.5%) responding cancer centres. In total, 30 questionnaires were completed, of which 13 were completed for cancer wards and 17 for palliative care wards. We found that 23.1% and 38.5% of the cancer wards routinely assessed QoL among inpatients and outpatients with cancer, respectively, whereas, in palliative care wards, 52.9% assessed QoL for outpatients with cancer and 70.6% for the inpatients. Wide variabilities were observed between the cancer centres in how, how often, when and which instruments they used to assess QoL. CONCLUSION A sizable proportion of the cancer wards, especially, and palliative care wards apparently does not routinely assess patients' QoL, and we found wide variabilities between the cancer centres in how they do it. To promote routine assessment of patients' QoL, we proposed several actions, such as addressing barriers to implementing patient-reported outcome measures through innovative e-health platforms.
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Affiliation(s)
- Rose Miranda
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Eveline Raemdonck
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lenzo Robijn
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Tonje Lundeby
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Isabelle Houbracken
- Laboratory of Medical and Molecular Oncology, Oncology Research Center, Vrije Universiteit Brussel, Brussels, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
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Morita T, Kawahara T, Stone P, Sykes N, Miccinesi G, Klein C, Stiel S, Hui D, Deliens L, Heijltjes MT, Mori M, Heckel M, Robijn L, Krishna L, Rietjens J. Intercountry and intracountry variations in opinions of palliative care specialist physicians in Germany, Italy, Japan and UK about continuous use of sedatives: an international cross-sectional survey. BMJ Open 2022; 12:e060489. [PMID: 35459681 PMCID: PMC9036469 DOI: 10.1136/bmjopen-2021-060489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To explore intercountry and intracountry differences in physician opinions about continuous use of sedatives (CUS), and factors associated with their approval of CUS. SETTINGS Secondary analysis of a questionnaire study. PARTICIPANTS Palliative care physicians in Germany (N=273), Italy (N=198), Japan (N=334) and the UK (N=111). PRIMARY AND SECONDARY OUTCOME MEASURES Physician approval for CUS in four situations, intention and treatment goal, how to use sedatives and beliefs about CUS. RESULTS There were no significant intercountry or intracountry differences in the degree of agreement with statements that (1) CUS is not necessary as suffering can always be relieved with other measures (mostly disagree); (2) intention of CUS is to alleviate suffering and (3) shortening the dying process is not intended. However, there were significant intercountry differences in agreement with statements that (1) CUS is acceptable for patients with longer survival or psychoexistential suffering; (2) decrease in consciousness is intended and (3) choice of neuroleptics or opioids. Acceptability of CUS for patients with longer survival or psychoexistential suffering and whether decrease in consciousness is intended also showed wide intracountry differences. Also, the proportion of physicians who agreed versus disagreed with the statement that CUS may not alleviate suffering adequately even in unresponsive patients, was approximately equal. Regression analyses revealed that both physician-related and country-related factors were independently associated with physicians' approval of CUS. CONCLUSION Variations in use of sedatives is due to both physician- and country-related factors, but palliative care physicians consistently agree on the value of sedatives to aid symptom control. Future research should focus on (1) whether sedatives should be used in patients with longer survival or with primarily psychoexistential suffering, (2) understanding physicians' intentions and treatment goals, (3) efficacy of different drugs and (4) understanding the actual experiences of patients receiving CUS.
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Affiliation(s)
- Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara Hospital, Hamamatsu, Shizuoka, Japan
| | - Takuya Kawahara
- Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nigel Sykes
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Guido Miccinesi
- Department of Oncological Network, Prevention and Research Institute-ISPRO, Firenze, Italy
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Nürnberg, Germany
| | - Stephanie Stiel
- Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, University of Texas, Austin, Texas, USA
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Madelon T Heijltjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Masanori Mori
- Palliative and Supportive care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Maria Heckel
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Lenzo Robijn
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Lalit Krishna
- The Division of Supportive and Palliative Care, National Cancer Center Singapore, National Cancer Center Singapore, Singapore
| | - Judith Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Heijltjes MT, Morita T, Mori M, Heckel M, Klein C, Stiel S, Miccinesi G, Deliens L, Robijn L, Stone P, Sykes N, Hui D, Krishna L, van Delden JJM, van der Heide A, Rietjens JAC. Physicians' Opinion and Practice With the Continuous Use of Sedatives in the Last Days of Life. J Pain Symptom Manage 2022; 63:78-87. [PMID: 34333097 DOI: 10.1016/j.jpainsymman.2021.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 11/18/2022]
Abstract
CONTEXT There are few international studies about the continuous use of sedatives (CUS) in the last days of life. OBJECTIVES We aim to describe the experiences and opinions regarding CUS of physicians caring for terminally ill patients in seven countries. METHODS Questionnaire study about practices and experiences with CUS in the last days of life among physicians caring for terminally ill patients in Belgium (n = 175), Germany (n = 546), Italy (n = 214), Japan (n = 513), the Netherlands (n = 829), United Kingdom (n = 114) and Singapore (n = 21). RESULTS The overall response rate was 22%. Of the respondents, 88-99% reported that they had clinical experience of CUS in the last 12 months. More than 90% of respondents indicated that they mostly used midazolam for sedation. The use of sedatives to relieve suffering in the last days of life was considered acceptable in cases of physical suffering (87%-99%). This percentage was lower but still substantial in cases of psycho-existential suffering in the absence of physical symptoms (45%-88%). These percentages were lower when the prognosis was at least several weeks (22%-66% for physical suffering and 5%-42% for psycho-existential suffering). Of the respondents, 10% or less agreed with the statement that CUS is unnecessary because suffering can be alleviated with other measures. A substantial proportion (41%-95%) agreed with the statement that a competent patient with severe suffering has the right to demand the use of sedatives in the last days of life. CONCLUSION Many respondents in our study considered CUS acceptable for the relief of physical and psycho-existential suffering in the last days of life. The acceptability was lower regarding CUS for psycho-existential suffering and regarding CUS for patients with a longer life expectancy.
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Affiliation(s)
- Madelon T Heijltjes
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care (M.T.H., J.J.M.V.D.), UMC Utrecht, Utrecht, The Netherlands.
| | - Tatsuya Morita
- Palliative and Supportive Care Division (T.M., M.M.), Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Masanori Mori
- Palliative and Supportive Care Division (T.M., M.M.), Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Maria Heckel
- Department of Palliative Medicine (M.H., C.K.), CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine (M.H., C.K.), CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stephanie Stiel
- Hannover Medical School (S.S.), Institute for General Practice and Palliative Care, Düsseldorf, Germany
| | - Guido Miccinesi
- Oncological network (G.M.), Prevention and Research Institute-ISPRO, Firenze, Italy
| | - Luc Deliens
- Vrije Universiteit Brussel (L.D.), Ixelles, Belgium
| | - Lenzo Robijn
- Department of Public Health and Primary Care (L.R.), Ghent University, Ghent, Belgium
| | - Patrick Stone
- Marie Curie Palliative Care Research Department (P.S., N.S.), University College London, London, United Kingdom
| | - Nigel Sykes
- Marie Curie Palliative Care Research Department (P.S., N.S.), University College London, London, United Kingdom
| | - David Hui
- MD Anderson Cancer Center (D.H.), University of Texas, Texas, USA
| | | | - Johannes J M van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care (M.T.H., J.J.M.V.D.), UMC Utrecht, Utrecht, The Netherlands
| | - Agnes van der Heide
- Erasmus MC (A.V.D.H., J.A.C.R.), University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Judith A C Rietjens
- Erasmus MC (A.V.D.H., J.A.C.R.), University Medical Center Rotterdam, Rotterdam, The Netherlands
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Vissers S, Robijn L, Dierickx S, Mortier F, Cohen J, Deliens L, Chambaere K. Control Measures for Continuous Deep Sedation Until Death: A Framing Analysis of the Views of Physicians. Qual Health Res 2021; 31:2390-2402. [PMID: 34617830 DOI: 10.1177/10497323211037648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Physicians have been subject to increasing external control to improve their medical practice, and scholars have theorized extensively about their opposition to such control. However, little empirical attention has been paid to the views and reasoning that lie behind this opposition. An in-depth understanding is necessary for enhancing the effectiveness and efficiency of external controls, and continuous deep sedation until death (CDS) is an interesting case in this regard. This study aims to explore how physicians frame control measures for CDS. We conducted 47 semi-structured interviews with Belgian physicians in 2019. A qualitative framing analysis was performed to analyze their views and reasoning. This study reveals that physicians approach CDS practice and control measures with different emphases. Controlling by mechanisms of professional self-regulation and state governance are put forward as appropriate means to improve CDS practice. Policymakers should take into consideration physicians' frames to develop sound control measures.
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Affiliation(s)
- Stijn Vissers
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Lenzo Robijn
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Sigrid Dierickx
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Freddy Mortier
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Bioethics Institute Ghent, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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Robijn L, Gijsberts MJ, Pype P, Rietjens J, Deliens L, Chambaere K. Continuous Palliative Sedation Until Death: The Development of a Practice Protocol for Nursing Homes. J Am Med Dir Assoc 2021; 22:1776.e1-1776.e7. [PMID: 33930319 DOI: 10.1016/j.jamda.2021.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Challenges inherent in the practice of continuous palliative sedation until death appear to be particularly pervasive in nursing homes. We aimed to develop a protocol to improve the quality of the practice in Belgian nursing homes. METHODS The development of the protocol was based on the Medical Research Council Framework and made use of the findings of a systematic review of existing improvement initiatives and focus groups with 71 health care professionals [palliative care physicians, general practitioners (GPs), and nursing home staff] identifying perceived barriers to the use of continuous palliative sedation until death in nursing homes. The protocol was then reviewed and refined by another 70 health care professionals (palliative care physicians, geriatricians, GPs, and nursing home staff) through 10 expert panels. RESULTS The final protocol was signed off by expert panels after 2 consultation rounds in which the remaining issues were ironed out. The protocol encompassed 7 sequential steps and is primarily focused on clarification of the medical and social situation, communication with all care providers involved and with the resident and/or relatives, the organization of care, the actual performance of continuous sedation, and the supporting of relatives and care providers during and after the procedure. Although consistent with existing guidelines, our protocol describes more comprehensively recommendations about coordination and collaboration practices in nursing homes as well as specific matters such as how to communicate with fellow residents and give them the opportunity to say goodbye in some way to the person who is dying. CONCLUSIONS AND IMPLICATIONS This study succeeded in developing a practice protocol for continuous palliative sedation until death adapted to the specific context of nursing homes. Before implementing it, future research should focus on developing profound implementation strategies and on thoroughly evaluating its effectiveness.
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Affiliation(s)
- Lenzo Robijn
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Public Health & Primary Care, Ghent University, Ghent, Belgium.
| | - Marie-Jose Gijsberts
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Peter Pype
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; Department of Public Health & Primary Care, Ghent University, Ghent, Belgium
| | - Judith Rietjens
- Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, the Netherlands
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Public Health & Primary Care, Ghent University, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Public Health & Primary Care, Ghent University, Ghent, Belgium
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Robijn L, Deliens L, Scherrens AL, Pauwels NS, Pype P, Rietjens J, Chambaere K. A systematic review of quality improvement initiatives for continuous sedation until death. Palliat Med 2021; 35:670-682. [PMID: 33722107 DOI: 10.1177/0269216321996990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Extensive debate surrounds the practice of continuous sedation until death within end-of-life care. AIM To provide insight into existing initiatives to support the practice of continuous sedation until death and assess their feasibility and effectiveness. DESIGN Systematic review and narrative synthesis, registered on PROSPERO (CRD42020149630). DATA SOURCES Records were searched through MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science from inception to April 16 2020. Peer-reviewed studies reporting original data on initiatives to support the practice of continuous sedation were included for review. RESULTS Twenty-one studies met the criteria and were included. Initiatives were focused on assessment tools of consciousness and discomfort (9), the use of guidelines and protocols (8), and expert consultation (3). All initiatives were reported as useful, acceptable, and feasible. Studies on the use of monitoring devices showed that a small proportion of patients were found to be awake, despite the patient being unresponsive according to the observer-based sedation scales. However, the wide range of values of these monitoring devices for comfortable and adequately sedated patients seems to hamper its overall implementation in daily clinical practice. Physicians reported changes in practice conform to guideline recommendations but the shift was modest at best. Expert consultation was regarded as supportive when sufficient expertise is lacking and helpful in avoiding possibly unnecessary sedations. CONCLUSIONS The reviewed initiatives may contribute to improvement of continuous sedation until death, though their evidence base is rather limited. More insight is needed into their feasibility, preconditions for effective implementation and impact in actual practice.
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Affiliation(s)
- Lenzo Robijn
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Luc Deliens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Anne-Lore Scherrens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Nele S Pauwels
- Ghent University, Knowledge Management Center Ghent, Ghent, Belgium
| | - Peter Pype
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Judith Rietjens
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Kenneth Chambaere
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
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Robijn L, Deliens L, Rietjens J, Pype P, Chambaere K. Barriers in the Decision Making About and Performance of Continuous Sedation Until Death in Nursing Homes. Gerontologist 2020; 60:916-925. [PMID: 31850500 DOI: 10.1093/geront/gnz165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES While decision making about and performance of continuous sedation involve many challenges, they appear to be particularly pervasive in nursing homes. This study aims to identify barriers to the decision making and performance of continuous sedation until death in Flemish nursing homes as experienced by the health care professionals involved. RESEARCH DESIGN AND METHODS Ten focus groups were held with 71 health care professionals including 16 palliative care physicians, 42 general practitioners, and 13 nursing home staff. Discussions were transcribed verbatim and analyzed using a constant comparative approach. RESULTS Perceived barriers concerned factors prior to and during sedation and were classified according to three types: (a) personal barriers related to knowledge and skills including the lack of clarity on what continuous sedation should be used for (linguistic ambiguity) and when and how it should be used (practical ambiguity); (b) relational barriers concerning communication and collaboration both between health care professionals and with family; (c) organizational barriers related to the organization of care in nursing homes where, for example, there is no on-site physician, or where the recommended medication is not always available. DISCUSSION AND IMPLICATIONS The findings suggest there are considerable challenges for sound decision making about and performance of continuous sedation until death in nursing homes. There is a need for multicomponent initiatives that provide guidance in the context of the complexity of a resident's medical situation, the family, and the specific organization of care, which would have the potential to facilitate and improve the decision-making process and performance of continuous sedation in nursing homes.
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Affiliation(s)
- Lenzo Robijn
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Judith Rietjens
- Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, the Netherlands
| | - Peter Pype
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
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8
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Robijn L, Seymour J, Deliens L, Korfage I, Brown J, Pype P, Van Der Heide A, Chambaere K, Rietjens J. The involvement of cancer patients in the four stages of decision-making preceding continuous sedation until death: A qualitative study. Palliat Med 2018; 32:1198-1207. [PMID: 29667509 DOI: 10.1177/0269216318770342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Involving patients in decision-making is considered to be particularly appropriate towards the end of life. Professional guidelines emphasize that the decision to initiate continuous sedation should be made in accordance with the wishes of the dying person and be preceded by their consent. AIM To describe the decision-making process preceding continuous sedation until death with particular attention to the involvement of the person who is dying. DESIGN Qualitative case studies using interviews. SETTING/PARTICIPANTS Interviews with 26 physicians, 30 nurses and 24 relatives caring for 24 patients with cancer who received continuous sedation until death in Belgium, the United Kingdom and the Netherlands. RESULTS We distinguished four stages of decision-making: initiation, information exchange, deliberation and the decision to start continuous sedation until death. There was wide variation in the role the patient had in the decision-making process. At one end of the spectrum (mostly in the United Kingdom), the physician discussed the possible use of sedation with the patient, but took the decision themselves. At the other end (mostly in Belgium and the Netherlands), the patient initiated the conversation and the physician's role was largely limited to evaluating if and when the medical criteria were met. CONCLUSION Decision-making about continuous sedation until death goes through four stages and the involvement of the patient in the decision-making varies. Acknowledging the potential sensitivity of raising the issue of end-of-life sedation, we recommend building into clinical practice regular opportunities to discuss the goals and preferences of the person who is dying for their future medical treatment and care.
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Affiliation(s)
- Lenzo Robijn
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Jane Seymour
- 3 The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Luc Deliens
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Ida Korfage
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
| | - Jayne Brown
- 5 School of Nursing and Midwifery, De Montfort University, Leicester, UK.,6 Centre for the Promotion of Excellence in Palliative Care, De Montfort University, Leicester, UK
| | - Peter Pype
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,7 Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Agnes Van Der Heide
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
| | - Kenneth Chambaere
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Judith Rietjens
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
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Scherrens AL, Beernaert K, Robijn L, Deliens L, Pauwels NS, Cohen J, Deforche B. The use of behavioural theories in end-of-life care research: A systematic review. Palliat Med 2018; 32:1055-1077. [PMID: 29569998 DOI: 10.1177/0269216318758212] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: It is necessary to understand behaviours that contribute to improvement in the quality of end-of-life care; use of behavioural theories allows identification of factors underlying end-of-life care behaviour, but little is known about the extent to which, and in what manner, these theories are used in an end-of-life care research context. Aim: To assess the number of end-of-life care studies that have used behavioural theories, which theories were used, to what extent main constructs were explored/measured and which behavioural outcomes were examined. Design: We conducted a systematic review. The protocol was registered on PROSPERO (CRD42016036009). Data sources: The MEDLINE (PubMed), PsycINFO, EMBASE, Web of Science and CINAHL databases were searched from inception to June 2017. We included studies aimed at understanding or changing end-of-life care behaviours and that explicitly referred to individual behavioural theories. Results: We screened 2231 records by title and abstract, retrieved 43 full-text articles and included 31 studies – 27 quantitative (of which four (quasi-)randomised controlled trials) and four qualitative – for data extraction. More than half used the Theory of Planned Behaviour (9), the Theory of Reasoned Action (4) or the Transtheoretical Model (8). In 9 of 31 studies, the theory was fully used, and 16 of the 31 studies focussed on behaviours in advance care planning. Conclusion: In end-of-life care research, the use of behavioural theories is limited. As many behaviours can determine the quality of care, their more extensive use may be warranted if we want to better understand and influence behaviours and improve end-of-life care.
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Affiliation(s)
- Anne-Lore Scherrens
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,2 Health Education and Promotion Research Group, Department of Public Health, Ghent University, Ghent, Belgium
| | - Kim Beernaert
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,3 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Lenzo Robijn
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,3 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Luc Deliens
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,3 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Nele S Pauwels
- 4 Knowledge Centre for Health Ghent, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium
| | - Benedicte Deforche
- 2 Health Education and Promotion Research Group, Department of Public Health, Ghent University, Ghent, Belgium
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Abarshi E, Rietjens J, Robijn L, Caraceni A, Payne S, Deliens L, Van den Block L. International variations in clinical practice guidelines for palliative sedation: a systematic review. BMJ Support Palliat Care 2017; 7:223-229. [PMID: 28432090 DOI: 10.1136/bmjspcare-2016-001159] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 01/09/2017] [Accepted: 04/01/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Palliative sedation is a highly debated medical practice, particularly regarding its proper use in end-of-life care. Worldwide, guidelines are used to standardise care and regulate this practice. In this review, we identify and compare national/regional clinical practice guidelines on palliative sedation against the European Association for Palliative Care (EAPC) palliative sedation Framework and assess the developmental quality of these guidelines using the Appraisal Guideline Research and Evaluation (AGREE II) instrument. METHODS Using the PRISMA criteria, we searched multiple databases (PubMed, CancerLit, CINAHL, Cochrane Library, NHS Evidence and Google Scholar) for relevant guidelines, and selected those written in English, Dutch and Italian; published between January 2000 and March 2016. RESULTS Of 264 hits, 13 guidelines-Belgium, Canada (3), Ireland, Italy, Japan, the Netherlands, Norway, Spain, Europe, and USA (2) were selected. 8 contained at least 9/10 recommendations published in the EAPC Framework; 9 recommended 'pre-emptive discussion of the potential role of sedation in end-of-life care'; 9 recommended 'nutrition/hydration while performing sedation' and 8 acknowledged the need to 'care for the medical team'. There were striking differences in terminologies used and in life expectancy preceding the practice. Selected guidelines were conceptually similar, comparing closely to the EAPC Framework recommendations, albeit with notable variations. CONCLUSIONS Based on AGREE II, 3 guidelines achieved top scores and could therefore be recommended for use in this context. Also, domains 'scope and purpose' and 'editorial independence' ranked highest and lowest, respectively-underscoring the importance of good reportage at the developmental stage.
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Affiliation(s)
- Ebun Abarshi
- International Observatory on End-of-Life Care, Lancaster, United Kingdom
| | - Judith Rietjens
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands.,End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Lenzo Robijn
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Augusto Caraceni
- Fondazione IRCCS Instituto Nazionale dei Tumori, Milan, Italy.,European Palliative Care Research Center, Norwegian University of Science and Technology Trondheim Norway, EAPC Research Network
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster, United Kingdom
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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11
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Robijn L, Cohen J, Rietjens J, Deliens L, Chambaere K. Trends in Continuous Deep Sedation until Death between 2007 and 2013: A Repeated Nationwide Survey. PLoS One 2016; 11:e0158188. [PMID: 27337064 PMCID: PMC4918927 DOI: 10.1371/journal.pone.0158188] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 06/10/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuous deep sedation until death is a highly debated medical practice, particularly regarding its potential to hasten death and its proper use in end-of-life care. A thorough analysis of important trends in this practice is needed to identify potentially problematic developments. This study aims to examine trends in the prevalence and practice characteristics of continuous deep sedation until death in Flanders, Belgium between 2007 and 2013, and to study variation on physicians' degree of palliative training. METHODS Population-based death certificate study in 2007 and 2013 in Flanders, Belgium. Reporting physicians received questionnaires about medical practices preceding the patient's death. Patient characteristics, clinical characteristics (drugs used, duration, artificial nutrition/hydration, intention and consent), and palliative care training of attending physician were recorded. We posed the following question regarding continuous deep sedation: 'Was the patient continuously and deeply sedated or kept in a coma until death by the use of one or more drugs'. RESULTS After the initial rise of continuous deep sedation to 14.5% in 2007 (95%CI 13.1%-15.9%), its use decreased to 12.0% in 2013 (95%CI 10.9%-13.2%). Compared with 2007, in 2013 opioids were less often used as sole drug and the decision to use continuous deep sedation was more often preceded by patient request. Compared to non-experts, palliative care experts more often used benzodiazepines and less often opioids, withheld artificial nutrition/hydration more often and performed sedation more often after a request from or with the consent of the patient or family. CONCLUSION Worldwide, this study is the first to show a decrease in the prevalence of continuous deep sedation. Despite positive changes in performance and decision-making towards more compliance with due care requirements, there is still room for improvement in the use of recommended drugs and in the involvement of patients and relatives in the decision-making process.
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Affiliation(s)
- Lenzo Robijn
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Judith Rietjens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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Robijn L, Chambaere K, Raus K, Rietjens J, Deliens L. Reasons for continuous sedation until death in cancer patients: a qualitative interview study. Eur J Cancer Care (Engl) 2015; 26. [PMID: 26515814 DOI: 10.1111/ecc.12405] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 11/28/2022]
Abstract
End-of-life sedation, though increasingly prevalent and widespread, remains a highly debated medical practice in the context of palliative medicine. This qualitative study aims to look more specifically at how health care workers justify their use of continuous sedation until death and which factors they report as playing a part in the decision-making process. In-depth interviews were held with 28 physicians and 22 nurses of 27 cancer patients in Belgium who had received continuous sedation until death in hospitals, palliative care units or at home. Our findings indicate that medical decision-making for continuous sedation is not only based on clinical indications but also related to morally complex issues such as the social context and the personal characteristics and preferences of individual patient and their relatives. The complex role of non-clinical factors in palliative sedation decision-making needs to be further studied to assess which medically or ethically relevant arguments are underlying daily clinical practice. Finally, our findings suggest that in some cases continuous sedation was resorted to as an alternative option at the end of life when euthanasia, a legally regulated option in Belgium, was no longer practically possible.
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Affiliation(s)
- L Robijn
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - K Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - K Raus
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Bioethics Institute Ghent, Department of Philosophy and Moral Science, Ghent University, Ghent, Belgium
| | - J Rietjens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - L Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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13
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Chambaere K, Cohen J, Robijn L, Bailey SK, Deliens L. End-of-Life Decisions in Individuals Dying with Dementia in Belgium. J Am Geriatr Soc 2015; 63:290-6. [DOI: 10.1111/jgs.13255] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kenneth Chambaere
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) and Ghent University; Brussels Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) and Ghent University; Brussels Belgium
| | - Lenzo Robijn
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) and Ghent University; Brussels Belgium
| | - S. Kathleen Bailey
- Department of Psychology; Lakehead University; Thunder Bay Ontario Canada
| | - Luc Deliens
- End-of-Life Care Research Group; Vrije Universiteit Brussel (VUB) and Ghent University; Brussels Belgium
- Ghent University Hospital; Ghent Belgium
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Bilsen J, Robijn L, Chambaere K, Cohen J, Deliens L. Nurses’ involvement in physician-assisted dying under the euthanasia law in Belgium. Int J Nurs Stud 2014; 51:1696-7. [DOI: 10.1016/j.ijnurstu.2014.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 05/20/2014] [Indexed: 10/25/2022]
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Affiliation(s)
- Judith A C Rietjens
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Lenzo Robijn
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Agnes van der Heide
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
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