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Brennan F. ‘To die with dignity’: an update on Palliative Care. Intern Med J 2017; 47:865-871. [DOI: 10.1111/imj.13520] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 02/06/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Frank Brennan
- Palliative Care; Calvary Hospital; Sydney New South Wales Australia
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52
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Wang DH. Beyond Code Status: Palliative Care Begins in the Emergency Department. Ann Emerg Med 2017; 69:437-443. [DOI: 10.1016/j.annemergmed.2016.10.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Indexed: 11/29/2022]
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53
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Sheahan L. Exploring the interface between 'physician-assisted death' and palliative care: cross-sectional data from Australasian palliative care specialists. Intern Med J 2017; 46:443-51. [PMID: 26762669 DOI: 10.1111/imj.13009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 12/10/2015] [Accepted: 12/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Legalisation of physician-assisted dying (PAD) remains a highly contested issue. In the Australasian context, the opinion and perspective of palliative care specialists have not been captured empirically, and are required to inform better the debate around this issue, moving forward. AIM To identify current attitudes and experiences of palliative care specialists in Australasia regarding requests for physician-assisted suicide and voluntary euthanasia, and to capture the opinion of palliative care specialists on the legalisation of these practices in the Australasian context. METHOD An anonymous, cross-sectional, online survey of Australasian specialists in palliative care, addressing the following six areas: (i) demographics; (ii) frequency of requests, and response given; (iii) understanding of the term 'voluntary euthanasia'; (iv) opinion regarding legalisation of physician-assisted suicide and voluntary euthanasia in Australasia, and willingness to participate if legal; (v) identification of the most important values guiding this opinion; and (vi) anticipated impact that legalisation of assisted death would have on palliative care practice. RESULTS Important findings include: (i) palliative care specialists are largely opposed to the legalisation of PAD; (ii) the proportional titration of opioids is not understood by any palliative care specialist studied to be 'voluntary euthanasia'; and (iii) there is a wide variation in frequency of requests, and one-third of palliative care specialists express discomfort in dealing with requests for assisted suicide or euthanasia. CONCLUSION Key areas for future research at the interface between PAD and best practice end-of-life care are identified, including exploration into why palliative care specialists are largely opposed to PAD, and consideration of the impact 'the opioid misconception' may have on the literature informing this debate.
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Affiliation(s)
- L Sheahan
- St George and Calvary Hospitals, Sydney, New South Wales, Australia.,Centre for Values Ethics and the Law in Medicine, University of Sydney, Sydney, New South Wales, Australia.,Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada.,School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Giles A, Sykes N. To explore the relationship between the use of midazolam and cessation of oral intake in the terminal phase of hospice inpatients: A retrospective case note review: Does midazolam affect oral intake in the dying? Palliat Med 2017; 31:89-92. [PMID: 27247086 DOI: 10.1177/0269216316647207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Sedative drugs are used to improve comfort in dying patients but have been accused of shortening survival by reducing patients' ability to maintain nutrition and hydration. However, as part of the dying process, patients in the last days of life often have impaired conscious levels and an inability to maintain oral intake. AIM To establish whether the decline in oral intake is related to the use of midazolam in the last week of life. DESIGN This is a retrospective case note review. SETTING/PARTICIPANTS The data were obtained from nursing records and medication charts of 125 consecutive hospice inpatients who died at a hospice in South London. RESULTS A total of 72 patients received midazolam on one or more days within the last 7 days of life (midazolam group) and 49 patients received no midazolam (control group). CONCLUSION Mean oral intake was reduced 7 days prior to death and declined sequentially over subsequent days in both patient groups. More patients required midazolam as death approached and most patients received midazolam for less than 3 days. Mean doses of midazolam used were low. Patients in the midazolam group had lower oral intake than those in the control group, but this association does not indicate causation.
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Sathornviriyapong A, Nagaviroj K, Anothaisintawee T. The association between different opioid doses and the survival of advanced cancer patients receiving palliative care. BMC Palliat Care 2016; 15:95. [PMID: 27871265 PMCID: PMC5117570 DOI: 10.1186/s12904-016-0169-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 11/15/2016] [Indexed: 11/16/2022] Open
Abstract
Background Concerns that opioids may hasten death can be a cause of the physicians’ reluctance to prescribe opioids, leading to inadequate symptom palliation. Our aim was to find if there was an association between different opioid doses and the survival of the cancer patients that participated in our palliative care program. Methods A retrospective study was conducted at Ramathibodi Hospital, Bangkok between January 2013 and December 2015. All of the cancer patients that were referred to palliative care teams by their primary physicians were included in the study. The study data included the patients’ demographics, disease status, comorbidities, functional status, type of services, cancer treatments, date of consultation, and the date of the patient’s death or last follow-up. The information concerning opioid use was collected by reviewing the medical records and this was converted to an oral morphine equivalent (OME), following a standard ratio. The time-varying covariate in the Cox regression analysis was applied in order to determine the association between different doses of opioids and patient survival. Results A total of 317 cancer patients were included in the study. The median (IQR) of the OME among our patients was 6.43 mg/day (0.53, 27.36). The univariate Cox regression analysis did not show any association between different opioid doses (OME ≤ 30 mg/day and > 30 mg/day) and the patients’ survival (p = 0.52). The PPS levels (p < 0.01), palliative care clinic visits (HR 0.32, 95%CI 0.24–0.43), home visits (HR 0.75, 95%CI 0.57–0.99), chemotherapy (HR 0.32, 95%CI 0.22–0.46), and radiotherapy (HR 0.53, 95%CI 0.36–0.78) were identified as factors that increased the probability of survival. Conclusions Our study has demonstrated that different opioid doses in advanced cancer patients are not associated with shortened survival period.
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Affiliation(s)
- Anon Sathornviriyapong
- Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Street, Rajthevi, Bangkok, 10400, Thailand
| | - Kittiphon Nagaviroj
- Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Street, Rajthevi, Bangkok, 10400, Thailand.
| | - Thunyarat Anothaisintawee
- Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Street, Rajthevi, Bangkok, 10400, Thailand
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56
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Fruhwald S, Pollesello P, Fruhwald F. Advanced heart failure: an appraisal of the potential of levosimendan in this end-stage scenario and some related ethical considerations. Expert Rev Cardiovasc Ther 2016; 14:1335-1347. [PMID: 27778514 DOI: 10.1080/14779072.2016.1247694] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The later stages of heart failure are characterized by a steady decline in quality of life. Clinical priorities should be to maintain functional capacity and quality of life. In the absence of sufficient organs for transplantation, options include left ventricular assist devices and inotropic support. Areas covered: We examined data published in the last two decades on the use of inotropes and inodilators in advanced heart failure. Expert commentary: In the literature, use of conventional inotropes, including adrenergic agonists and phosphodiesterase inhibitors, appears to be suboptimal for achieving the clinical priorities of late-stage heart failure. Evidence suggests instead that the calcium-sensitizing inodilator levosimendan, administered intermittently, delivers improvements in functional capacity and quality of life and does so with no adverse impact on life expectancy. At a terminal or near-terminal stage of heart failure, the therapeutic philosophy should shift towards meeting patients' existential priorities rather than traditional heart failure-centric targets.
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Affiliation(s)
- Sonja Fruhwald
- a Department of Anesthesiology and Intensive Care Medicine, Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine , Medical University of Graz , Graz , Austria
| | - Piero Pollesello
- b Critical Care Proprietary Products , Orion Pharma , Espoo , Finland
| | - Friedrich Fruhwald
- c Department of Internal Medicine, Division of Cardiology , Medical University of Graz , Graz , Austria
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57
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Chao YS, Boivin A, Marcoux I, Garnon G, Mays N, Lehoux P, Prémont MC, Leeuwen EV, Pineault R. International changes in end-of-life practices over time: a systematic review. BMC Health Serv Res 2016; 16:539. [PMID: 27716238 PMCID: PMC5048435 DOI: 10.1186/s12913-016-1749-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/29/2016] [Indexed: 11/10/2022] Open
Abstract
Background End-of-life policies are hotly debated in many countries, with international evidence frequently used to support or oppose legal reforms. Existing reviews are limited by their focus on specific practices or selected jurisdictions. The objective is to review international time trends in end-of-life practices. Methods We conducted a systematic review of empirical studies on medical end-of-life practices, including treatment withdrawal, the use of drugs for symptom management, and the intentional use of lethal drugs. A search strategy was conducted in MEDLINE, EMBASE, Web of Science, Sociological Abstracts, PAIS International, Worldwide Political Science Abstracts, International Bibliography of the Social Sciences and CINAHL. We included studies that described physicians’ actual practices and estimated annual frequency at the jurisdictional level. End-of-life practice frequencies were analyzed for variations over time, using logit regression. Results Among 8183 references, 39 jurisdiction-wide surveys conducted between 1990 and 2010 were identified. Of those, 22 surveys used sufficiently similar research methods to allow further statistical analysis. Significant differences were found across surveys in the frequency of treatment withdrawal, use of opiates or sedatives and the intentional use of lethal drugs (X2 > 1000, p < 0.001 for all). Regression analyses showed increased use of opiates and sedatives over time (p < 0.001), which could reflect more intense symptom management at the end of life, or increase in these drugs to intentionally cause patients’ death. Conclusion The use of opiates and sedatives appears to have significantly increased over time between 1990 and 2010. Better distinction between practices with different legal status is required to properly interpret the policy significance of these changes. Research on the effects of public policies should take a comprehensive look at trends in end-of-life practice patterns and their associations with policy changes.
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Affiliation(s)
- Yi-Sheng Chao
- University of Montreal Hospital Centre Research Centre (CRCHUM), Montreal, Canada
| | - Antoine Boivin
- University of Montreal Hospital Centre Research Centre (CRCHUM), Montreal, Canada. .,Institut de recherche en santé publique de l'Université de Montréal, Montréal, Canada.
| | - Isabelle Marcoux
- Interdisciplinary School of Health Science, University of Ottawa, Ottawa, Canada
| | | | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Pascale Lehoux
- Département d'administration de la santé, Université de Montréal, Montreal, Canada
| | | | - Evert van Leeuwen
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Raynald Pineault
- Département de santé publique de Montréal, Institut National de Santé Publique du Québec, Montreal, Canada
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58
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Materstvedt LJ, Magelssen M. Medical murder in Belgium and the Netherlands. JOURNAL OF MEDICAL ETHICS 2016; 42:621-624. [PMID: 27114470 DOI: 10.1136/medethics-2015-103128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 03/31/2016] [Indexed: 06/05/2023]
Abstract
This article is a response to Raphael Cohen-Almagor's paper entitled 'First do no harm: intentionally shortening lives of patients without their explicit request in Belgium'. His paper deals with very important matters of life and death, however its concept usage is in part misleading. For instance, the fact that medical murder takes place both in Belgium and the Netherlands is missed. Cohen-Almagor calls such acts 'worrying' and considers them to be 'abuse'. However, it remains an open question whether or not there can be such a thing as legitimate murder in a medical context. From the combined perspectives of justice and the duty to end unbearable suffering, there might be. Thus, key arguments for euthanasia are also prominent in an argument for medical murder.
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Affiliation(s)
- Lars Johan Materstvedt
- Department of Philosophy and Religious Studies, Faculty of Humanities, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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59
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Abstract
Despite advances in the detection, pathological diagnosis and therapeutics of lung cancer, many patients still develop advanced, incurable and progressively fatal disease. As physicians, the duties to cure sometimes, relieve often and comfort always should be a constant reminder to us of the needs that must be met when caring for a patient with lung cancer. Four key areas of end-of-life care in advanced lung cancer begin with first recognizing 'when a patient is approaching the end of life'. The clinician should be able to recognize when the focus of care needs to shift from an aggressive life-sustaining approach to an approach that helps prepare and support a patient and family members through a period of progressive, inevitable decline. Once the needs are recognized, the second key area is appropriate communication, where the clinician should assist patients and family members in understanding where they are in the disease trajectory and what to expect. This involves developing rapport, breaking bad news, managing expectations and navigating care plans. Subsequently, the third key area is symptom management that focuses on the goals to first and foremost provide comfort and dignity. Symptoms that are common towards the end of life in lung cancer include pain, dyspnoea, delirium and respiratory secretions. Such symptoms need to be anticipated and addressed promptly with appropriate medications and explanations to the patient and family. Lastly, in order for physicians to provide quality end-of-life care, it is necessary to understand the ethical principles applied to end-of-life-care interventions. Misconceptions about euthanasia versus withholding or withdrawing life-sustaining treatments may lead to physician distress and inappropriate decision making.
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Affiliation(s)
- Richard B L Lim
- Department of Palliative Medicine, Hospital Selayang, Lebuhraya Selayang-Kepong, 68100 Batu Caves, Selangor Darul Ehsan, Malaysia
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60
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Gonçalves F, Almeida A, Pereira S. A Protocol for the Control of Agitation in Palliative Care. Am J Hosp Palliat Care 2016; 33:948-951. [DOI: 10.1177/1049909115598929] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Agitation is a distressing and dangerous behavior for all involved. Objective: To study a protocol effectiveness and safety. Methods: The time when the protocol was initiated and when the agitation was controlled, the number of doses needed and the complications observed were recorded. Results: One hundred and thirty-five inpatients of a palliative care service were included. The most frequent diagnosis was head and neck cancer, 37 (27%). The protocol was used 584 times, from 1 to 31 times on each patient, median of 3 times. Five hundred and thirty-four (91%) agitation episodes were controlled with only the first dose of the protocol, without significant complications. Conclusion: From those results, it can be said that this protocol is effective and safe.
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Affiliation(s)
| | - Ana Almeida
- Portuguese Institute of Oncology, Porto, Portugal
| | - Sara Pereira
- Portuguese Institute of Oncology, Porto, Portugal
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Soh TLGB, Krishna LKR, Sim SW, Yee ACP. Distancing sedation in end-of-life care from physician-assisted suicide and euthanasia. Singapore Med J 2016; 57:220-7. [PMID: 27211055 DOI: 10.11622/smedj.2016086] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Lipuma equates continuous sedation until death (CSD) to physician-assisted suicide/euthanasia (PAS/E) based on the premise that iatrogenic unconsciousness negates social function and, thus, personhood, leaving a patient effectively 'dead'. Others have extrapolated upon this position further, to suggest that any use of sedation and/or opioids at the end of life would be analogous to CSD and thus tantamount to PAS/E. These posits sit diametrically opposite to standard end-of-life care practices. This paper will refute Lipuma's position and the posits borne from it. We first show that prevailing end-of-life care guidelines require proportional and monitored use of sedatives and/or opioids to attenuate fears that the use of such treatment could hasten death. These guidelines also classify CSD as a last resort treatment, employed only when symptoms prove intractable, and not amenable to all standard treatment options. Furthermore, CSD is applied only when deemed appropriate by a multidisciplinary palliative medicine team. We also show that empirical data based on local views of personhood will discount concerns that iatrogenic unconsciousness is tantamount to a loss of personhood and death.
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Affiliation(s)
- Tze Ling Gwendoline Beatrice Soh
- Division of Palliative Medicine, National Cancer Centre, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | - Lalit Kumar Radha Krishna
- Division of Palliative Medicine, National Cancer Centre, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore.,Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shin Wei Sim
- Division of Palliative Medicine, National Cancer Centre, Singapore
| | - Alethea Chung Peng Yee
- Division of Palliative Medicine, National Cancer Centre, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
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62
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Schur S, Weixler D, Gabl C, Kreye G, Likar R, Masel EK, Mayrhofer M, Reiner F, Schmidmayr B, Kirchheiner K, Watzke HH. Sedation at the end of life - a nation-wide study in palliative care units in Austria. BMC Palliat Care 2016; 15:50. [PMID: 27180238 PMCID: PMC4868021 DOI: 10.1186/s12904-016-0121-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 05/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sedation is used to an increasing extent in end-of-life care. Definitions and indications in this field are based on expert opinions and case series. Little is known about this practice at palliative care units in Austria. METHODS Patients who died in Austrian palliative care units between June 2012 and June 2013 were identified. A predefined set of baseline characteristics and information on sedation during the last two weeks before death were obtained by reviewing the patients' charts. RESULTS The data of 2414 patients from 23 palliative care units were available for analysis. Five hundred two (21 %) patients received sedation in the last two weeks preceding their death, 356 (71 %) received continuous sedation until death, and 119 (24 %) received intermittent sedation. The median duration of sedation was 48 h (IQR 10-72 h); 168 patients (34 %) were sedated for less than 24 h. Indications for sedation were delirium (51 %), existential distress (32 %), dyspnea (30 %), and pain (20 %). Midazolam was the most frequently used drug (79 %), followed by lorazepam (13 %), and haloperidol (10 %). Sedated patients were significantly younger (median age 67 years vs. 74 years, p ≤ 0.001, r = 0.22), suffered more often from an oncological disease (92 % vs. 82 %, p ≤ 0.001, φ = 0.107), and were hospitalized more frequently (94 % vs. 76 %, p ≤ 0.001, φ = 0.175). The median number of days between admission to a palliative care ward/mobile palliative care team and death did not differ significantly in sedated versus non-sedated patients (10 vs. 9 days; p = 0.491). CONCLUSION This study provides insights into the practice of end-of-life sedation in Austria. Critical appraisal of these data will serve as a starting point for the development of nation-wide guidelines for palliative sedation in Austria.
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Affiliation(s)
- Sophie Schur
- Clinical Division of Palliative Care, Department for Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | | | - Christoph Gabl
- Mobile Hospice and Palliative Care Team, Tiroler Hospizgemeinschaft, Innsbruck, Austria
| | - Gudrun Kreye
- Department of Internal Medicine, University Hospital Krems, Krems, Austria
| | - Rudolf Likar
- Department of Anaesthesiology and Intensive Medicine, Interdisciplinary Center of Pain Therapy and Palliative Medicine, General Hospital Klagenfurt, Klagenfurt, Austria
| | - Eva Katharina Masel
- Clinical Division of Palliative Care, Department for Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Michael Mayrhofer
- Clinical Division of Palliative Care, Department for Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Franz Reiner
- Department for Palliative Care, Salzkammergut-Klinikum, Vöcklabruck, Austria
| | - Barbara Schmidmayr
- Department of Internal Medicine, Krankenhaus der Elisabethinen, Graz, Austria
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Herbert Hans Watzke
- Clinical Division of Palliative Care, Department for Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Douglas C, Clarke M, Alexander S, Khatun M. A tertiary hospital audit of opioids and sedatives administered in the last 24 h of life. Intern Med J 2016; 46:325-31. [DOI: 10.1111/imj.12985] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 12/04/2015] [Accepted: 12/15/2015] [Indexed: 11/28/2022]
Affiliation(s)
- C. Douglas
- Palliative and Supportive Care Service; Brisbane Queensland Australia
| | - M. Clarke
- Internal Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - S. Alexander
- Internal Medicine; Rockhampton Hospital; Rockhampton Queensland Australia
| | - M. Khatun
- School of Public Health; University of Queensland; Brisbane Queensland Australia
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64
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Bidet G, Daoust L, Duval M, Ducruet T, Toledano B, Humbert N, Gauvin F. An Order Protocol for Respiratory Distress/Acute Pain Crisis in Pediatric Palliative Care Patients: Medical and Nursing Staff Perceptions. J Palliat Med 2016; 19:306-13. [PMID: 26788836 DOI: 10.1089/jpm.2015.0100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND An order protocol for distress (OPD), including respiratory distress and acute pain crisis, has been established for pediatric palliative care patients at Sainte-Justine Hospital (SJH). After discussion with the patient/his or her family, the OPD is prescribed by the attending physician whenever judged appropriate. The OPD can then be initiated by the bedside nurse when necessary; the physician is notified after the first dose is administered. OBJECTIVES The study objectives were to evaluate the perceptions and experience of the medical/nursing staff towards the use of the OPD. METHODS A survey was distributed to all physicians/nurses working on wards with pediatric palliative care patients. Answers to the survey were anonymous, done on a voluntary basis, and after consent of the participant. RESULTS Surveys (258/548) were answered corresponding to a response rate of 47%. According to the respondents, the most important motivations in using the OPD were the desire to relieve patient's distress and the speed of relief of distress by the OPD; the most important obstacles were going against the patient's/his or her family's wishes and fear of hastening death. The respondents reported that the OPD was frequently (56%) or always (36%) effective in relieving the patient's distress. The respondents felt sometimes (16%), frequently (34%), or always (41%) comfortable in giving the OPD. They thought the OPD could never (12%), rarely (32%), sometimes (46%), frequently (8%), or always (1%) hasten death. Physicians were less favorable than nurses with the autonomy of bedside nurses to initiate the OPD before notifying the physician (p = 0.04). Overall, 95% of respondents considered that they would use the OPD in the future. CONCLUSIONS Data from this survey shows that respondents are in favor of using the OPD at SJH and find it effective. Further training as well as support for health care professionals are mandatory in such palliative care settings.
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Affiliation(s)
- Gwenaëlle Bidet
- 1 Palliative Care Unit, Department of Pediatrics, Sainte-Justine Hospital , Montréal, Québec, Canada
| | - Lysanne Daoust
- 1 Palliative Care Unit, Department of Pediatrics, Sainte-Justine Hospital , Montréal, Québec, Canada
| | - Michel Duval
- 2 Hemato-Oncology Service, Department of Pediatrics, Sainte-Justine Hospital , Montréal, Québec, Canada
| | - Thierry Ducruet
- 3 Applied Clinical Research Unit, Department of Pediatrics, Sainte-Justine Hospital , Montréal, Québec, Canada
| | - Baruch Toledano
- 4 Pediatric Critical Care Unit, Department of Pediatrics, Sainte-Justine Hospital , Montréal, Québec, Canada
| | - Nago Humbert
- 1 Palliative Care Unit, Department of Pediatrics, Sainte-Justine Hospital , Montréal, Québec, Canada
| | - France Gauvin
- 1 Palliative Care Unit, Department of Pediatrics, Sainte-Justine Hospital , Montréal, Québec, Canada
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65
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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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66
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Thomas T, Barclay S. Continuous subcutaneous infusion in palliative care: a review of current practice. Int J Palliat Nurs 2015; 21:60, 62-4. [PMID: 25715160 DOI: 10.12968/ijpn.2015.21.2.60] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Syringe drivers are widely used in palliative care, and this article reviews the challenges and outstanding questions associated with their use. Misperceptions among the lay public and some health professionals can be addressed by sensitive communication with patients and families and clear thinking in clinical teams concerning the drugs and doses used, particularly in non-malignant disease. Good levels of knowledge concerning syringe driver use has been found among GPs and community nurses, although this is not the case in some nursing home teams. The advantages of newer devices, safety and efficacy of drug combinations, selection of diluent, and management of site reactions are discussed.
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Affiliation(s)
- Tabitha Thomas
- Consultant Physician in Palliative Medicine, Arthur Rank House Hospice, Cambridge, UK
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67
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Dirven L, Sizoo EM, Taphoorn MJB. Anaplastic gliomas: end-of-life care recommendations. CNS Oncol 2015; 4:357-65. [PMID: 26509292 DOI: 10.2217/cns.15.31] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Despite multimodal antitumor treatment, all patients with an anaplastic glioma will be confronted with incurability in due course and enter the end-of-life (EOL) phase; the period when the patients' condition declines and tumor-directed treatment is no longer effective. Although palliative care is important in all stages of the disease, it is of utmost importance in the EOL phase. The main goal of palliative care is to improve or maintain the quality of life of the patients and their relatives through the prevention and relief of suffering. This review focuses on different aspects of the EOL phase (symptoms and signs, EOL decision-making, advance care planning, organization of care and caregiver burden) and will provide recommendations to optimize palliative care.
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Affiliation(s)
- Linda Dirven
- VU University Medical Center, Department of Neurology, POBOX 7057, 1007 MB Amsterdam, The Netherlands
| | - Eefje M Sizoo
- VU University Medical Center, Department of Neurology, POBOX 7057, 1007 MB Amsterdam, The Netherlands
| | - Martin J B Taphoorn
- VU University Medical Center, Department of Neurology, POBOX 7057, 1007 MB Amsterdam, The Netherlands.,Medical Center Haaglanden, Department of Neurology, The Hague, The Netherlands
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Mherekumombe MF, Collins JJ. Patient-controlled analgesia for children at home. J Pain Symptom Manage 2015; 49:923-7. [PMID: 25546288 DOI: 10.1016/j.jpainsymman.2014.10.007] [Citation(s) in RCA: 7] [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: 03/01/2014] [Revised: 10/15/2014] [Accepted: 10/22/2014] [Indexed: 11/18/2022]
Abstract
CONTEXT Pain is a common and significant symptom experienced by children with advanced malignant disease. There is limited research on pain management of these children at home. OBJECTIVES To describe and review the indications for using patient-controlled analgesia (PCA) in the form of a Computerized Ambulatory Drug Delivery device (CADD(®)) in the home setting. METHODS A retrospective chart review was conducted in children discharged home with opioid infusions using a CADD. Charts from January 2008 to February 2012 were surveyed. RESULTS Thirty-seven CADDs were dispensed during the study period, and of these, 33 were prescribed for patients with cancer-related pain. A third of the CADDs were commenced at home and almost all PCA CADDs were used for end-of-life care. Hydromorphone was the most commonly prescribed opioid. Patients remained at home and pain control was achieved by either increasing the opioid dose or switching the opioid and using adjuvant therapy. Sixteen patients were readmitted to hospital from home and three admissions were related to pain. The median duration on a PCA CADD at home was 33.7 days (range, 1-150 days), and the mean morphine equivalent dose was 2.13 mg/kg/day. CONCLUSION PCA with a CADD can be used to manage pain in the home setting. Dose adjustments and opioid switches were performed with no adverse incidents.
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Affiliation(s)
| | - John J Collins
- The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Kinoshita S, Miyashita M, Morita T, Sato K, Miyazaki T, Shoji A, Chiba Y, Tsuneto S, Shima Y. Changes in Perceptions of Opioids Before and After Admission to Palliative Care Units in Japan: Results of a Nationwide Bereaved Family Member Survey. Am J Hosp Palliat Care 2015; 33:431-8. [PMID: 25862807 DOI: 10.1177/1049909115579407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study aimed to clarify perspectives of bereaved family members regarding opioids and compare perceptions before admission and after bereavement. A cross-sectional questionnaire survey for bereaved family members in 100 inpatient palliative care units was administered. Participants were 297 bereaved family members of patients who used opioids. Many bereaved family members had misconceptions of opioids before admission. There was improvement after bereavement, but understanding remained low. Respondents less than 65 years old showed significantly greater decreases in misconceptions regarding opioids compared to older generations, after bereavement. Bereaved family members who were misinformed about opioids by physicians were significantly more likely to have misconceptions about opioids. Educational interventions for physicians are needed to ensure that they offer correct information to the general population.
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Affiliation(s)
- Satomi Kinoshita
- College of Nursing, Kanto Gakuin University, Yokohama, Kanagawa, Japan
| | - Mitsunori Miyashita
- Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Kazuki Sato
- Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Tamana Miyazaki
- Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Ayaka Shoji
- Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Yurika Chiba
- Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Satoru Tsuneto
- Department of Palliative Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
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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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Førde R, Materstvedt LJ, Markestad T, Kongsgaard UE, von Hofacker S, Brelin S, Ore S, Laudal M. Palliative sedation at the end of life – revised guidelines. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2015; 135:220-1. [PMID: 25668536 DOI: 10.4045/tidsskr.14.1116] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Minami S, Fujimoto K, Ogata Y, Yamamoto S, Komuta K. Opioids have no negative effect on the survival time of patients with advanced lung cancer in an acute care hospital. Support Care Cancer 2015; 23:2245-54. [PMID: 25564223 DOI: 10.1007/s00520-014-2592-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 12/21/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study is to determine whether or not opioid administration influenced the survival time of patients with advanced lung cancer in an acute care hospital setting. METHODS This was a single institutional and retrospective study. We reviewed patients with advanced lung cancer who had died from January 2008 to December 2013 at the Osaka Police Hospital. We compared survival times, calculated from the time of the last hospitalization or the last chemotherapy, between patients who had not used any opioids, those who had used a low dose of opioids (< 60 mg/day), and those who had used a higher dose of opioids (≥ 60 mg/day). RESULTS A total of 369 patients, of which 284 had received chemotherapy, were analyzed. Opioid users were generally younger than nonusers. There was no significant difference in survival time after the last hospitalization in terms of opioid dose at the last admission and mean daily opioid dose; there was also no significant difference in survival time after the last chemotherapy in terms of the mean daily opioid dose and the opioid dose at death. Univariate and multivariate Cox proportional hazard analysis regarding survival time after the last hospitalization or the last chemotherapy did not reveal any opioid-related variables as a significant predictive factor. CONCLUSIONS Opioids were found to have no negative influence on survival time even in an acute care hospital.
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Affiliation(s)
- Seigo Minami
- Department of Respiratory Medicine, Osaka Police Hospital, 10-31 Kitayama-cho, Tennoji-ku, Osaka-City, Osaka, 543-0035, Japan,
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Seymour J, Rietjens J, Bruinsma S, Deliens L, Sterckx S, Mortier F, Brown J, Mathers N, van der Heide A. Using continuous sedation until death for cancer patients: a qualitative interview study of physicians' and nurses' practice in three European countries. Palliat Med 2015; 29:48-59. [PMID: 25062816 PMCID: PMC4266692 DOI: 10.1177/0269216314543319] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Extensive debate surrounds the practice of continuous sedation until death to control refractory symptoms in terminal cancer care. We examined reported practice of United Kingdom, Belgian and Dutch physicians and nurses. METHODS Qualitative case studies using interviews. SETTING Hospitals, the domestic home and hospices or palliative care units. PARTICIPANTS In all, 57 Physicians and 73 nurses involved in the care of 84 cancer patients. RESULTS UK respondents reported a continuum of practice from the provision of low doses of sedatives to control terminal restlessness to rarely encountered deep sedation. In contrast, Belgian respondents predominantly described the use of deep sedation, emphasizing the importance of responding to the patient's request. Dutch respondents emphasized making an official medical decision informed by the patient's wish and establishing that a refractory symptom was present. Respondents employed rationales that showed different stances towards four key issues: the preservation of consciousness, concerns about the potential hastening of death, whether they perceived continuous sedation until death as an 'alternative' to euthanasia and whether they sought to follow guidelines or frameworks for practice. CONCLUSION This qualitative analysis suggests that there is systematic variation in end-of-life care sedation practice and its conceptualization in the United Kingdom, Belgium and the Netherlands.
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Affiliation(s)
- Jane Seymour
- School of Health Sciences, Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Judith Rietjens
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Sophie Bruinsma
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Sigrid Sterckx
- Bioethics Institute Ghent, Ghent University, Ghent, Belgium Department of Philosophy and Moral Sciences, Vrije Universiteit Brussel, Brussels, Belgium
| | - Freddy Mortier
- Bioethics Institute Ghent, Ghent University, Ghent, Belgium
| | - Jayne Brown
- School of Nursing and Midwifery, Center for the Promotion of Excellence in Palliative Care, De Montfort University, Leicester, UK
| | - Nigel Mathers
- Academic Unit of Primary Medical Care, Northern General Hospital, University of Sheffield, Sheffield, UK
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Scott JF. The Case Against Clinical Guidelines for Palliative Sedation. PHILOSOPHY AND MEDICINE 2015. [DOI: 10.1007/978-94-017-9106-9_10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Chambaere K, Bernheim JL, Downar J, Deliens L. Characteristics of Belgian "life-ending acts without explicit patient request": a large-scale death certificate survey revisited. CMAJ Open 2014; 2:E262-7. [PMID: 25485252 PMCID: PMC4257563 DOI: 10.9778/cmajo.20140034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND "Life-ending acts without explicit patient request," as identified in robust international studies, are central in current debates on physician-assisted dying. Despite their contentiousness, little attention has been paid to their actual characteristics and to what extent they truly represent nonvoluntary termination of life. METHODS We analyzed the 66 cases of life-ending acts without explicit patient request identified in a large-scale survey of physicians certifying a representative sample of deaths (n = 6927) in Flanders, Belgium, in 2007. The characteristics we studied included physicians' labelling of the act, treatment course and doses used, and patient involvement in the decision. RESULTS In most cases (87.9%), physicians labelled their acts in terms of symptom treatment rather than in terms of ending life. By comparing drug combinations and doses of opioids used, we found that the life-ending acts were similar to intensified pain and symptom treatment and were distinct from euthanasia. In 45 cases, there was at least 1 characteristic inconsistent with the common understanding of the practice: either patients had previously expressed a wish for ending life (16/66, 24.4%), physicians reported that the administered doses had not been higher than necessary to relieve suffering (22/66, 33.3%), or both (7/66, 10.6%). INTERPRETATION Most of the cases we studied did not fit the label of "nonvoluntary life-ending" for at least 1 of the following reasons: the drugs were administered with a focus on symptom control; a hastened death was highly unlikely; or the act was taken in accordance with the patient's previously expressed wishes. Thus, we recommend a more nuanced view of life-ending acts without explicit patient request in the debate on physician-assisted dying.
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Affiliation(s)
- Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Jan L Bernheim
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - James Downar
- Department of Medicine, University Health Network, Toronto, Ont. ; University of Toronto, Toronto, Ont
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium ; Department of Medical Oncology, University Hospital Ghent, Ghent, Belgium
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Chiang JK, Kao YH. Prediction of Patient Survival by Change in Daily Opioid Dosage in Advanced Cancer Patients: A Prospective Hospital-based Epidemiologic Study. Jpn J Clin Oncol 2014; 44:1189-97. [DOI: 10.1093/jjco/hyu153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol 2014; 12:77-92. [DOI: 10.1038/nrclinonc.2014.147] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Macaden SC, Salins N, Muckaden M, Kulkarni P, Joad A, Nirabhawane V, Simha S. End of life care policy for the dying: consensus position statement of Indian association of palliative care. Indian J Palliat Care 2014; 20:171-81. [PMID: 25191002 PMCID: PMC4154162 DOI: 10.4103/0973-1075.138384] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE To develop an End of Life Care (EOLC) Policy for patients who are dying with an advanced life limiting illness. To improve the quality of care of the dying by limiting unnecessary therapeutic medical interventions, providing access to trained palliative care providers, ensuring availability of essential medications for pain and symptom control and improving awareness of EOLC issues through education initiatives. EVIDENCE A review of Country reports, observational studies and key surveys demonstrates that EOLC in India is delivered ineffectively, with a majority of the Indian population dying with no access to palliative care at end of life and essential medications for pain and symptom control. Limited awareness of EOLC among public and health care providers, lack of EOLC education, absent EOLC policy and ambiguous legal standpoint are some of the major barriers in effective EOLC delivery. RECOMMENDATIONS Access to receive good palliative and EOLC is a human right. All patients are entitled to a dignified death. Government of India (GOI) to take urgent steps towards a legislation supporting good EOLC, and all hospitals and health care institutions to have a working EOLC policyProviding a comprehensive care process that minimizes physical and non physical symptoms in the end of life phase and ensuring access to essential medications for pain and symptom controlPalliative care and EOLC to be part of all hospital and community/home based programsStandards of palliative and EOLC as established by appropriate authorities and Indian Association of Palliative Care (IAPC) met and standards accredited and monitored by national and international accreditation bodiesAll health care providers with direct patient contact are urged to undergo EOLC certification, and EOLC training should be incorporated into the curriculum of health care education.
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Affiliation(s)
- Stanley C Macaden
- Palliative Medicine Consultant, National Coordinator, Palliative Care Program of Christian Medical Association of India, India
| | - Naveen Salins
- Associate Editor, Consultant, Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Maryann Muckaden
- Associate Editor, Consultant, Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | | | - Anjum Joad
- Department of Palliative Medicine, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Vivek Nirabhawane
- Palliative Medicine Specialist, Cipla Palliative Care and Training Centre, Pune, Maharashtra, India
| | - Srinagesh Simha
- Medical Director, Karunashraya Hospice, Bangalore, Karnataka, India
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Abstract
Despite their proven efficacy and safety, opioid and sedative use for palliation in patients afflicted with cancer in Singapore have been shown to be a fraction of that in other countries. This paper explores the various psychosocial and system-related factors that appear to propagate this conservative approach to care in what is largely a western-influenced care practice. A search for publications relating to sedative and opioid usage in Asia was performed on PubMed, Google, Google Scholar, World Health Organization, and Singapore's government agency websites using search terms such as "opioids," "sedatives," "palliation," "end-of-life-care," "pain management," "palliative care," "cancer pain," "Asia," "Singapore," and "morphine." Findings were classified into three broad groups - system-related, physician-related, and patient-related factors. A cautious medico-legal climate, shortage of physicians trained in palliative care, and lack of instruments for symptom assessment of patients at the end of life contribute to system-related barriers. Physician-related barriers include delayed access to palliative care due to late referrals, knowledge deficits in non-palliative medicine physicians, and sub-optimal care provided by palliative physicians. Patients' under-reporting of symptoms and fear of addiction, tolerance, and side effects of opioids and sedatives may lead to conservative opioid use in palliative care as well. System-related, physician-related, and patient-related factors play crucial roles in steering the management of palliative patients. Addressing and increasing the awareness of these factors may help ensure patients receive adequate relief and control of distressing symptoms.
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Affiliation(s)
- Shin Wei Sim
- Department of Palliative Medicine, National Cancer Center, Singapore 11 Hospital Drive, Singapore
| | - Shirlynn Ho
- Department of Palliative Medicine, National Cancer Center, Singapore 11 Hospital Drive, Singapore
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A systematic review of the influence of opioids on advanced cancer patient survival. Curr Opin Support Palliat Care 2014; 7:424-30. [PMID: 24145680 DOI: 10.1097/spc.0b013e328365763a] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Many health professionals still believe that opioids shorten the lifespan of patients. This situation implies that the ethical doctrine of double effect is often invoked to justify their use in extreme circumstances. The objective of this study is to revise the evidence existing in the recently published literature regarding the effect on patient survival of opioid used to control disease symptoms. RECENT FINDINGS A review of the scientific literature regarding the effects of opioids on symptom control and survival does not provide any evidence that there is an association between these two variables. SUMMARY The studies revised have not shown that the use of opioids for symptom control in advanced disease stages or in the last days of life has any effect on patient survival. Similarly, survival was not influenced by either the use of higher or lower doses of opioids, or by the practice of administering a double dose at night.
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Bruinsma SM, Brown J, van der Heide A, Deliens L, Anquinet L, Payne SA, Seymour JE, Rietjens JAC. Making sense of continuous sedation in end-of-life care for cancer patients: an interview study with bereaved relatives in three European countries. Support Care Cancer 2014; 22:3243-52. [PMID: 25022759 DOI: 10.1007/s00520-014-2344-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 06/29/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of the study was to explore relatives' descriptions and experiences of continuous sedation in end-of-life care for cancer patients and to identify and explain differences between respondents from the Netherlands, Belgium, and the UK. METHODS In-depth interviews were held between January 2011 and May 2012 with 38 relatives of 32 cancer patients who received continuous sedation until death in hospitals, the community, and hospices/palliative care units. RESULTS Relatives' descriptions of the practice referred to the outcome, to practical aspects, and to the goals of sedation. While most relatives believed sedation had contributed to a 'good death' for the patient, yet many expressed concerns. These related to anxieties about the patient's wellbeing, their own wellbeing, and questions about whether continuous sedation had shortened the patient's life (mostly UK), or whether an alternative approach would have been better. Such concerns seemed to have been prompted by relatives witnessing unexpected events such as the patient coming to awareness during sedation. In the Netherlands and in Belgium, several relatives reported that the start of the sedation allowed for a planned moment of 'saying goodbye'. In contrast, UK relatives discerned neither an explicit point at which sedation was started nor a specific moment of farewell. CONCLUSIONS Relatives believed that sedation contributed to the patient having a good death. Nevertheless, they also expressed concerns that may have been provoked by unexpected events for which they were unprepared. There seems to exist differences in the process of saying goodbye between the NL/BE and the UK.
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Affiliation(s)
- S M Bruinsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands,
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McKinnon M, Azevedo C, Bush SH, Lawlor P, Pereira J. Practice and documentation of palliative sedation: a quality improvement initiative. ACTA ACUST UNITED AC 2014; 21:100-3. [PMID: 24764700 DOI: 10.3747/co.21.1773] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Palliative sedation (ps), the continuous use of sedating doses of medication to intentionally reduce consciousness and relieve refractory symptoms at end of life, is ethically acceptable if administered according to standards of best practice. Procedural guidelines outlining the appropriate use of ps and the need for rigorous documentation have been developed. As a quality improvement strategy, we audited the practice and documentation of ps on our palliative care unit (pcu). METHODS A pharmacy database search of admissions in 2008 identified, for a subsequent chart review, patients who had received either a continuous infusion of midazolam (≥10 mg/24 h), regular parenteral dosing of methotrimeprazine (≥75 mg daily), or regular phenobarbital. Documentation of the decision-making process, consent, and medication use was collected using a data extraction form based on current international ps standards. RESULTS Interpretation and comparison of data were difficult because of an apparent lack of a consistent operational definition of ps. Patient records had no specific documentation in relation to ps initiation, to clearly identified refractory symptoms, and to informed consent in 60 (64.5%), 43 (46.2%), and 38 (40.9%) charts respectively. Variation in the medications used was marked: 54 patients (58%) were started on a single agent and 39 (42%), on multiple agents. The 40 patients (43%) started on midazolam alone received a mean daily dose of 21.4 mg (standard deviation: 24.6 mg). CONCLUSIONS The lack of documentation and standardized practice of ps on our pcu has resulted in a quality improvement program to address those gaps. They also highlight the importance of conducting research and developing clinical guidelines in this area.
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Affiliation(s)
- M McKinnon
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON
| | - C Azevedo
- Department of Medical Oncology, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - S H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON. ; Bruyère Research Institute, Ottawa, ON
| | - P Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON. ; Bruyère Research Institute, Ottawa, ON
| | - J Pereira
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON. ; Bruyère Research Institute, Ottawa, ON
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Rietjens JAC, Voorhees JR, van der Heide A, Drickamer MA. Approaches to suffering at the end of life: the use of sedation in the USA and Netherlands. JOURNAL OF MEDICAL ETHICS 2014; 40:235-240. [PMID: 22982490 DOI: 10.1136/medethics-2012-100561] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Studies describing physicians' experiences with sedation at the end of life are indispensible for informed palliative care practice, but they are scarce. We describe the accounts of physicians from the USA and the Netherlands, two countries with different regulations on end-of-life decisions regarding their use of sedation. METHODS Qualitative face-to-face interviews were held in 2007-2008 with 36 physicians (18 from the Netherlands, 18 from the USA), including primary care physicians and specialists. We applied purposive sampling and conducted constant comparative analyses. RESULTS In both countries, the use of sedation was described in diverse terms, especially in the USA, and was often experienced as emotionally challenging. Respondents stated different and sometimes multiple intentions for their use of sedation. Besides alleviating severe suffering, most Dutch respondents justified its use by stating that it does not hasten death, while most American respondents indicated that it might hasten death but that this was justifiable as long as that was not their primary intention. While many Dutch respondents indicated that they initiated open discussions about sedation proactively to inform patients about their options and to allow planning, the accounts of American respondents showed fewer and less-open discussions, mostly late in the dying process and with the patient's relatives. CONCLUSIONS The justification for sedation and the openness with which it is discussed were found to differ in the accounts of respondents from the USA and the Netherlands. Further clarification of practices and research into the effect and effectiveness of the use of sedation is recommended to enhance informed reflection and policy making.
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Affiliation(s)
- Judith A C Rietjens
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
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Hendriks SA, Smalbrugge M, Hertogh CMPM, van der Steen JT. Dying with dementia: symptoms, treatment, and quality of life in the last week of life. J Pain Symptom Manage 2014; 47:710-20. [PMID: 23916680 DOI: 10.1016/j.jpainsymman.2013.05.015] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/18/2013] [Accepted: 05/22/2013] [Indexed: 11/25/2022]
Abstract
CONTEXT Burdensome symptoms present frequently in dementia at the end of life, but we know little about the symptom control provided, such as type and dosage of medication. OBJECTIVES To investigate symptom prevalence and prescribed treatment, explore associations with quality of life (QOL) in the last week of life, and examine symptom prevalence by cause of death of nursing home residents with dementia. METHODS Within two weeks after death, physicians completed questionnaires about symptoms and treatment in the last week for 330 nursing home residents with dementia in the Dutch End of Life in Dementia study (2007-2011). We used linear regression to assess associations with QOL, measured by the Quality of Life in Late-Stage Dementia scale. Causes of death were abstracted from death certificates. RESULTS Pain was the most common symptom (52%), followed by agitation (35%) and shortness of breath (35%). Pain and shortness of breath were mostly treated with opioids and agitation mainly with anxiolytics. At the day of death, 77% received opioids, with a median of 90 mg/24 hours (oral equivalents), and 21% received palliative sedation. Pain and agitation were associated with a lower QOL. Death from respiratory infection was associated with the largest symptom burden. CONCLUSION Symptoms are common in dementia at the end of life, despite the large majority of residents receiving opioids. Dosages may be suboptimal with regard to weighing of effects and side effects. Future research may employ observation on a day-to-day basis to better assess effectiveness of symptom control and possible side effects.
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Affiliation(s)
- Simone A Hendriks
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Jenny T van der Steen
- Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
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88
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Sizoo EM, Grisold W, Taphoorn MJB. Neurologic aspects of palliative care: the end of life setting. HANDBOOK OF CLINICAL NEUROLOGY 2014; 121:1219-1225. [PMID: 24365413 DOI: 10.1016/b978-0-7020-4088-7.00081-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
As there are, to date, few curative treatment options for many neurologic diseases, end of life (EOL) care is an important aspect of the treatment of neurologic patients. In the EOL phase, treatment should be aimed at relieving symptoms, maintaining quality of life, and facilitating a peaceful and dignified way of dying. Common signs and symptoms in the EOL phase of neurologic patients are raised intracranial pressure, seizures, confusion, cognitive deficits, and impaired motor function. Supportive treatment of these symptoms (such as analgesic drugs, dexamethasone, antiepileptic and neuroleptic drugs) is of major importance to maintain quality of life as long as possible. Another key aspect of EOL care is EOL decision making, such as withholding or withdrawing life-sustaining treatment, and palliative sedation. The main goal of EOL decision making is the prevention and relief of suffering, even if this might hasten death. Especially in advanced stages of many neurologic diseases, confusion, cognitive deficits, communication deficits, and decreasing levels of consciousness may impair the competence of patients to participate in EOL decision making. Given that patient autonomy is increasingly essential, advance care planning (ACP) at an early stage of the disease should be considered.
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Affiliation(s)
- Eefje M Sizoo
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands.
| | - Wolfgang Grisold
- Department of Neurology, Kaiser Franz Josep Hospital, Vienna, Austria
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89
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Représentation de la sédation en situation palliative chez les pneumologues. Rev Mal Respir 2014; 31:48-56. [DOI: 10.1016/j.rmr.2013.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 05/12/2013] [Indexed: 11/19/2022]
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90
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Consultation with specialist palliative care services in palliative sedation: considerations of Dutch physicians. Support Care Cancer 2013; 22:225-31. [PMID: 24037413 DOI: 10.1007/s00520-013-1972-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 08/27/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Palliative sedation is considered a normal medical practice by the Royal Dutch Medical Association. Therefore, consultation of an expert is not considered mandatory. The European Association of Palliative Care (EAPC) framework for palliative sedation, however, is more stringent: it considers the use of palliative sedation without consulting an expert as injudicious and insists on input from a multi-professional palliative care team. This study investigates the considerations of Dutch physicians concerning consultation about palliative sedation with specialist palliative care services. METHODS Fifty-four physicians were interviewed on their most recent case of palliative sedation. RESULTS Reasons to consult were a lack of expertise and the view that consultation was generally supportive. Reasons not to consult were sufficient expertise, the view that palliative sedation is a normal medical procedure, time pressure, fear of disagreement with the service and regarding consultation as having little added value. Arguments in favour of mandatory consultation were that many physicians lack expertise and that palliative sedation is an exceptional intervention. Arguments against mandatory consultation were practical obstacles that may preclude fulfilling such an obligation (i.e. lack of time), palliative sedation being a standard medical procedure, corroding a physician's responsibility and deterring physicians from applying palliative sedation. CONCLUSION Consultation about palliative sedation with specialist palliative care services is regarded as supportive and helpful when physicians lack expertise. However, Dutch physicians have both practical and theoretical objections against mandatory consultation. Based on the findings in this study, there seems to be little support among Dutch physicians for the EAPC recommendations on obligatory consultation.
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91
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American Society for Pain Management Nursing Position Statement: Pain Management at the End of Life. Pain Manag Nurs 2013; 14:172-5. [DOI: 10.1016/j.pmn.2013.07.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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92
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Horn R. Euthanasia and end-of-life practices in France and Germany. A comparative study. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2013; 16:197-209. [PMID: 22020798 DOI: 10.1007/s11019-011-9357-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The objective of this paper is to understand from a sociological perspective how the moral question of euthanasia, framed as the "right to die", emerges and is dealt with in society. It takes France and Germany as case studies, two countries in which euthanasia is prohibited and which have similar legislation on the issue. I presuppose that, and explore how, each society has its own specificities in terms of practical, social and political norms that affect the ways in which they deal with these issues. The paper thus seeks to understand how requests for the "right to die" emerge in each society, through both the debate (analysis of daily newspapers, medical and philosophical literature, legal texts) and the practices (ethnographic work in three French and two German hospitals) that elucidate the phenomenon. It does so, however, without attempting to solve the moral question of euthanasia. In spite of the differences observed between these two countries, the central issue at stake in their respective debates is the question of the individual's autonomy to choose the conditions in which he or she wishes to die; these conditions depend, amongst others, on the doctor-patient relationship, the organisation of end-of-life care in hospital settings, and more generally, on the way autonomy is defined and handled in the public debate.
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Affiliation(s)
- Ruth Horn
- Centre for Ethics in Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
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93
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Pardon K, Chambaere K, Pasman HRW, Deschepper R, Rietjens J, Deliens L. Trends in end-of-life decision making in patients with and without cancer. J Clin Oncol 2013; 31:1450-7. [PMID: 23478055 DOI: 10.1200/jco.2012.44.5916] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Because of cancer's high symptom burden and specific disease course, patients with cancer are more likely than other patients to face end-of-life decisions that have possible or certain life-shortening effects (ELDs). This study examines the incidence of ELDs in patients with cancer compared with patients without cancer and the trends in ELD incidence from 1998-2007. PATIENTS AND METHODS A nationwide death certificate study in Flanders, Belgium, was conducted in 2007, analogous to one completed in 1998. Physicians who had signed selected death certificates (n = 6,927) were sent a questionnaire. RESULTS The response rate was 58.4%. Nonsudden deaths were studied. Intensified symptom alleviation occurred more in patients with cancer than in those without (53.8% v 31.7%; P < .001) as did euthanasia (6.8% v 0.9%; P < .001). There was no difference between groups in nontreatment decisions and life-ending acts without patient's explicit request. Patients with cancer were less involved in the end-of-life decision-making process than patients without cancer (69.7% v 83.5%; P = .001). From 1998 to 2007, ELD incidence has increased in patients with cancer (+6.7%) and even more in patients without cancer (+14.9%) because of an increase in intensified symptom alleviation. In patients with cancer, euthanasia rates increased strongly and life-ending acts without the patient's explicit request decreased. CONCLUSION The higher ELD incidence in patients with cancer compared with those without is probably related to differences in disease trajectories and access to end-of-life care. During the period from 1998 to 2007, when euthanasia was legalized and palliative care intensified, overall ELDs increased, including those as a result of symptom alleviation and euthanasia, with a decrease in life-ending acts without explicit request.
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Affiliation(s)
- Koen Pardon
- End-of-life Care Research Group, Ghent University and Vrije Universiteit Brussels, Laarbeeklaan 103, 1090 Brussels, Belgium.
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94
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Bruinsma S, Rietjens J, van der Heide A. Palliative sedation: a focus group study on the experiences of relatives. J Palliat Med 2013; 16:349-55. [PMID: 23421537 DOI: 10.1089/jpm.2012.0410] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Most studies that have investigated the practice of palliative sedation have focused on physicians' practices and attitudes. OBJECTIVE The aim of this study was to explore relatives' experiences with palliative sedation and to gain more insight in positive and negative elements in their evaluation of palliative sedation. DESIGN Focus groups and individual interviews. SETTING Various care settings in the Netherlands. SUBJECTS A total of 14 relatives of patients who received palliative sedation until death participated. RESULTS Most relatives evaluated the provision of palliative sedation of their dying family member positively. Positive experiences were related to: the beneficial impact of palliative sedation on the patient's suffering, the opportunity that was offered to prepare for the patient's death, their involvement in the decision-making and care for the patient, and the pleasant care environment. However, the majority of the relatives were unsatisfied with one or more aspects of how information was being provided for. Some relatives were frustrated about the fact that nurses were not authorized to make decisions about the care for the patient and about the absence of physicians during weekends. None of the relatives mentioned the loss of the ability to communicate with the patient during the sedation and the possibility of "hastening death" as disadvantages of palliative sedation. CONCLUSION Relatives tend to evaluate the provision of palliative sedation to their severely suffering family member positively because it contributes to a peaceful dying process. However, relatives indicated discontent with how information was being provided and with the communication in general.
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Affiliation(s)
- Sophie Bruinsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
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95
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Dietz I, Schmitz A, Lampey I, Schulz C. Evidence for the use of Levomepromazine for symptom control in the palliative care setting: a systematic review. BMC Palliat Care 2013; 12:2. [PMID: 23331515 PMCID: PMC3602665 DOI: 10.1186/1472-684x-12-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 01/15/2013] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Levomepromazine is an antipsychotic drug that is used clinically for a variety of distressing symptoms in palliative and end-of-life care. We undertook a systematic review based on the question "What is the published evidence for the use of levomepromazine in palliative symptom control?". METHODS To determine the level of evidence for the use of levomepromazine in palliative symptom control, and to discover gaps in evidence, relevant studies were identified using a detailed, multi-step search strategy. Emerging data was then scrutinized using appropriate assessment tools, and the strength of evidence systematically graded in accordance with the Oxford Centre for Evidence-Based Medicine's 'levels of evidence' tool. The electronic databases Medline, Embase, Cochrane, PsychInfo and Ovid Nursing, together with hand-searching and cross-referencing provided the full research platform on which the review is based. RESULTS 33 articles including 9 systematic reviews met the inclusion criteria: 15 on palliative sedation, 8 regarding nausea and three on delirium and restlessness, one on pain and six with other foci. The studies varied greatly in both design and sample size. Levels of evidence ranged from level 2b to level 5, with the majority being level 3 (non-randomized, non-consecutive or cohort studies n = 22), with the quality of reporting for the included studies being only low to medium. CONCLUSION Levomepromazine is widely used in palliative care as antipsychotic, anxiolytic, antiemetic and sedative drug. However, the supporting evidence is limited to open series and case reports. Thus prospective randomized trials are needed to support evidence-based guidelines.
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Affiliation(s)
- Isabel Dietz
- Clinic for Anaesthesiology HELIOS Clinic Wuppertal, University Witten/Herdecke, Witten, Germany
| | - Andrea Schmitz
- Interdisciplinary Center for Palliative Medicine, University Hospital Dusseldorf, Dusseldorf University, Dusseldorf, Germany
| | - Ingrid Lampey
- Interdisciplinary Center for Palliative Medicine, University Hospital Dusseldorf, Dusseldorf University, Dusseldorf, Germany
- NELCS Northeast London (NHS) Community Services, London, United Kingdom
| | - Christian Schulz
- Interdisciplinary Center for Palliative Medicine, University Hospital Dusseldorf, Dusseldorf University, Dusseldorf, Germany
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96
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Abstract
Palliative sedation (PS) is a treatment option in case of refractory symptoms at the end of life. The emotional impact on nurses and doctors has been widely studied. We explore the experience of family members during a PS procedure. Method: An anonymous questionnaire was sent to the closest family members (n = 17) of patients who died while receiving palliative sedation. Results: The response rate was 59% (10 of 17). Nine relatives were sufficiently informed about PS. In all, 70% evaluated the chosen moment for initiation of PS as adequate. All the relatives noticed a significant improvement in the refractory symptom with a mean reduction in the estimated suffering of 6.25 points on a visual analog scale. Conclusions: Palliative sedation should be performed in the best possible way for the patient and his family in order to efficiently reduce a refractory symptom.
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97
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Ben-Aharon I, Gafter-Gvili A, Leibovici L, Stemmer SM. Interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis. Acta Oncol 2012; 51:996-1008. [PMID: 22934558 DOI: 10.3109/0284186x.2012.709638] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Dyspnea is commonly encountered by many cancer patients in the terminal stage of their disease and it severely hampers their quality of life. We aimed to evaluate the role of interventions to alleviate dyspnea. METHODS Systematic review and meta-analysis of randomized controlled trials assessing all interventions for dyspnea palliation in cancer patients, and searched the Cochrane Library, MEDLINE, conference proceedings, and references. RESULTS Our search yielded 18 trials. Eight studies evaluated opioids in any route of administration, seven studies evaluated the use of oxygen, two studies assessed the role of benzodiazepines and two studies evaluated the role of furosemide in alleviating cancer-related dyspnea. Weighted mean difference (WMD) was calculated for continuous variables that were reported on the same scale. For continuous data reported in different scales, standardized mean difference (SMD) was calculated. Meta-analysis of three trials yielded a positive effect for opioid administration, WMD -1.31[95% CI (-2.49)-(- 0.13)]. Meta-analysis of the six studies showed lack of benefit to oxygen to improve dyspnea, SMD -0.3[95% CI -1.06-0.47]. The role of benzodiazepines remains unclear, furosemide was not beneficial. CONCLUSIONS Our systematic review and meta-analysis demonstrate a beneficial effect to opioids in alleviating cancer-related dyspnea, and no advantage for the use of oxygen.
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Affiliation(s)
- Irit Ben-Aharon
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah-Tiqva, Israel.
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98
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Onwuteaka-Philipsen BD, Brinkman-Stoppelenburg A, Penning C, de Jong-Krul GJF, van Delden JJM, van der Heide A. Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey. Lancet 2012; 380:908-15. [PMID: 22789501 DOI: 10.1016/s0140-6736(12)61034-4] [Citation(s) in RCA: 169] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 2002, the euthanasia act came into effect in the Netherlands, which was followed by a slight decrease in the euthanasia frequency. We assessed frequency and characteristics of euthanasia, physician-assisted suicide, and other end-of-life practices in 2010, and assessed trends since 1990. METHODS In 1990, 1995, 2001, 2005, and 2010 we did nationwide studies of a stratified sample from the death registry of Statistics Netherlands, to which all deaths and causes were reported. We mailed questionnaires to physicians attending these deaths (2010: n=8496 deaths). All cases were weighted to adjust for the stratification procedure and for differences in response rates in relation to the age, sex, marital status, region of residence, and cause and place of death. FINDINGS In 2010, of all deaths in the Netherlands, 2·8% (95% CI 2·5-3·2; 475 of 6861) were the result of euthanasia. This rate is higher than the 1·7% (1·5-1·8; 294 of 9965) in 2005, but comparable with those in 2001 and 1995. Distribution of sex, age, and diagnosis was stable between 1990 and 2010. In 2010, 77% (3136 of 4050) of all cases of euthanasia or physician-assisted suicide were reported to a review committee (80% [1933 of 2425] in 2005). Ending of life without an explicit patient request in 2010 occurred less often (0·2%; 95% CI 0·1-0·3; 13 of 6861) than in 2005, 2001, 1995, and 1990 (0·8%; 0·6-1·1; 45 of 5197). Continuous deep sedation until death occurred more frequently in 2010 (12·3% [11·6-13·1; 789 of 6861]) than in 2005 (8·2% [7·8-8·6; 521 of 9965]). Of all deaths in 2010, 0·4% (0·3-0·6; 18 of 6861) were the result of the patient's decision to stop eating and drinking to end life; in half of these cases the patient had made a euthanasia request that was not granted. INTERPRETATION Our study provides insight in consequences of regulating euthanasia and physician-assisted suicide within the broader context of end-of-life practices. In the Netherlands the euthanasia law resulted in a relatively transparent practice. Although translating these results to other countries is not straightforward, they can inform the debate on legalisation of assisted dying in other countries. FUNDING The Netherlands Organization for Research and Development (ZonMw).
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Affiliation(s)
- Bregje D Onwuteaka-Philipsen
- VU University Medical Center, Department of Public and Occupational Health and EMGO Institute for Health and Care Research, VUmc Expertise Center for Palliative Care, Amsterdam, Netherlands.
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99
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Bruinsma SM, Rietjens JAC, Seymour JE, Anquinet L, van der Heide A. The experiences of relatives with the practice of palliative sedation: a systematic review. J Pain Symptom Manage 2012; 44:431-45. [PMID: 22658470 DOI: 10.1016/j.jpainsymman.2011.09.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 09/14/2011] [Accepted: 09/15/2011] [Indexed: 01/03/2023]
Abstract
CONTEXT Guidelines about palliative sedation typically include recommendations to protect the well-being of relatives. OBJECTIVES The aim of this study was to systematically review evidence on the experiences of relatives with the practice of palliative sedation. METHODS PubMed, Embase, Web of Science, PsycINFO, and CINAHL were searched for empirical studies on relatives' experiences with palliative sedation. We investigated relatives' involvement in the decision-making and sedation processes, whether they received adequate information and support, and relatives' emotions. RESULTS Of the 564 studies identified, 39 were included. The studies (30 quantitative, six qualitative, and three mixed methods) were conducted in 16 countries; three studies were based on relatives' reports, 26 on physicians' and nurses' proxy reports, seven on medical records, and three combined different sources. The 39 studies yielded a combined total of 8791 respondents or studied cases. Caregivers involved relatives in the decision making in 69%-100% of all cases (19 quantitative studies), and in 60%-100% of all cases, relatives were reported to have received adequate information (five quantitative studies). Only two quantitative studies reported on relatives' involvement in the provision of sedation. Despite the fact that the majority of relatives were reported to be comfortable with the use of palliative sedation (seven quantitative studies, four qualitative studies), several studies found that relatives were distressed by the use of sedation (five quantitative studies, five qualitative studies). No studies reported specifically about the support provided to the relatives. CONCLUSION Relatives' experiences with palliative sedation are mainly studied from the perspective of proxies, mostly professional caregivers. The majority of relatives seems to be comfortable with the use of palliative sedation; however, they may experience substantial distress by the use of sedation.
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Affiliation(s)
- Sophie M Bruinsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
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100
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Papadimos TJ, Maldonado Y, Tripathi RS, Kothari DS, Rosenberg AL. An overview of end-of-life issues in the intensive care unit. Int J Crit Illn Inj Sci 2012; 1:138-46. [PMID: 22229139 PMCID: PMC3249847 DOI: 10.4103/2229-5151.84801] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.
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Affiliation(s)
- Thomas J Papadimos
- Department of Anesthesiology, Division of Critical Care Medicine, The Ohio State University Medical Center, Columbus OH 43210, USA
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