Sedative use in the last week of life and the implications for end-of-life decision making

What to do when a competent ICU patient does not want to live anymore but is dependent on life-sustaining treatment? Experience from The Netherlands

If patients on the intensive care unit (ICU) are awake and life-sustaining treatment is suspended because of the patients’ request, because of recovering from the disease, or because independence from organ function supportive or replacement therapy outside the ICU can no longer be achieved, these patients can suffer before they inevitably die. In The Netherlands, two scenarios are possible for these patients: (1) deep palliative (terminal) sedation through ongoing administration of barbiturates or benzodiazepines before withdrawal of treatment, or (2) deliberate termination of life (euthanasia) before termination of treatment. In this article we describe two awake patients who asked for withdrawal of life-sustaining measures, but who were dependent on mechanical ventilation. We discuss the doctrine of double effect in relation to palliative sedation on the ICU. Administration of sedatives and analgesics before withdrawal of treatment is seen as normal palliative care. We conclude that the doctrine of the double effect is not applicable in this situation, and mentioning it criminalised the practice unnecessarily and wrongfully.

Is the doctrine of double effect irrelevant in end-of-life decision making?

In this paper, we consider three arguments for the irrelevance of the doctrine of double effect in end-of-life decision making. The third argument is our own and, to that extent, we seek to defend it. The first argument is that end-of-life decisions do not in fact shorten lives and that therefore there is no need for the doctrine in justification of these decisions. We reject this argument; some end-of-life decisions clearly shorten lives. The second is that the doctrine of double effect is not recognized in UK law (and similar jurisdictions); therefore, clinicians cannot use it as the basis for justification of their decisions. Against this we suggest that while the doctrine might have dubious legal grounds, it could be of relevance in some ways, e.g. in marking the boundary between acceptable and unacceptable practice in relation to the clinician's duty to relieve pain and suffering. The third is that the doctrine is irrelevant because it requires there to be a bad effect that needs justification. This is not the case in end-of-life care for patients diagnosed as dying. Here, bringing about a satisfactory dying process for a patient is a good effect, not a bad one. What matters is that patients die without pain and suffering. This marks a crucial departure from the double-effect doctrine; if the patient's death is not a bad effect then the doctrine is clearly irrelevant. A diagnosis of dying allows clinicians to focus on good dying and not to worry about whether their intervention affects the time of death. For a patient diagnosed as dying, time of death is rarely important. In our conclusion we suggest that acceptance of our argument might be problematic for opponents of physician-assisted death. We suggest one way in which these opponents might argue for a distinction between such practice and palliative care; this relies on the double-effect doctrine's distinction between foresight and intention.

Physician reports of medication use with explicit intention of hastening the end of life in the absence of explicit patient request in general practice in Belgium

BACKGROUND

Although the incidence of the use of life-ending drugs without explicit patient request has been estimated in several studies, in-depth empirical research on this controversial practice is nonexistent. Based on face-to-face interviews with the clinicians involved in cases where patients died following such a decision in general practice in Belgium, we investigated the clinical characteristics of the patients, the decision-making process, and the way the practice was conducted.

METHODS

Mortality follow-back study in 2005-2006 using the nationwide Sentinel Network of General Practitioners, a surveillance instrument representative of all GPs in Belgium. Standardised face-to-face interviews were conducted with all GPs who reported a non-sudden death in their practice, at home or in a care home, which was preceded by the use of a drug prescribed, supplied or administered by a physician without an explicit patient request.

RESULTS

Of the 2690 deaths registered by the GPs, 17 were eligible to be included in the study. Thirteen interviews were conducted. GPs indicated that at the time of the decision all patients were without prospect of improvement, with persistent and unbearable suffering to a (very) high degree in nine cases. Twelve patients were judged to lack the competence to make decisions. GPs were unaware of their patient's end-of-life wishes in nine cases, but always discussed the practice with other caregivers and/or the patient's relatives. All but one patient received opioids to hasten death. All GPs believed that end-of-life quality had been "improved considerably".

CONCLUSIONS

The practice of using life-ending drugs without explicit patient request in general practice in Belgium mainly involves non-competent patients experiencing persistent and unbearable suffering whose end-of-life wishes can no longer be ascertained. GPs do not act as isolated decision-makers and they believe they act in the best interests of the patient. Advance care planning could help to inform GPs about patients' wishes prior to their loss of competence.

Continuous Deep Sedation Until Death: Palliation or Physician-Assisted Death?

Published literature have not discerned end-of-life palliative versus life-shortening effects of pharmacologically maintaining continuous deep sedation until death (ie, dying in deep sleep) compared with common sedation practices relieving distress in the final conscious phase of dying. Continuous deep sedation predictably suppresses brainstem vital centers and shortens life. Continuous deep sedation remains controversial as palliation for existential suffering and in elective death requests by discontinuation of chronic ventilation or circulatory support with mechanical devices. Continuous deep sedation contravenes the double-effect principle because: (1) it induces permanent coma (intent of action) for the contingency relief of suffering and for social isolation (desired outcomes) and (2) because of its predictable and proportional life-shortening effect. Continuous deep sedation should be distinguished from common sedation practices for palliation and characterized instead as physician-assisted death.

European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care

The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review.

When cancer symptoms cannot be controlled: the role of palliative sedation

PURPOSE OF REVIEW

Palliative sedation, the intentional lowering of consciousness for refractory and unbearable distress, has been much discussed during the last decade. In recent years, much research has been published about this subject that will be discussed in this review. The review concentrates on: a brief overview of the main developments during the last decade, an exploration of current debate regarding ethical dilemmas, the development of clinical guidelines, and the application of palliative sedation.

RECENT FINDINGS

Main findings are that palliative sedation is mostly described in retrospective studies and that the terminology palliative sedation in now common in the majority of the studies. In addition, life-shortening effects for palliative sedation are scarcely reported, although not absent. A number of guidelines have been developed and published, although systematic implementation needs more attention. Consequently, palliative sedation has become more clearly positioned as a medical treatment, to be distinguished from active life shortening.

SUMMARY

Caregivers should apply palliative sedation proportionally, guided by the symptoms of the patient without striving for deep coma and without motives for life shortening. Clinical and multidisciplinary assessment of refractory symptoms is recommended as is patient monitoring during sedation. Future research should concentrate on proportional sedation rather than continuous deep sedation exclusively, preferably in a prospective design.

Controlled sedation for refractory symptoms in dying patients

Terminally ill cancer patients near the end of life may experience intolerable suffering refractory to palliative treatment. Although sedation is considered to be an effective treatment when aggressive efforts fail to provide relief in terminally ill patients, it remains controversial. The aim of this study was to assess the need and effectiveness of sedation in dying patients with intractable symptoms, and the thoughts of relatives regarding sedation. A prospective cohort study was performed on a consecutive sample of dying patients admitted to an acute pain relief and palliative care unit within a cancer center. Indications for sedation, opioid and midazolam doses, level of delirium and sedation, nutrition, hydration, rattle, inability to cough and swallow, pharyngeal aspiration, duration of sedation and survival, and use of anticholinergics or other drugs were recorded. Family members were interviewed. Forty-two of 77 dying patients were sedated, and had a longer survival than those who were not sedated (P=0.003). Prevalent indications for sedation were dyspnea and/or delirium. Twelve patients began with an intermediate sedation, and 38 patients started with definitive sedation. The median sedation duration was 22 hours. Opioid doses did not change during sedation. Agitated delirium significantly decreased with increasing doses of midazolam, whereas the capacity to communicate concomitantly decreased. Interviewed relatives were actively involved in the process of end-of-life care, and the decision to sedate, and the efficacy of sedation, were considered appropriate by almost all relatives. Controlled sedation is successful in dying patients with untreatable symptoms, did not hasten death, and yielded satisfactory results for relatives. This study also points to the importance of palliative care and the experience of professionals skilled in both symptom control and end-of-life care.

Palliative sedation therapy

It is sometimes not possible to relieve symptoms adequately in dying patients. When all other remedies have failed, sedation can be a useful means to relieve terminal suffering. When used appropriately, palliative sedation does not, and should not, shorten life.

Palliative sedation until death: an approach from Kant's ethics of virtue

This paper is concerned with the moral justification for palliative sedation until death. Palliative sedation involves the intentional lowering of consciousness for the relief of untreatable symptoms. The paper focuses on the moral problems surrounding the intentional lowering of consciousness until death itself, rather than possible adjacent life-shortening effects. Starting from a Kantian perspective on virtue, it is shown that continuous deep sedation until death (CDS) does not conflict with the perfect duty of moral self-preservation because CDS does not destroy capacities for agency. In addition, it is argued that CDS can frustrate the imperfect duty of self-cultivation by reducing consciousness permanently. Nevertheless, there are cases where CDS is morally acceptable, namely, cases where the agent has already permanently lost the possibility for free action in advance of sedation--for example, due to excruciating and ongoing pain. Because the latter can be difficult to diagnose properly, safeguards may be needed in order to prevent the application of CDS for the wrong reasons.

Palliative sedation: a review of the research literature

The overall aim of this paper is to systematically review the following important aspects of palliative sedation: prevalence, indications, survival, medication, food and fluid intake, decision making, attitudes of physicians, family experiences, and efficacy and safety. A thorough search of different databases was conducted for pertinent research articles published from 1966 to June 2007. The following keywords were used: end of life, sedation, terminal sedation, palliative sedation, refractory symptoms, and palliative care. Language of the articles was limited to English, French, German, and Dutch. Papers reporting solely on the sedatives used in palliative care, without explicitly reporting the prevalence or intensity of sedation, and papers not reporting on primary research (such as reviews or theoretical articles) were excluded. Methodological quality was assessed according to the criteria of Hawker et al. (2002). The search yielded 130 articles, 33.8% of which were peer-reviewed empirical research studies. Thirty-three research papers and one thesis were included in this systematic review. This review reveals that there still are many inconsistencies with regard to the prevalence, the effect of sedation, food and fluid intake, the possible life-shortening effect, and the decision-making process. Further research to clarify all of this should be based on multicenter, prospective, longitudinal, and international studies that use a uniform definition of palliative sedation, and valid and reliable instruments. Only through such research will it be possible to resolve some of the important ethical issues related to palliative sedation.

Palliative sedation in a specialized unit for acute palliative care in a cancer hospital: comparing patients dying with and without palliative sedation

Palliative sedation is undergoing extensive debate. The aims of this study were to describe the practice of palliative sedation at a specialized acute palliative care unit and to study whether patients who received palliative sedation differed from patients who did not. We performed a systematic retrospective analysis of the medical and nursing records of all 157 cancer patients who died at the acute palliative care unit between 2001 and 2005. Palliative sedation, defined as continuous deep sedation prior to death, was used for 43% of all deceased patients. In 87% of the sedated patients, it was started in the last two days before death. Sedated and nonsedated patients did not differ in survival after admission (eight days vs. seven days, P=0.12). Sedated patients were younger (55 years vs. 59 years, P=0.04) and more often had malignancies of the digestive tract (P<0.01). In both groups, common symptoms at admission were pain (79% vs. 87%, P=0.23), constipation, (40% vs. 48%, P=0.46), and dyspnea (32% vs. 29%, P=0.77). On the day that palliative sedation was started, sedated patients more often suffered from dyspnea and delirium than nonsedated patients at a comparable day before death. The most important indications for palliative sedation were terminal restlessness (60%) and dyspnea (46%). We conclude that at the studied acute palliative care unit, patients who ultimately received palliative sedation did not have symptoms different than nonsedated patients at admission, but on the day at which the sedation was started, they suffered more often from delirium and dyspnea.

Inappropriateness of using opioids for end-stage palliative sedation: a Dutch study

To be able to distinguish end-stage palliative sedation from euthanasia without having to refer to intentions that are difficult to verify, physicians must be able to manage palliative sedation appropriately (i.e., see that death is not hastened as a result of disproportionate medication). In the present study, we assessed whether or not this requirement is met in the Netherlands. We sent a retrospective questionnaire to 1,464 medical specialists, general practitioners, and nursing home physicians in the Netherlands. Furthermore, we held two sets of 20 and 22 semi-structured in-depth interviews with general practitioners, internists, lung specialists, and nursing home physicians. Although most guidelines discourage the administration of opioids alone for purposes of palliative sedation, opioids alone were administered for 22% of all the patients reported upon. Those physicians who were more experienced, general practitioners, and physicians who had consulted a palliative care expert administered only opioids significantly less often than the other physicians. The interviewees reported difficulties in assessing the appropriateness of medication, feeling uncertain about the pharmacokinetics of drugs used in moribund patients. Given that no more than 2% of the respondents perceived palliative sedation to be used as a form of euthanasia and that the use of opioids alone was not associated with shorter survival rates, the inappropriate use of opioids can only be attributed to a lack of knowledge or skill and/or a tradition of alleviating refractory dyspnoea with the use of opioids and not as an intentional means of hastening death.

Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine

BACKGROUND

These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence.

PRINCIPAL FINDINGS

Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient's death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula.

CONCLUSIONS

End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.

Having a difficult time leaving: experiences and attitudes of nurses with palliative sedation

BACKGROUND

Palliative sedation is an important topic of medical and ethical debates. Although nurses often participate in its use, little is known about their attitudes and experiences.

METHODS

In a qualitative study, we explored nurses' attitudes and experiences with palliative sedation. In semi-structured interviews with 16 nurses, we collected data about their most memorable cases of palliative sedation. Interviews were transcribed, coded and analysed using constant comparative analysis.

RESULTS

In all of the described cases, palliative sedation was used primarily to address physical suffering in severely ill patients. Concomitant reasons for the use of palliative sedation were nonphysical suffering, the patient's wish and the family's distress about the patient's suffering. The use of palliative sedation for the patient's nonphysical suffering was often difficult for many of the nurses. Nurses had different perspectives on whether palliative sedation may have had a life-shortening effect on the patient. Some thought that it had not accelerated death; others thought that it may have accelerated death but that this was justified when there was no other way of relieving discomfort. A third group thought that palliative sedation was close to the practice of euthanasia and they often found it difficult to be involved in its use. Nevertheless, palliative sedation was considered by all the nurses to positively contribute to the patient's quality of dying in all discussed cases.

CONCLUSIONS

The struggles that nurses in this study cohort experienced indicate the need for further study and may suggest the need for more nursing education and discussion about ethical aspects of palliative sedation.

Palliative care in the surgical intensive care unit: where least expected, where most needed

Despite dramatic improvements in survival from a broad range of afflictions seen in the surgical critical care unit, the problem of suffering in its many forms and its long-term consequences will remain as long as mortality characterizes the human condition. Palliative care in the surgical intensive care unit is an extension of time-honoured surgical principles and traditions that aims to relieve suffering and improve quality of life associated with serious illness as an end in it self or as part of treatment to save and prolong life.

Sedation in palliative care

PURPOSE OF REVIEW

Palliative sedation, the conscious induction of sleep in patients with a very short life expectancy who suffer intractable physical and existential distress, may offer the patient and his or her relatives a more peaceful dying. This technique is still subject to several ethical and medical controversies justifying a review of the recent literature on this subject.

RECENT FINDINGS

The available evidence consists of few prospective trials and mainly retrospectively collected case reports. Two guidelines are published in the period under review. The most important points stressed in these reviews are the careful information exchange with the patient, if possible, and his or her proxies, a gradually increased sedation allowing respite if possible to evaluate the effect of the sedation and the need for consultation with colleagues, preferentially physicians experienced in palliative care. Stopping artificial nutrition and hydration is a medical decision that should be taken after evaluation of the potential side effects and consultation with the patient and relatives.

SUMMARY

Palliative sedation may be considered for terminally ill patients who suffer intractable symptoms. Ideally it should be included in the patient's trajectory that has been described and discussed earlier when the disease was judged to be incurable. The main goal is to offer comfort.

Palliative Sedation Therapy in the Last Weeks of Life: A Literature Review and Recommendations for Standards

PURPOSE

Palliative sedation therapy (PST) is a controversial issue. There is a need for internationally accepted definitions and standards.

METHODS

A systematic review of the literature was performed by an international panel of 29 palliative care experts. Draft papers were written on various topics concerning PST. This paper is a summary of the individual papers, written after two meetings and extensive e-mail discussions.

RESULTS

PST is defined as the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness, using appropriate drugs carefully titrated to the cessation of symptoms. The initial dose of sedatives should usually be small enough to maintain the patients' ability to communicate periodically. The team looking after the patient should have enough expertise and experience to judge the symptom as refractory. Advice from palliative care specialists is strongly recommended before initiating PST. In the case of continuous and deep PST, the disease should be irreversible and advanced, with death expected within hours to days. Midazolam should be considered first-line choice. The decision whether or not to withhold or withdraw hydration should be discussed separately. Hydration should be offered only if it is considered likely that the benefit will outweigh the harm. PST is distinct from euthanasia because (1) it has the intent to provide symptom relief, (2) it is a proportionate intervention, and (3) the death of the patient is not a criterion for success. PST and its outcome should be carefully monitored and documented.

CONCLUSION

When other treatments fail to relieve suffering in the imminently dying patient, PST is a valid palliative care option.

Unrestricted opiate administration for pain and suffering at the end of life: knowledge and attitudes as barriers to care

BACKGROUND

Pain and symptom management is critical for quality end-of-life care in the hospital. Although guidelines support the use of unrestricted opiate administration to treat refractory pain and suffering in the dying patient, many patients die suffering with symptoms that could have been addressed.

METHODS

A multidisciplinary convenience sample of 381 hospital-based health care providers completed a survey evaluating their understanding of the principles of treating refractory pain and suffering at the end of life in the hospital, knowledge of the institution's policy about how to implement such care, and attitudes about and comfort with such treatment.

RESULTS

Respondents recognized pain and symptom management as a goal of unrestricted opiate use at the end of life, but 12% identified comfort for families or treatment of nonphysical suffering as the principal goal of this modality. Two thirds of respondents felt that unrestricted opiates were used too rarely and 45% felt they were used too late. However, 16% felt uncomfortable administering unrestricted opiates and 21% of physicians and nurses who had used restricted opiates reported having felt pressured to increase dosing of opiates. Knowledge deficits concerning appropriate candidates for unrestricted opiates and the protocol for appropriate implementation were common.

CONCLUSIONS

Knowledge deficits and attitudinal concerns may hamper the administration of unrestricted opiates for refractory pain and suffering at the end of life in the hospital. Clinician education and clarification of the appropriate use of this modality when there are differences in clinician and family perception of discomfort are needed.

Opioid use and survival at the end of life: a survey of a hospice population

Concern that opioids hasten death may be among the reasons that pain is treated inadequately in populations with advanced illness. Studies that assess the true risks are needed. To determine whether survival after last opioid dose change is associated with opioid dosing characteristics and other factors, data from the National Hospice Outcomes Project, a large prospective cohort study involving 13 U.S. hospice programs, were analyzed. Of 1,306 patients, 725 received opioids and underwent at least one dose change before death. Subsamples based on maximum opioid dose compared patients receiving usual doses with those receiving high-dose therapy. Spearman rank correlations examined bivariate associations between survival after final dose change and other variables, including dose in morphine equivalent mg and percentage dose increase. Multivariate least squares regression analyses determined associations between survival and other variables, including those significant in bivariate analyses. The mean+/-SD number of days between final dose change and death was 12.46+/-23.11. Multivariate models demonstrated a significant association between shorter survival and higher opioid dose, a cancer diagnosis, unresponsiveness, and pain of <5 on a 0-10 scale, but none of these models explained >10% of the variance in time till death. Analyses of subsamples did not reveal additional effects of dose. This analysis revealed that opioid dosing was associated with time till death, but this factor would explain very little of the variation in survival. In a hospice population, survival is influenced by complex factors, many of which may not be measurable. Based on these findings, concern about hastening death does not justify withholding opioid therapy.

'Death rattle' after withdrawal of mechanical ventilation: practical and ethical considerations

The noise produced by oscillatory movements of secretions in oropharynx, hypopharynx and trachea during inspiration and expiration in unconscious terminal patients is often described as 'the death rattle'. The reported incidence of death rattle in terminally ill patients varied between six and 92%. It is most commonly reported in patients dying from pulmonary malignancies, primary brain tumours or brain metastases, and predicts death within 48 hours in 75% of the patients. Clinical studies demonstrate that hyoscine hydrobromide is effective at improving symptoms. After withdrawal of artificial ventilation on the intensive care unit, excessive respiratory secretions resulting in rattling breathing, during the last hours of life, is not uncommon. Physicians and nurses experience considerable difficulties and frustrations in treating the death rattle. The distressing experience and negative influence in the bereavement process indicates an ethical demand to treat this symptom from the perspective of others merely than that of the patient. This article provides practical and ethical considerations in the management of this near-death symptom. The fact that relatives were relieved in almost all cases, in which a positive effect was obtained, makes treatment in anticipation of death rattle an ethical demand. In practice, injectable scopolamine is the reference drug for symptomatic treatment of death rattle.

Continuous deep sedation: physicians' experiences in six European countries

Continuous deep sedation (CDS) is sometimes used to treat refractory symptoms in terminally ill patients. The aim of this paper was to estimate the frequency and characteristics of CDS in six European countries: Belgium, Denmark, Italy, The Netherlands, Sweden, and Switzerland. Deaths reported to death registries were sampled and the reporting doctors received a mailed questionnaire about the medical decision making that preceded the death of the patient. The total number of deaths studied was 20,480. The response rate ranged between 44% (Italy) and 75% (The Netherlands). Of all deaths, CDS was applied in 2.5% in Denmark and up to 8.5% in Italy. Of all patients receiving CDS, 35% (Italy) and up to 64% (Denmark and The Netherlands) did not receive artificial nutrition or hydration. Patients who received CDS were more often male, younger than 80 years old, more likely to have had cancer, and died more often in a hospital compared to nonsudden deaths without CDS. The high variability of frequency and characteristics of CDS in the studied European countries points out the importance of medical education and scientific debate on this issue.

Effects of opioids and sedatives on survival in an Australian inpatient palliative care population

AIMS

To assess whether opioid and sedative medication use affects survival (from hospice admission to death) of patients in an Australian inpatient palliative care unit.

BACKGROUND

Retrospective audit. Newcastle Mercy Hospice--a tertiary referral palliative care unit. All patients who died in the hospice between 1 February and 31 December 2000.

METHODS

Length of survival from hospice admission to death, and the median and mean doses of opioids and sedatives used in the last 24 h of life. Comparison of these with published studies outside of Australia.

RESULTS

In this study, the use of opioids, benzodiazepines and haloperidol did not have an association with shortened survival and the only statistical significant finding was an increased survival in patients who were on 300 mg/day or more of oral morphine equivalent (OME). The proportion of patients requiring greater than or equal to 300 mg OME/day (at 28%) was higher than published studies, but the mean dose of 371 mg OME/day was within the range of other studies. The proportion of patients receiving sedatives (94%) was higher than other studies, but the median dose of parenteral midazolam equivalent of 12.5 mg per 24 h was lower than other studies from outside Australia.

CONCLUSIONS

There was no association between the doses of opioids and sedatives on the last day of life and survival (from hospice admission to death) in this population of palliative care patients.

When nothing helps: propofol as sedative and antiemetic in palliative cancer care

Benzodiazepines, neuroleptics, and barbiturates are commonly used for sedation to achieve symptom control in end-of-life care. Propofol has several advantages over traditional sedating agents that would indicate its use in treatment-refractory situations. We report on the use of propofol in 35 patients. In 22 patients, propofol was used for palliative sedation when treatment with benzodiazepines had failed. The mean dose range during treatment was between 0.90 and 2.13 mg/kg/h. The effect was assessed as good or very good in 91% of the patients. Thirteen patients were treated with propofol due to intractable nausea and vomiting. The mean dose range during the infusion period was 0.67-1.01 mg/kg/h. The effect was judged as good or very good in 69% of the patients. Based on our experience, we propose clinical guidelines on the safe use of propofol in specialized palliative inpatient units.

Assessing quality of end-of-life hospital care in a southern European regional health service

Objectives:During the final period of life, patients with cancer in the Basque Country are given treatment in different types of hospital care. This study compared the quality of care according to the type of care in one of the autonomous communities in Spain.

Methods:A retrospective study was carried out of cancer patients who died in conventional hospital services, home hospitalization services, and palliative care units. In addition to hospital stay and readmission number, variables based on the recommendations of Spanish Society for Palliative Care were studied.

Results:End-of-life was diagnosed in 57 percent of a sample of 486 patients, 3 days before death (median). The use of symptom control scales was only documented in the clinical records of eight patients. Sociofamily evaluation was not found. Patients in conventional hospital services were less frequently diagnosed with end-of-life and agony and were significantly different from the rest in the reasons for admission, symptoms assessed, drugs used, administration routes, and dosage forms. Pain was evaluated in 50 percent of the patients and was better controlled in palliative care units. Patients not diagnosed with agony (52 percent) were more frequently not given specific treatment.

Conclusions:End-of-life in cancer patients was diagnosed too late. The quality of care in palliative care units and by home hospitalization service was better than that in conventional hospitalization. Nevertheless, there were areas for improvement in the three modalities of care.

Ethical validity of palliative sedation therapy: a multicenter, prospective, observational study conducted on specialized palliative care units in Japan

Although palliative sedation therapy is often required in terminally ill cancer patients to achieve acceptable symptom relief, empirical data supporting the ethical validity of this approach are lacking. The primary aim of this study was to systematically investigate whether empirical evidence supports the ethical validity of sedation. This was a multicenter, prospective, observational study, which was conducted by 21 specialized palliative care units in Japan. One-hundred two consecutive adult cancer patients who received continuous deep sedation were enrolled. Continuous deep sedation was defined as the continuous use of sedative medications to relieve intolerable and refractory distress by achieving almost or complete unconsciousness until death. Prior to the study, we conceptualized the ethical validity of sedation from the viewpoints of physicians' intent, proportionality, and autonomy. Sedation was performed mainly with midazolam and phenobarbital. The initial doses of midazolam and phenobarbital were 1.5 mg/hour and 20 mg/hour, respectively. Main administration routes were continuous subcutaneous infusion and continuous intravenous infusion, and no rapid intravenous injection was reported. Of 59 patients who received artificial hydration or could intake adequate fluids/foods orally before sedation, 63% received artificial hydration therapy after sedation, and in the remaining patients, artificial hydration was withheld or withdrawn due to fluid retention symptoms and/or patient wishes. Of 66 patients who were able to verbally express themselves, 95% explicitly stated that symptoms were intolerable. The etiologies of the symptoms requiring sedation were primarily related to the progression of the underlying malignancy, such as cancer cachexia and organ failure, and standard palliative treatments had failed: steroids in 68% of patients with fatigue, opioids in 95% of patients with dyspnea, antisecretion medications in 75% of patients with bronchial secretion, antipsychotic medications in 74% of patients with delirium, and opioids in all patients with pain. On the basis of the Palliative Prognostic Index, 94% of the patients were predicted to die within 3 weeks. Before sedation, 67% of the patients expressed explicit wishes for sedation. In the remaining 34 patients, previous wishes for sedation were noted in 4 patients, and in the other 30 patients, the families were involved in the decision-making process. The chief reason for patient non-involvement in the decision making was cognitive impairment. These data indicate that palliative sedation therapy performed in specialized palliative care units in Japan generally followed the principles of double effect, proportionality, and autonomy.

Efficacy and safety of palliative sedation therapy: a multicenter, prospective, observational study conducted on specialized palliative care units in Japan

Although palliative sedation therapy is often required in terminally ill cancer patients, its efficacy and safety are not sufficiently understood. The primary aims of this multicenter observational study were to 1) explore the efficacy and safety of palliative sedation therapy, and 2) identify the factors contributing to inadequate symptom relief and complications, using a prospective study design, clearly defined measurement methods, and a consecutive sample from 21 specialized palliative care units in Japan. A sample of 102 consecutive adult cancer patients who received continuous deep sedation were enrolled. Physicians prospectively evaluated the intensity of patient symptoms, communication capacity, respiratory rate, and complications related to sedation. Symptoms were measured on the Agitation Distress Scale, the Memorial Delirium Assessment Scale, and the ad hoc symptom severity scale (0 = no symptoms, 1 = mild and tolerable symptoms, 2 = intolerable symptoms for less than 15 minutes in the previous one hour, and 3 = intolerable symptoms continuing for more than 15 minutes in the previous one hour). Inadequate symptom relief was defined as presence of hyperactive delirium (item 9 of the Memorial Delirium Assessment Scale >or=2) or grade 2 or 3 symptom intensity 4 hours after sedation. The degree of communication capacity was measured on the Communication Capacity Scale. Palliative sedation therapy succeeded in symptom alleviation in 83% of the cases. Median time elapsed before patients initially had one continuous hour of deep sedation was 60 minutes, but 49% of the patients awakened once after falling into a deeply sedated state. The percentage of patients who were capable of explicit communication decreased from 40% before sedation to 7.1% 4 hours after sedation, and the mean Communication Capacity Score significantly decreased to the level of 15 points (P < 0.001). The respiratory rates did not significantly decrease after sedation (18 +/- 9.0 to 16 +/- 9.4/min, P = 0.62), but respiratory and/or circulatory suppression (respiratory rate <or= 8/min, systolic blood pressure <or= 60mHg, or 50% or more reduction) occurred in 20%, with fatal outcomes in 3.9%. There were no statistically significant differences in patient age, sex, performance status, target symptoms, or classes and initial dose of sedative medications between the patients with adequate and inadequate symptom relief. Respiratory and/or circulatory suppression was significantly more likely to occur in patients receiving sedation for delirium and those with higher levels on the Agitation Distress Scale. Higher dose of midazolam was significantly correlated with younger age, absence of icterus, pre-exposure to midazolam, and length of sedation. Palliative sedation therapy is effective and safe in the majority of terminally ill cancer patients with refractory symptoms. However, a small number of patients experience fatal complications related to sedation. Comparison studies of different sedation regimens are needed to determine the most effective and safe sedation protocol.

Terminal Care: The Last Weeks of Life

BACKGROUND

The care of patients in their last weeks of life is a fundamental palliative care skill, but few evidence-based reviews have focused on this critical period.

METHOD

A systematic review of published literature and expert opinion related to care in the last weeks of life.

RESULTS

The evidence base informing terminal care is largely descriptive, retrospective, or extrapolated. While home deaths and hospice use are increasing, medical care near death is becoming more aggressive and hospice lengths of stay remain short. Though the prediction of impending death remains imprecise, studies have identified several common terminal signs and symptoms. Decreased communication near death complicates the determination of patient wishes, and advanced directives prior to the terminal stage are recommended. Anorexia and cachexia are common in dying patients but there is no evidence that this process is painful or responsive to intervention. While there is general consensus that artificial nutrition is not beneficial in dying patients, the use of artificial hydration is controversial, especially in the setting of delirium. Breathlessness has been shown to benefit from oral and parenteral opioids but not anxiolytics. Accumulation of respiratory tract secretions (death rattle) is common and usually responds to antimuscarinics. Physical pain typically decreases toward death but its assessment in dying patients is difficult. Terminal delirium may occur in up to one-third of patients, may have a reversible cause, and may respond to antipsychotics or benzodiazepines. Palliative sedation is controversial but widely used, especially internationally. Caregiver stress and bereavement may benefit from improved communication and hospice involvement.

CONCLUSION

While the terminal care literature is characterized by varying quality, numerous knowledge gaps, and frequent inconsistencies, it supports several common clinical interventions. More research is needed to resolve controversies, define effective therapies, and improve the outcomes of dying patients.

Legalised euthanasia will violate the rights of vulnerable patients

Doctors in the United Kingdom can accompany their patients every step of the way, up until the last. The law stops them helping their patients take the final step, even if that is the patient's fervent wish. Next month's debate in the House of Lords could begin the process of changing the law. To help doctors decide where they stand we publish a range of opinions