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Prampart S, Huon JF, Colpaert A, Delavaud C, Nizard J, Evin A. Deep continuous sedation at the patient's request until death in a palliative care unit: retrospective study. BMJ Support Palliat Care 2024; 14:60-64. [PMID: 37696585 DOI: 10.1136/spcare-2023-004551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Limited descriptive data are available on continuous and deep sedation maintained until death (CDSUD) at the patient's request in palliative care units. This study aimed to describe such practices in the context of refractory suffering or after a request to stop life-sustaining treatment, evaluating the duration and dosage of sedative treatments used. METHODS This retrospective observational study included consecutively hospitalised patients in a palliative care unit from January 2020 to December 2021. Data on patient profiles, reasons for the sedation request, duration of sedation and doses of sedatives were collected. RESULTS Among 42 patients who underwent CDSUD, 79% occurred due to refractory suffering. In cases of sedation following a request to stop life support, high-dose corticosteroid therapy was the most commonly involved life-sustaining treatment. Midazolam was always the first-line sedative treatment. Chlorpromazine was added in 79% of cases, and propofol in 40%, to achieve a deep level of sedation. The mean maximum doses of midazolam, chlorpromazine and propofol were 7.6 mg/hour (±1.9), 3.3 mg/hour (±0.9) and 1.7 mg/kg/hour, respectively. The average duration of sedation was 37 hours. CONCLUSIONS This study provides new descriptive elements on CDSUD. Notably, it highlights the use of second-line sedative molecules, such as propofol.
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Affiliation(s)
- Simon Prampart
- CHU de Nantes, Service de Soins Palliatifs et de Support, Nantes Université, Nantes, France
| | - Jean Francois Huon
- CHU de Nantes, Pharmacie, Nantes Université, Nantes, France
- INSERM UMR 1246 SPHERE, Nantes Université, Nantes, France
| | - Andre Colpaert
- CHU de Nantes, Service de Soins Palliatifs et de Support, Nantes Université, Nantes, France
| | - Clémence Delavaud
- CHU de Nantes, Service de Soins Palliatifs et de Support, Nantes Université, Nantes, France
| | - Julien Nizard
- CHU de Nantes, Service de Soins Palliatifs et de Support, Nantes Université, Nantes, France
- EA4391 Therapeutic and Nervous Excitability, Universite Paris-Est Creteil Val de Marne, Creteil, France
| | - Adrien Evin
- CHU de Nantes, Service de Soins Palliatifs et de Support, Nantes Université, Nantes, France
- INSERM UMR 1246 SPHERE, Nantes Université, Nantes, France
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Lojo-Cruz C, Mora-Delgado J, Rivas Jiménez V, Carmona Espinazo F, López-Sáez JB. Survival Outcomes in Palliative Sedation Based on Referring Versus On-Call Physician Prescription. J Clin Med 2023; 12:5187. [PMID: 37629229 PMCID: PMC10455353 DOI: 10.3390/jcm12165187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
This study sought to determine the survival duration of patients who underwent palliative sedation, comparing those who received prescriptions from referring physicians versus on-call physicians. It included all patients over 18 years old who died in the Palliative Care, Internal Medicine, and Oncology units at the Hospital Universitario of Jerez de la Frontera between 1 January 2019, and 31 December 2019. Various factors were analyzed, including age, gender, oncological or non-oncological disease, type of primary tumor and refractory symptoms. Statistical analysis was employed to compare survival times between patients who received palliative sedation from referring physicians and those prescribed by on-call physicians, while accounting for other potential confounding variables. This study revealed that the median survival time after the initiation of palliative sedation was 25 h, with an interquartile range of 8 to 48 h. Notably, if the sedation was prescribed by referring physicians, the median survival time was 30 h, while it decreased to 17 h when prescribed by on-call physicians (RR 0.357; 95% CI 0.146-0.873; p = 0.024). Furthermore, dyspnea as a refractory symptom was associated with a shorter survival time (RR 0.307; 95% CI 0.095-0.985; p = 0.047). The findings suggest that the on-call physician often administered palliative sedation to rapidly deteriorating patients, particularly those experiencing dyspnea, which likely contributed to the shorter survival time following sedation initiation. This study underscores the importance of careful patient selection and prompt initiation of palliative sedation to alleviate suffering.
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Affiliation(s)
- Cristina Lojo-Cruz
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Juan Mora-Delgado
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Víctor Rivas Jiménez
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Fernando Carmona Espinazo
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Puerta del Mar, Avenida Ana de Viya 21, 11009 Cádiz, Spain;
| | - Juan-Bosco López-Sáez
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Puerto Real, Calle Romería 7, 11510 Puerto Real, Spain;
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Garcia ACM, Isidoro GM, Paiva EMDC, Silva AE, Costa ICP, Bornemann-Cimenti H. Palliative Sedation at Home: A Scoping Review. Am J Hosp Palliat Care 2023; 40:173-182. [PMID: 35466700 DOI: 10.1177/10499091221096412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Palliative Sedation (PS) is an effective measure for the relief of refractory symptoms in end-of-life patients. This intervention can be performed at home, respecting the patients' and their families' decisions. A scoping review was performed to map the available evidence in the literature on the performance of PS at home. This review included 23 studies. Most were conducted in European countries with adult cancer patients. Patients, family members and healthcare providers participated in the decision making regarding the use of PS at home. PS was used primarily to manage refractory symptoms (pain, delirium, dyspnea, and others), and in 1 of the studies PS was mentioned as a possible intervention for shortening life. The most commonly used medication was midazolam and the average duration ranged from 4 h to 7 days. There are few reports on adverse events related to PS. This intervention seems to be a feasible possibility for the management of refractory symptoms in patients at the end of life, despite the fact that it can represent specific challenges for healthcare providers, patients and families. However, the literature is limited regarding PS in children and in people with diseases other than cancer, as well as on the evaluation of possible adverse effects related to this intervention. Furthermore, it is essential to have a broad ethical, clinical and legal debate on whether to consider the use of PS for the purpose of shortening life in specific cases.
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Affiliation(s)
| | | | | | - Alexandre E Silva
- Nursing Department - Campus Centro-Oeste Dona Lindu, 74383Federal University of São João del-Rei, Divinópolis, Brazil
| | | | - Helmar Bornemann-Cimenti
- Departement of Anesthesiology and Intensive Care Medicine, 31475Medical University of Graz, Graz, Austria
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Update on Prevalence of Pain in Patients with Cancer 2022: A Systematic Literature Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15030591. [PMID: 36765547 PMCID: PMC9913127 DOI: 10.3390/cancers15030591] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
Experiencing pain and insufficient relief can be devastating and negatively affect a patient's quality of life. Developments in oncology such as new treatments and adjusted pain management guidelines may have influenced the prevalence of cancer pain and severity in patients. This review aims to provide an overview of the prevalence and severity of pain in cancer patients in the 2014-2021 literature period. A systematic literature search was performed using the databases PubMed, Embase, CINAHL, and Cochrane. Titles and abstracts were screened, and full texts were evaluated and assessed on methodological quality. A meta-analysis was performed on the pooled prevalence and severity rates. A meta-regression analysis was used to explore differences between treatment groups. We identified 10,637 studies, of which 444 studies were included. The overall prevalence of pain was 44.5%. Moderate to severe pain was experienced by 30.6% of the patients, a lower proportion compared to previous research. Pain experienced by cancer survivors was significantly lower compared to most treatment groups. Our results imply that both the prevalence of pain and pain severity declined in the past decade. Increased attention to the assessment and management of pain might have fostered the decline in the prevalence and severity of pain.
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Hedman C, Rosso A, Häggström O, Nordén C, Fürst CJ, Schelin MEC. Sedation in specialized palliative care: A cross-sectional study. PLoS One 2022; 17:e0270483. [PMID: 35802571 PMCID: PMC9269455 DOI: 10.1371/journal.pone.0270483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/12/2022] [Indexed: 11/19/2022] Open
Abstract
Background Palliative sedation is used to relieve refractory symptoms and is part of clinical practice in Sweden. Yet we do not know how frequently this practice occurs, how decision-making takes place, or even which medications are preferentially used. Objectives To understand the current practice of palliative sedation in Sweden. Methods We conducted a retrospective cross-sectional medical record-based study. For 690 consecutive deceased patients from 11 of 12 specialized palliative care units in the southernmost region of Sweden who underwent palliative sedation during 2016, we collected data on whether the patient died during sedation and, for sedated patients, the decision-making process, medication used, and depth of sedation. Results Eight percent of patients were sedated. Almost all (94%) were given midazolam, sometimes in combination with propofol. The proportions of sedation were similar in the patient groups with and without cancer. The largest proportion of the sedated patients died in inpatient care, but 23% died at home, with specialized palliative home care. Among the patients with a decision to sedate, 42% died deeply unconscious, while for those without such a decision the corresponding figure was 16%. In only one case was there more than one physician involved in the decision to use palliative sedation. Conclusion 8% of patients in specialized palliative care received palliative sedation, which is lower than international measures but much increased compared to an earlier Swedish assessment. The level of consciousness achieved often did not correspond to the planned level; this, together with indications of a scattered decision process, shows a need for clear guidelines.
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Affiliation(s)
- Christel Hedman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
- R&D Department, Stockholms Sjukhem Foundation, Stockholm, Sweden
- * E-mail:
| | - Aldana Rosso
- Division of Geriatric Medicine, Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
| | - Ola Häggström
- Unit of Palliative Care Kristianstad, Region Skåne, Kristianstad, Sweden
| | | | - Carl Johan Fürst
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
| | - Maria E. C. Schelin
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
- Department of Research and Development, Skåne University Hospital, Lund, Sweden
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Belar A, Arantzamendi M, Menten J, Payne S, Hasselaar J, Centeno C. The Decision-Making Process for Palliative Sedation for Patients with Advanced Cancer-Analysis from a Systematic Review of Prospective Studies. Cancers (Basel) 2022; 14:301. [PMID: 35053464 PMCID: PMC8773810 DOI: 10.3390/cancers14020301] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The involvement of patients in decision making about their healthcare plans is being emphasized. In the context of palliative sedation, it is unclear how these decisions are made and who are involved in. The aim of the study is to understand how this decision-making is taken. METHOD Information from a systematic review on clinical aspects of palliative sedation prospective studies were included. PubMed, CINAHL, Cochrane, MEDLINE, and EMBASE were searched (January 2014-December 2019). Data extraction and analysis regarded: (a) When and by whom the decision-making process is initiated; (b) patient involvement; (c) family involvement and (d) healthcare involvement. RESULTS Data about decision making were reported in 8/10 included articles. Palliative sedation was reported in 1137 patients (only 16 of them were non-cancer). Palliative sedation was introduced by the palliative care team during the disease process, at admission, or when patients experienced refractory symptoms. Only two studies explicitly mentioned the involvement of patients in decision making. Co-decision between families and the regular health care professionals was usual, and the health care professionals involved had been working in palliative care services. CONCLUSION Patient participation in decision making appeared to be compromised by limited physical or cognitive capacity and family participation is described. The possibility of palliative sedation should be discussed earlier in the disease process.
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Affiliation(s)
- Alazne Belar
- Institute for Culture and Society-Atlantes, Universidad de Navarra, 31009 Pamplona, Spain; (A.B.); (C.C.)
- IdiSNA—Instituto de Investigacion Sanitaria de Navarra, 31008 Pamplona, Spain
| | - Maria Arantzamendi
- Institute for Culture and Society-Atlantes, Universidad de Navarra, 31009 Pamplona, Spain; (A.B.); (C.C.)
- IdiSNA—Instituto de Investigacion Sanitaria de Navarra, 31008 Pamplona, Spain
| | - Johan Menten
- Department of Oncology, Laboratory of Experimental Radiotherapy, Katholieke Universiteit, 3000 Leuven, Belgium;
| | - Sheila Payne
- Division of Health Research, Lancaster University, Lancaster LA1 4YW, UK;
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands;
| | - Carlos Centeno
- Institute for Culture and Society-Atlantes, Universidad de Navarra, 31009 Pamplona, Spain; (A.B.); (C.C.)
- IdiSNA—Instituto de Investigacion Sanitaria de Navarra, 31008 Pamplona, Spain
- Departamento Medicina Paliativa, Clínica Universidad de Navarra, 31001 Pamplona, Spain
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Twycross RG, Wong AKY, Vivat B. Comment on Ramos-Rincon et al. Palliative Sedation in COVID-19 End-of-Life Care. Retrospective Cohort Study. Medicina 2021, 57, 873. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010082. [PMID: 35056390 PMCID: PMC8778193 DOI: 10.3390/medicina58010082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/30/2021] [Accepted: 12/30/2021] [Indexed: 11/16/2022]
Abstract
We read with interest the article by Ramos-Rincon and colleagues about patients with COVID-19 dying in acute medical wards in a Spanish University hospital [...].
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Affiliation(s)
| | - Aaron Kee Yee Wong
- Department of Palliative Care, The Royal Melbourne Hospital, 300 Gratton Street, Parkville, VIC 3050, Australia;
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK;
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Vivat B, Twycross R. CSD Continuous Sedation Until Death; A Response to Changing Practices in the Use of Continuous Sedation at the End of Life: A Systematic Review of the Literature (Heijltjes et al., 2020). J Pain Symptom Manage 2022; 63:e139-e141. [PMID: 34562594 DOI: 10.1016/j.jpainsymman.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry (B.V.), University College London, London, UK.
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Ahn HK, Ahn HY, Park SJ, Hwang IC. Characteristics Associated with Survival in Patients Receiving Continuous Deep Sedation in a Hospice Care Unit. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2021; 24:254-260. [PMID: 37674644 PMCID: PMC10180067 DOI: 10.14475/jhpc.2021.24.4.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/07/2021] [Accepted: 09/30/2021] [Indexed: 09/08/2023]
Abstract
Continuous deep sedation (CDS) is an extreme form of palliative sedation to relieve refractory symptoms at the end of life. In this study, we shared our experiences with CDS and examined the clinical characteristics associated with survival in patients with terminal cancer who received CDS. We conducted a chart audit of 106 consecutive patients with terminal cancer who received CDS at a single hospice care unit between January 2014 and December 2016. Survival was defined as the first day of admission to the date of death. The associations between clinical characteristics and survival were presented as hazard ratios and 95% confidence intervals using a Cox proportional hazard model. The mean age of participants was 65.2 years, and 33.0% (n=35) were women. Diazepam was the most commonly administered drug, and haloperidol or lorazepam were also used if needed. One sedative was enough for a majority of the patients. Stepwise multivariate analysis identified poor functioning, a high Palliative Prognostic Index score, hyperbilirubinemia, high serum ferritin levels, and a low number of sedatives as independent poor prognostic factors. Our experiences and findings are expected to be helpful for shared decision-making and further research on palliative sedation.
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Affiliation(s)
- Hee Kyung Ahn
- Oncology Division, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Hong Yup Ahn
- Department of Statistics, Dongguk University, Seoul, Korea
| | | | - In Cheol Hwang
- Department of Family Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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Palliative sedation in patients with advanced cancer in a specialized unit in a middle-income country: A retrospective cohort study. Palliat Support Care 2021; 20:491-495. [PMID: 34425935 DOI: 10.1017/s1478951521001371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To describe the 5-year practice on palliative sedation in a specialized palliative care unit in a deprived region in Brazil, and to compare survival of patients with advanced cancer who were and were not sedated during their end-of-life care. METHOD Retrospective cohort study in a tertiary teaching hospital. We described the practice of palliative sedation and compared the survival time between patients who were and were not sedated in their last days of life. RESULTS We included 906 patients who were admitted to the palliative care unit during the study period, of whom, 92 (10.2%) received palliative sedation. Patients who were sedated were younger, presented with higher rates of delirium, and reported more pain, suffering, and dyspnea than those who were not sedated. Median hospital survival of patients who received palliative sedation was 9.30 (CI 95%, 7.51-11.81) days and of patients who were not sedated was 8.2 (CI 95%, 7.3-9.0) days (P = 0.31). Adjusted for age and sex, palliative sedation was not significantly associated with hospital survival (hazard ratio = 0.93; CI 95%, 0.74-1.15). SIGNIFICANCE OF RESULTS Palliative sedation can be accomplished even in a deprived area. Delirium, dyspnea, and pain were more common in patients who were sedated. Median survival was not reduced in patients who were sedated.
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Arantzamendi M, Belar A, Payne S, Rijpstra M, Preston N, Menten J, Van der Elst M, Radbruch L, Hasselaar J, Centeno C. Clinical Aspects of Palliative Sedation in Prospective Studies. A Systematic Review. J Pain Symptom Manage 2021; 61:831-844.e10. [PMID: 32961218 DOI: 10.1016/j.jpainsymman.2020.09.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/25/2022]
Abstract
CONTEXT Near the end of life when patients experience refractory symptoms, palliative sedation may be considered as a last treatment. Clinical guidelines have been developed, but they are mainly based on expert opinion or retrospective chart reviews. Therefore, evidence for the clinical aspects of palliative sedation is needed. OBJECTIVES To explore clinical aspects of palliative sedation in recent prospective studies. METHODS Systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered at PROSPERO. PubMed, CINAHL, Cochrane, MEDLINE, and EMBASE were searched (January 2014-December 2019), combining sedation, palliative care, and prospective. Article quality was assessed. RESULTS Ten prospective articles were included, involving predominantly patients with cancer. Most frequently reported refractory symptoms were delirium (41%-83%), pain (25%-65%), and dyspnea (16%-59%). In some articles, psychological and existential distress were mentioned (16%-59%). Only a few articles specified the tools used to assess symptoms. Level of sedation assessment tools were the Richmond Agitation Sedation Scale, Ramsay Sedation Scale, Glasgow Coma Scale, and Bispectral Index monitoring. The palliative sedation practice shows an underlying need for proportionality in relation to symptom intensity. Midazolam was the main sedative used. Other reported medications were phenobarbital, promethazine, and anesthetic medication-propofol. The only study that reported level of patient's discomfort as a palliative sedation outcome showed a decrease in patient discomfort. CONCLUSION Assessment of refractory symptoms should include physical evaluation with standardized tools applied and interviews for psychological and existential evaluation by expert clinicians working in teams. Future research needs to evaluate the effectiveness of palliative sedation for refractory symptom relief.
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Affiliation(s)
- Maria Arantzamendi
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain
| | - Alazne Belar
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain.
| | - Sheila Payne
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Maaike Rijpstra
- Department of Anaesthesiology, Pain, Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Nancy Preston
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Johan Menten
- Department of Oncology, Laboratory of experimental radiotherapy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Michael Van der Elst
- Department of Oncology, Laboratory of experimental radiotherapy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Lukas Radbruch
- Department of Palliative Medicine, Universitaetsklinikum Bonn, Bonn, Germany
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain, Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Carlos Centeno
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain; Clínica Universidad de Navarra, Departamento Medicina Paliativa, Pamplona, Spain
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Belar A, Arantzamendi M, Payne S, Preston N, Rijpstra M, Hasselaar J, Radbruch L, Vanderelst M, Ling J, Centeno C. How to measure the effects and potential adverse events of palliative sedation? An integrative review. Palliat Med 2021; 35:295-314. [PMID: 33307989 PMCID: PMC7897792 DOI: 10.1177/0269216320974264] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Palliative sedation is the monitored use of medications intended to relieve refractory suffering. The assessment of palliative sedation has been focused on the assess of the level of consciousness but a more comprehensive approach to assessment is needed. AIM To understand how the potential effects and possible adverse events of palliative sedation in Palliative Care patients are measured. DESIGN Integrative review of most recent empirical research. DATA SOURCES Cochrane Library, Embase, Medline, PubMed, and CINAHL were searched (2010-2020) using the terms sedation, palliative care, terminal care, assessment. Limits included studies in English and adults. Inclusion criteria were: scientific assessment papers, effects and complications of palliative sedation; patients with incurable illness. RESULTS Out of 588 titles, 26 fulfilled inclusion criteria. The Discomfort Scale-Dementia of Alzheimer Type and Patient Comfort Score were used to assess comfort. The Richmond Agitation-Sedation Scale and The Ramsay Sedation Scale are the most used to measure its effect. Refractory symptoms were assessed through multi-symptom or specific scales; except for psychological or existential distress. Delirium was assessed using the Memorial Delirium Assessment Scale and pain through the Critical Care Pain Observation Tool. The use of technical approaches to monitor effects is upcoming. There is lack of measurement of possible adverse events and variability in timing measurement. CONCLUSIONS There are palliative care validated instruments to assess the sedation effect but this review shows the need for a more standardized approach when assessing it. Instruments should be used within an experienced and trained expert, providing a holistic assessment.
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Affiliation(s)
- Alazne Belar
- Institute for Culture and Society-ATLANTES, Universidad de Navarra, Pamplona, Spain
- IdISNA, Pamplona, Spain
| | - María Arantzamendi
- Institute for Culture and Society-ATLANTES, Universidad de Navarra, Pamplona, Spain
- IdISNA, Pamplona, Spain
| | - Sheila Payne
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Nancy Preston
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Maaike Rijpstra
- Department of Anaesthesiology, Pain, Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain, Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Lukas Radbruch
- Department of Palliative Medicine, Universitaetsklinikum Bonn, Bonn, Germany
| | - Michael Vanderelst
- Department of Oncology, Laboratory of experimental radiotherapy, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Julie Ling
- European Association of Palliative Care, Vilvoorde, Belgium
| | - Carlos Centeno
- Institute for Culture and Society-ATLANTES, Universidad de Navarra, Pamplona, Spain
- IdISNA, Pamplona, Spain
- Clínica Universidad de Navarra, Departamento Medicina Paliativa, Pamplona, Spain
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Development and validation of the Terminal Delirium-Related Distress Scale to assess irreversible terminal delirium. Palliat Support Care 2021; 19:287-293. [PMID: 33397541 DOI: 10.1017/s1478951520001340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is no tool to appropriately assess terminal delirium, including the natural terminal course. The objective of this study was to develop an evaluation scale to assess distress from irreversible terminal delirium and to examine the validity of the scale. METHOD Based on previous qualitative analysis and systematic literature searches, we carried out a survey regarding the views of bereaved families and developed a questionnaire. We extracted items that bereaved families regarded as important and constructed an evaluation scale of terminal delirium. Then, we applied the questionnaire in a cross-sectional questionnaire survey of bereaved relatives of cancer patients who were admitted to a hospice or a palliative care unit. RESULTS We developed the Terminal Delirium-Related Distress Scale (TDDS), a 24 item questionnaire consisting of five subscales (support for families and respect for a patient, ability to communicate, hallucinations and delusions, adequate information about the treatment of delirium, and agitation and restlessness). Two hundred and eighty-one bereaved relatives participated in the validation phase. The construct validity was shown to be good by repeated factor analysis. Convergent validity, confirmed by the correlation between the TDDS and the Care Evaluation Scale (r = 0.651, P < 0.001), was also good. The TDDS had good internal consistency (Cronbach's alpha coefficient for all 24 items = 0.84). SIGNIFICANCE OF RESULTS This study showed that the TDDS is a valid and feasible measure of irreversible terminal delirium.
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Heijltjes MT, van Thiel GJMW, Rietjens JAC, van der Heide A, de Graeff A, van Delden JJM. Changing Practices in the Use of Continuous Sedation at the End of Life: A Systematic Review of the Literature. J Pain Symptom Manage 2020; 60:828-846.e3. [PMID: 32599152 DOI: 10.1016/j.jpainsymman.2020.06.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/14/2020] [Indexed: 01/10/2023]
Abstract
CONTEXT The use of continuous sedation until death (CSD) has been highly debated for many years. It is unknown how the use of CSD evolves over time. Reports suggest that there is an international increase in the use of CSD for terminally ill patients. OBJECTIVE To gain insight in developments in the use of CSD in various countries and subpopulations. METHODS We performed a search of the literature published between January 2000 and April 2020, in PubMed, Embase, CINAHL, PsycInfo, and the Cochrane Library by using the Preferred reporting items for systematic review and meta-analysis protocols guidelines. The search contained the following terms: continuous sedation, terminal sedation, palliative sedation, deep sedation, end-of-life sedation, sedation practice, and sedation until death. RESULTS We found 23 articles on 16 nationwide studies and 38 articles on 37 subpopulation studies. In nationwide studies on frequencies of CSD in deceased persons varied from 3% in Denmark in 2001 to 18% in The Netherlands in 2015. Nationwide studies indicate an increase in the use of CSD. Frequencies of CSD in the different subpopulations varied too widely to observe time trends. Over the years, more studies reported on the use of CSD for nonphysical symptoms including fear, anxiety, and psycho-existential distress. In some studies, there was an increase in requests for sedation of patients from their families. CONCLUSIONS The frequency of CSD seems to increase over time, possibly partly because of an extension of indications for sedation, from mainly physical symptoms to also nonphysical symptoms.
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Affiliation(s)
- Madelon T Heijltjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Ghislaine J M W van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alexander de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, The Netherlands and Academic Hospice Demeter, De Bilt, The Netherlands
| | - Johannes J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Krooupa AM, Vivat B, McKeever S, Marcus E, Sawyer J, Stone P. Identification and evaluation of observational measures for the assessment and/or monitoring of level of consciousness in adult palliative care patients: A systematic review for I-CAN-CARE. Palliat Med 2020; 34:83-113. [PMID: 31434526 PMCID: PMC6952953 DOI: 10.1177/0269216319871666] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The use of observational measures to assess palliative care patients' level of consciousness may improve patient care and comfort. However, there is limited knowledge regarding the validity and reliability of these measures in palliative care settings. AIM To identify and evaluate the psychometric performance of observational level of consciousness measures used in palliative care. DESIGN Systematic review; PROSPERO registration: CRD42017073080. DATA SOURCES We searched six databases until November 2018, using search terms combining subject headings and free-text terms. Psychometric performance for each identified tool was appraised independently by two reviewers following established criteria for developing and evaluating health outcome measures. RESULTS We found 35 different levels of consciousness tools used in 65 studies. Only seven studies reported information about psychometric performance of just eight tools. All other studies used either ad hoc measures for which no formal validation had been undertaken (n = 21) or established tools mainly developed and validated in non-palliative care settings (n = 37). The Consciousness Scale for Palliative Care and a modified version of the Richmond Agitation-Sedation Scale received the highest ratings in our appraisal, but, since psychometric evidence was limited, no tool could be assessed for all psychometric properties. CONCLUSION An increasing number of studies in palliative care are using observational measures of level of consciousness. However, only a few of these tools have been tested for their psychometric performance in that context. Future research in this area should validate and/or refine the existing measures, rather than developing new tools.
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Affiliation(s)
- Anna-Maria Krooupa
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Stephen McKeever
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK.,school of Nursing, Faculty of Health, Social Care and Education, Kingston Hill, UK
| | - Elena Marcus
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Joseph Sawyer
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Paddy Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
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